Ethnicity and psychopathology in an aging hospital-based population. A comparison of African-American and Anglo-European patients

Investigating ethnic variations in reporting of psychotic symptoms: a multiple-group confirmatory factor analysis of the Psychosis Screening Questionnaire

BACKGROUND

Epidemiological evidence suggests risk for psychosis varies with ethnicity in Western countries. However, there is little evidence to date on the cross-cultural validity of screening instruments used for such comparisons.

METHODS

Combining two existing UK population-based cohorts, we examined risk for reporting psychotic symptoms across White British (n = 3467), White Irish (n = 851), Caribbean (n = 1899), Indian (n = 2590), Pakistani (n = 1956) and Bangladeshi groups (n = 1248). We assessed the psychometric properties of the Psychosis Screening Questionnaire (PSQ) with a multiple-group confirmatory factor analysis, assessing the equivalence of factor loadings, response thresholds and residual variances in an analysis of measurement non-invariance.

RESULTS

Compared with prevalence among British Whites (5.4%), the prevalence of self-reported psychotic symptoms was greater in the Caribbean group (12.7%, adjusted OR = 2.38 [95% CI 1.84-3.07]). Prevalence was also increased among Pakistani individuals (8.3%, adjusted OR = 1.36 [1.01-1.84]) although this difference was driven by a greater likelihood of reporting paranoid symptoms. PSQ items for thought interference, strange experience and hallucination were measured in equivalent ways across ethnic groups. However, our measurement models suggested that paranoid symptoms were measured less reliably among ethnic minorities than among British Whites and appeared to exaggerate latent differences between Pakistani and White British groups when measurement non-invariance was not accounted for.

CONCLUSIONS

Notwithstanding evidence for measurement non-invariance, the greater risk for reporting psychotic symptoms among Caribbean individuals is unlikely to be an artefact of measurement. Greater residual variance in the recording of paranoid symptoms among ethnic minority respondents warrants caution in using this item to investigate ethnic variation in psychosis risk.

Depression in Older Ethnic Groups

The generality of George's model of the social precursors of depression was tested in a sample of older persons ( N = 803) from three ethnic groups: U.S.-born African Americans, African Caribbeans, and U.S.-born European Americans. The social precursors model includes demographic variables, early events and achievements, later events and achievements, social integration, vulnerability and protective factors, and provoking agents and coping efforts. Zero-order correlations indicated that nearly all the predictor variables were significantly associated with depression. A test of the overall model with all six stages was followed by separate regressions for each ethnic group. Four of the six stages of the model contributed unique variance to the prediction of depressed affect in European Americans but only two in the case of African Americans and African Caribbeans. The most robust and consistent predictor of depression was the sixth-stage variables of stress and emotion regulation.

A Gender and Racial Epidemiological Profile of Public Psychiatric Hospitals in the Western Cape

The aim of this archival epidemiological study was to identify gender and racial patterns of psychiatric diagnosis and management in admissions to mental hospitals. The hospital records of a random, stratified sample ( N =2110) of all patients admitted to the three public psychiatric hospitals in the Western Cape for a calendar year were studied for gender and racial differences regarding demographics, admission-related variables, diagnosis and management, both during hospitalisation and on discharge. Analysis was done for race groups within females and males and differ-ences between groups were tested by chi-square tests. Consistently significant differences in psychiatric diagnosis and management across race and gender were found, many in line with other international and African studies. Anomalies of diagnosis and treatment reflect past inequities of South African society and suggest the role of both social factors and bias in psychiatric hospital practice. Implications for future mental health research, training and practice are raised.

A Comparison Of Depressive Symptons In African Americans And Caucasian Americans

The study examined group differences in depressive symptomatology on the Beck Depression Inventory in 278 African Americans and 278 Caucasian Americans seeking psychotherapy. Relative to Caucasian Americans, African Americans reported less pessimism, dissatisfaction, self-blame, and suicidal ideation and more sense of punishment and weight change, but for reasons unrelated to depression. Self-dislike was a stronger manifestation of depression in Caucasian Americans, and sleep disturbance, loss of appetite, and loss of libido were stronger manifestations of depression in African Americans. Group differences were not accounted for by gender, marital status, age, or education. The study contributes to the understanding of sociocultural variants of self reported depression by distinguishing different ways in which symptomatology may differ.

Racial differences in adherence to antidepressant treatment in later life

OBJECTIVE

Although antidepressants are an effective treatment for later-life depression, older patients often choose not to initiate or to discontinue medication treatment prematurely. Although racial differences in depression treatment preferences have been reported, little is known about racial differences in antidepressant medication adherence among older patients.

DESIGN

Prospective, observational study comparing antidepressant adherence for older African American and white primary care patients.

PARTICIPANTS

A total of 188 subjects age 60 and older, diagnosed with clinically significant depression with a new recommendation for antidepressant treatment by their primary care physician.

MEASUREMENT

Study participants were assessed at study entry and at the 4-month follow-up (encompassing the acute treatment phase). Depression medication adherence was based on a well-validated self-report measure.

RESULTS

At the 4-month follow-up, 61.2% of subjects reported that they were adherent to their antidepressant medication. In unadjusted and two of the three adjusted analyses, African American subjects (n = 82) had significantly lower rates of 4-month antidepressant adherence than white subjects (n = 106). African American women had the lowest adherence rates (44.4%) followed by African American men (56.8%), white men (65.3%), and white women (73.7%). In logistic regression models controlling for demographic, illness, and functional status variables, significant differences persisted between African American women and white women in reported 4-month antidepressant adherence (OR: 3.58, 95% CI: 1.27-10.07, Wald χ(2) = 2.42, df = 1, p <0.02).

CONCLUSIONS

The results demonstrate racial and gender differences in antidepressant adherence in older adults. Depression treatment interventions for older adults should take into account the potential impact of race and gender on adherence to prescribed medications.

Ethnic and clinical characteristics of a Portuguese psychiatric inpatient population

The present study examined the association between ethnicity and clinical characteristics of patients admitted to a psychiatric inpatient unit in Portugal. The only ethnicity-related terms routinely recorded in the medical records were "Black" (mainly from the African Portuguese-speaking countries of Cape Verde, Angola, Guinea, Sao Tome and Mozambique) and "White." Black immigrants appeared to be over-represented, comprising 19.6% of inpatients; and were younger and more frequently male when compared with White inpatients. They were more frequently diagnosed with schizophrenia and acute or transient psychosis, and less frequently diagnosed with delusional and personality disorders than White inpatients. These results are consistent with previous studies in the US and UK, and highlight the need for more culturally sensitive care in mental health services.

Reconceptualizing access: a cultural competence approach to improving the mental health of African American women

Despite the prevalence of mental illness among African American women, only a limited number of them seek or accept help from mental health service delivery systems. An extensive review of the literature revealed that (1) racism and discrimination, (2) socioeconomic status, (3) stress and well being, and (4) housing and neighborhood conditions must be considered in an assessment of the mental health status of African American women. These factors negatively affect their mental health and should be addressed in eliminating disparities in access to and utilization of mental health services. We recommend a process by which mental health providers reconceptualize access to mental health services using a socio-cultural framework. The knowledge gained in this process will result in increased provider cultural competence. This developmental process would be facilitated by the use of a socio-cultural conceptual model for treatment engagement. The model takes into consideration the barriers to mental health treatment services that, in part, have to be eliminated by mental health providers in order to decrease disparities and enhance both access to and utilization of mental health services by African American women.

Cross-ethnic evaluation of psychotic symptom content in hospitalized middle-aged and older adults

OBJECTIVE

The objective of this study was to examine ethnic differences in the content of delusions and hallucinations among a tri-ethnic sample of adult psychiatric inpatients older than 40 years who were hospitalized with an acute psychotic episode.

METHODS

A chart review of inpatient episodes for 133 middle-aged and older adult patients (31 African Americans, 50 Latinos, and 52 Euro-Americans) with a mean age of 50 years was performed at an acute behavioral medicine unit at a university hospital. All patients were diagnosed with a severe psychotic disorder. The content and frequency of psychotic symptoms were systematically reviewed using a structured checklist and comparisons across ethnic groups were made using chi(2) statistics.

RESULTS

Ethnic group differences were found in the contents and subtypes of delusions and hallucinations. Significant ethnic differences were found in symptom content, consistent with findings from studies on younger samples of inpatients. Euro-Americans were nearly twice as likely as Latinos to report delusions of grandiosity. African Americans were more likely than Latinos to report general paranoid delusions of persecution. Latinos reported more culturally influenced contents than the other groups.

CONCLUSION

Raising provider awareness of ethnic variation in symptom expression is a key step in the process of developing effective treatments for ethnically diverse middle-aged and older patient populations.

Effect of race and sex on primary care physicians' diagnosis and treatment of late-life depression

OBJECTIVES

To examine primary care physician (PCP) contributions toward racial and sex differences in the diagnosis and treatment of late-life depression.

DESIGN

Survey using a computerized instrument incorporating video interviews and text, with volunteer PCPs randomly assigned to one of four standardized video vignettes of an elderly patient depicting late-life depression. Vignettes differed only in the patient/actor's race (white/African-American) or sex.

SETTING

American Academy of Family Physicians meeting, San Diego, California, 2002.

PARTICIPANTS

One hundred seventy-eight U.S.-practicing postresidency PCPs who were asked to participate in a clinical decision-making study.

MEASUREMENTS

The computerized survey instrument assessed PCPs' diagnoses, first-line treatment and management recommendations, and judgment of personal characteristics/behaviors for the patients in the vignettes.

RESULTS

Eighty-five percent of all PCPs correctly diagnosed the elderly patient(s) with major depression. There were no significant differences in the diagnosis of depression, treatment recommendations, or PCP assessment of most patient characteristics by the race or sex of the patient/actor in the vignette, but PCP characteristics, most notably the location of medical school training (U.S. vs international), affected the likelihood of a depression diagnosis and treatment recommendations.

CONCLUSION

Given standardized symptom-pictures, PCPs are just as likely to diagnose and treat depression in African-American as in white older people, suggesting that bias based simply on apparent patient race is not a likely explanation for the lower rates of depression diagnosis and treatment in older African Americans. PCPs who have trained at international medical schools may benefit from targeted training initiatives on the diagnosis and treatment of late-life depression.

Racial differences in the frequency of depressive symptoms among community dwelling elders: the role of socioeconomic factors

In a biracial sample of community dwelling elders (n=4162, the Duke EPESE), African-Americans endorsed more items than Whites on a standardized depression scale, the CES-D, in unadjusted, cross-sectional analyses. However, indices of socioeconomic status (e.g., education and problems meeting needs) were found to mediate the relationship between race and depression. When these socioeconomic variables were included in cross-sectional analyses, the association between depressive symptoms and race reversed such that Whites were significantly more likely to endorse depressive symptoms than African-Americans. Further, whereas in unadjusted, longitudinal analyses, race was unrelated to changes in depressive symptoms over time, with the inclusion of the socioeconomic variables Whites were found to endorse more depressive symptoms than African-Americans. We conclude that socioeconomic variables influence the size and direction of racial differences in the endorsement of depressive symptoms in community dwelling elders.

Late-life depression among black and white elderly homecare patients

OBJECTIVE

The authors compared the prevalence of major depressive disorder (MDD) and the prescription rates of antidepressant medication, by race, among frail, older homecare patients.

METHODS

A random sample of 56 black and 458 white newly admitted homecare patients age 65 and over was assessed for MDD with structured interviews and medical records, and antidepressant prescription rates were tallied.

RESULTS

The prevalence of MDD did not differ significantly across racial groups. Only 16.7% of black patients and 32.0% of white patients were prescribed antidepressant medication.

CONCLUSIONS

Prevalence of MDD was similar among black and white elderly homecare patients. In both groups, depression is undertreated and contributes to the burden of this frail, older patient group.

Cultural aspects of psychosis in the elderly

The elderly population is rapidly growing and increasing in diversity. Furthermore, mental disorders are common in this population. Elderly patients are at increased risk for developing psychotic symptoms. Consequently, clinicians must increase their awareness of culture and its effect on psychosis in the elderly. This article briefly reviews the components of cultural assessments, cultural issues pertaining to diagnosis and treatment, and culture-bound syndromes. Some studies have demonstrated ethnic differences in the presention, assessment, diagnosis, and treatment of psychotic disorders in the elderly. These differences may be explained by factors including clinicians' bias, cultural distance between patients and clinicians, culturally biased diagnostic instruments, stereotypes of psychopathology, and biological and other environmental factors. However, some studies have not documented ethnic differences in diagnosing and treating psychotic disorders. Appropriate assessments and diagnoses include patients' and clinicians' ethnic and cultural contexts. Rigorous methodological research is needed to further evaluate the prevalence and treatment of psychotic disorders in ethnic minority elders.

Recorded delirium in a national sample of elderly inpatients: potential implications for recognition

This retrospective study examined delirium and related confusional diagnoses recorded in patients older than age 60 discharged from Veterans Affairs (VA) acute inpatient units nationally in 1996 (n = 267,947). Only 4% of patients had delirium or related confusional diagnoses recorded. Patients with recorded delirium had significantly higher mortality than did those without recorded delirium or those with other confusional diagnoses ("organic psychoses"); the most common delirium types were dementia with delirium and alcohol intoxication/withdrawal delirium. Organic psychoses patients had the longest lengths of stay and significantly more admissions to nonmedical/surgical units and discharges to nursing homes; almost 20% were African American. The recorded rate of delirium in the VA health system likely underestimates true prevalence and possibly reflects nonrecognition of delirium in many older veterans. Certain motoric and etiologic types of delirium may be more commonly diagnosed and recorded. Future research should prospectively examine recognition of motoric and etiologic delirium subtypes and racial differences in delirium diagnoses.

Complexity in late-life depression: impact of confounding factors on diagnosis, treatment, and outcomes

Late-life depression is a heterogeneous syndrome. Although depression in elderly patients is highly treatable, a number of factors or confounds create complexity in its overall management. Patient factors, such as medical illness, neuropsychiatric comorbidity, and race, may interact with provider factors to make management more complex. Outcomes and services research indicate that these factors, particularly medical illness, affect whether late-life depression is appropriately detected, diagnosed, and treated. Attention to such factors must be included in an agenda for mental health services research, with emphasis on the delivery of effective treatment to elderly patients with depression and improved outcomes in clinical settings.

Depressive syndromes and functional disability in dementia

The goals of this study were to assess (1) the prevalence of major and minor depression in Alzheimer's disease (AD), ischemic vascular dementia (IVD), and mixed dementia (AD/IVD); (2) demographic and clinical variables that may be associated with depression; and (3) the relationship between depression severity and the level of functional impairment and cognitive decline. Demographic variables, depression diagnoses, Mini-Mental State Examination scores, and Blessed Roth Dementia Rating Scale scores were compared in patients with AD (N = 582), IVD (N = 48), and mixed dementia (N = 61) using analysis of variance and linear regression models. Data were collected using standardized rating instruments at the time of the patients' initial evaluations at the University dementia clinics. The results were that (1) depression was related to lower education, (2) major depression was more prevalent in IVD compared to probable AD, and (3) functional impairment was greater in patients with minor or major depression compared to patients without depression. Our data suggest that the level of functional disability in dementia may be related to severity of depression. Additional studies are needed to validate our results and examine the contribution of additional neurobiologic factors to the pathophysiology of depression in dementia.

Cross-cultural comparison of long-term psychiatric patients hospitalized in Tokyo, Japan and Honolulu, Hawaii

The aim of this study is to cross-culturally explore the crucial and often conflicting issues of least restrictive placement of long-term psychiatric patients in Hawaii and Japan, and the need to provide high-quality care for such patients. Policy implications are discussed. A survey instrument facilitated the comparison of records from psychiatric patients hospitalized over 1 year in Hawaii, as of January 1993, and psychiatric patients hospitalized over 1 year in Japan, as of January 1996. The survey instrument was translated and validated for use in both countries. Interrater reliability averaged 0.96. The 30 subjects in Japan were all men (Japanese), and primarily unmarried. The 83 subjects in Hawaii were mostly men (Hawaiian or other ethnic minority), and unmarried. Subjects in Japan tended to be older, hospitalized longer, and were judged to be more dysfunctional than those in Hawaii. No significant relationship was revealed between nursing diagnoses and Axis I diagnoses in either sample. Although significant clinical differences were found between the two groups, the policy issues are similar: how to place patients in the least restrictive environment and how to provide high quality of care given the limited available resources. Nurses in both countries must become more vocal advocates for policy changes to improve the care of long-term patients.

Geropsychiatric consultation for African-American and Caucasian patients

We assessed differences in the referral rates of African-American and Caucasian elderly for geropsychiatric consultation. Reasons for referral, assigned diagnoses, and interventions made were also compared. A retrospective chart review of psychiatric consultations was completed for patients aged 65 years and older for a 2-year period. Significantly more consultations were requested Caucasian elderly (6.2%) than for African-American elderly (3.8%). African-American elderly were referred for evaluation of psychosis significantly more often and for assessment of suicide potential significantly less often than Caucasians. Consultants diagnosed African-American elderly with psychotic disorders, specifically schizophrenia, and dementia significantly more often than Caucasians. Caucasian elderly were significantly more often diagnosed with mood disorders, especially depressive disorders. Interventions/recommendations made for Caucasian and African-American elderly did not differ for the most part. Recommendations for legal measures were suggested for African-American elderly more often than for Caucasians. Differences between Caucasian and African-American elderly were observed in consultation referral rates, reasons for referral, and psychiatric diagnoses made. The potential impact of cultural variables and the racial and age differences between hospital staff and patients may account for some of these findings. Further awareness of the needs of African-American elderly is required.

Screening African-American elderly for the presence of depressive symptoms: a preliminary investigation

Several authors have reported that older African-Americans with multiple medical problems and decreased activities of daily living are at an increased risk of reporting symptoms of depression. African-Americans were more likely to report symptoms of anger, irritability, denial of illness, and to spontaneously report symptoms that did not reflect a change in mood, but rather forbearance of a difficult time or somatic complaints. This paper describes the results of a study to assess the presence of depressive symptoms in older African-American community residents. A new instrument, the Baker Belief Scale, is compared with the Center for Epidemiologic Studies-Depression Scale (CES-D) and the association of medical illnesses, social network, and level of physical function in activities of daily living (ADL). Ninety-six African-American men and women, aged 60 years or older, with equal representation from urban and rural counties in western Tennessee comprised the sample. The sample was stratified, in each of the two counties, into three age categories; 60-69, 70-79, and 80 years and older. A screening battery consisting of the Short Portable Mental Status Questionnaire, the CES-D, the Lubben Social Network Scale, and the Katz ADL were administered to the sample. Current medical illnesses were recorded with demographic data. There was a significant association between the CES-D score and the BBS score for those who screened positive for symptoms of depression. In addition there was a significant relationship between CES-D score and specific medical illnesses, social network, physical function in ADL, and residence (urban vs. rural). Residents who screened positive (N = 19) for depressive symptomatology with CES-D scores of 16 or higher exhibited a higher frequency of hypertension, arteriosclerosis, and circulatory problems than those who tested negative (N = 77). More urban residents (N = 13) than rural residents (N = 6) screened positive for symptoms of depression. Approximately 21% (N = 20) of the 96 respondents had scores of 20 or less on the Lubben Social Network Scale, suggesting a group of "at risk" for social isolation.