Race and beliefs about mental health treatment among anxious primary care patients

Differences in Primary Care Management of Patients With Adult Attention Deficit Hyperactivity Disorder (ADHD) Based on Race and Ethnicity

OBJECTIVE

Examine differences in care patterns around adult ADHD between race (White/Non-White) and ethnic (Hispanic/Non-Hispanic) groups utilizing existing quality measures (QMs), concerning diagnosis, treatment, and medication prescribing.

METHODS

The AAFP National Research Network in partnership with SUNY Upstate Medical used an EHR dataset to evaluate achievement of 10 ADHD QMs. The dataset was obtained from DARTNet Institute and includes 4 million patients of 873 behavioral and primary care practices with at least 100 patients from 2010 to 2020. Patients 18-years or older with adult ADHD were included in this analysis.

RESULTS

White patients and Non-Hispanic/Latinx patients were more likely to achieve these QMs than Non-White patients and Hispanic/Latinx patients, respectively. Differences between groups concerning medication and monitoring demonstrate a disparity for Non-White and Hispanic/Latinx populations.

CONCLUSIONS

Using QMs in EHR data can help identify gaps in ADHD research. There is a need to continue investigating disparities of quality adult ADHD care.

An Integrative Review of Barriers and Facilitators Associated With Mental Health Help Seeking Among Indigenous Populations

OBJECTIVE

Indigenous populations, compared with majority populations, have a reduced likelihood of receiving professional help for mental health, contributing to health disparities. To increase use of and access to mental health services for Indigenous people, specific factors that affect service use need to be examined. An integrative review was undertaken of the barriers to and facilitators of help seeking and service use for Indigenous populations in Canada, the United States, Australia, and the Pacific Islands.

METHODS

Five databases-PsycINFO, PubMed, Web of Science, Social Services Abstracts, and Bibliography of Native North Americans-and gray literature were searched to identify original studies with data specific to Indigenous people. A qualitative analysis of common themes among the studies was conducted, along with a quality appraisal of included articles. Of the 1,010 records identified, the final synthesis included 41 articles.

RESULTS

Six main themes emerged: informal supports, which were often used as a first choice for help seeking compared with formal services; structural obstacles and supports; stigma and shame; self-reliance and uncertainty about services; cultural factors and mistrust of mainstream services; and the need for outreach and information regarding mental illness and services.

CONCLUSIONS

Policy implications include needed structural changes to decrease mistrust of mainstream systems and services and increased funding and resource availability. Along with technology-facilitated treatment, programs for Indigenous people, families, and communities that enhance education and foster positive relationships can serve as a first step toward Indigenous people becoming comfortable with the idea of talking about mental health and with seeking treatment.

The wounds that do not heal: Black expendability and the traumatizing aftereffects of anti-Black police violence

Purpose

The murders of Black people at the hands of police in 2020 have led to global protests that have called on public officials to defund or abolish the police. What has been drowned out in these conversations, however, is the traumatizing aftereffects of anti-Black police violence as a public health crisis. In this paper, I argue that the racial terrorism of anti-Black police violence is a deeply felt wound in Black communities that extends beyond the individuals who directly experience it and that this type of collective trauma must be understood as an urgent public health crisis.

Design/methodology/approach

Using published studies and online commentaries on anti-Black police violence and its mental health impacts in Canada and the United States, this paper examines the mental health impacts of anti-Black police violence at both the individual and community levels.

Findings

A public health response to the traumatizing aftereffects of anti-Black police violence and other forms of state violence must highlight important policy imperatives, such as policies of action focused on improving the public health system. It must also encompass a recognition that the public health crisis of anti-Black police violence is not solvable solely by public health agencies alone. Rather, strategic opportunities to address this crisis arise at every level of governmental interaction, including law enforcement, health care, employment, business, education and the media.

Originality/value

While the impact of anti-Black police violence on the mental health of Black individuals has been emerging in the literature over the last several years, what has been less focused on and what I address in this paper is how the threat of that violence lingers in Black communities long after the protestors have packed up their megaphones, resulting in collective trauma in Black communities.

Racial and Ethnic Disparities in Treatment and Treatment Type for Depression in a National Sample of Medicaid Recipients

OBJECTIVE

The purpose of this secondary data analysis was to describe racial-ethnic disparities in receipt of depression treatment and treatment modality among adult Medicaid beneficiaries with depression from a nationally representative sample-28 states and the District of Columbia-of Medicaid beneficiaries (N=599,421).

METHODS

Medicaid claims data were extracted from the full 2008-2009 Medicaid Analytic Extract file. The primary outcome was type of depression treatment: medication only, therapy only, medication and therapy, and no treatment. The secondary outcome was treatment for depression (yes-no). Crude and adjusted odds ratios (AORs) were generated for univariate and multivariate models, respectively, and 95% confidence intervals of odds ratios and p values were calculated.

RESULTS

There were 599,421 individuals in the sample. Rates of depression treatment were lower for African Americans and Hispanics, compared with Caucasians. Percentages receiving no treatment were 19.9% of African Americans, 15.2% of Hispanics, and 11.9% of Caucasians. After full adjustment, African Americans were about half as likely as Caucasians to receive treatment (AOR=0.52), Hispanics were about a third as likely (AOR=0.71), and those from other racial-ethnic groups were about a fifth as likely (AOR=0.84). Caucasians were more likely than any other group to receive medication only.

CONCLUSIONS

This study contributes to evidence about the intersection of social factors and health outcomes and discusses health care engagement, stigma, and policy drivers of racial-ethnic disparities. The study is the first to identify disparities in rates and types of depression treatment among racial-ethnic subgroups of Medicaid beneficiaries in a nationally representative sample.

Variation of Behavioral Health Care by Behavioral Health Symptom Profile Among a Diverse Group of Pregnant and Parenting Mothers

This study examines the association between behavioral health symptoms and use of behavioral health care (BHC; i.e., past year counseling and/or regular use of psychiatric medication) among a diverse group of mothers of toddlers. Data were from the Fragile Families and Child Wellbeing study (N = 4205 mothers). The association between symptom profiles (i.e., depressive, anxiety, and alcohol and drug dependence) and use of BHC was estimated with logistic regression models. Potential moderation by race/ethnicity was examined. Complex symptom profiles, older age, functional limitations, prior behavioral health symptoms, and having Medicaid were associated with increased BHC use. While BHC use varied by symptom profile (but not by race/ethnicity), BHC use was low across profiles. Pregnant women and women of color were most likely to have unmet needs, underscoring the need to improve screening and management systems for these populations.

A Review of Mental Health and Mental Health Care Disparities Research: 2011-2014

Racial/ethnic minorities in the United States are more likely than Whites to have severe and persistent mental disorders and less likely to access mental health care. This comprehensive review evaluates studies of mental health and mental health care disparities funded by the National Institute of Mental Health (NIMH) to provide a benchmark for the 2015 NIMH revised strategic plan. A total of 615 articles were categorized into five pathways underlying mental health care and three pathways underlying mental health disparities. Identified studies demonstrate that socioeconomic mechanisms and demographic moderators of disparities in mental health status and treatment are well described, as are treatment options that support diverse patient needs. In contrast, there is a need for studies that focus on community- and policy-level predictors of mental health care disparities, link discrimination- and trauma-induced neurobiological pathways to disparities in mental illness, assess the cost effectiveness of disparities reduction programs, and scale up culturally adapted interventions.

Factors Associated with American Indian Mental Health Service Use in Comparison with White Older Adults

OBJECTIVE

Our objective was to identify the factors that impact mental health service use among American Indian (AI) older adults living in South Dakota compared to their White counterparts.

DESIGN AND METHODS

Using a cross-sectional design with 735 participants (n = 502 Whites, n = 233 AIs), we used ordinal regressions to analyze the extent to which predisposing, need, and enabling/hindering factors predicted the level of mental health service utilization.

RESULTS

White older adults used more mental health services as compared with AI older adults. For both groups, more adverse childhood experiences along with prior negative experience with mental health service use were significantly related to an increased level of mental health service use. Compared to their White counterparts, AI older adults who reported a higher level of depressive symptoms, better self-perceived physical health, and a more positive attitude toward mental health services tended to use more mental health services.

CONCLUSIONS

To reduce mental health disparities among AI older adults, community, local government, and academic partners should pay attention to how to encourage the use of mental health services to meet the unique needs of AI older adults.

Improving outcomes for patients with medication-resistant anxiety: effects of collaborative care with cognitive behavioral therapy

BACKGROUND

Many patients with anxiety disorders remain symptomatic after receiving evidence-based treatment, yet research on treatment-resistant anxiety is limited. We evaluated effects of cognitive behavioral therapy (CBT) on outcomes of patients with medication-resistant anxiety disorders using data from the Coordinated Anxiety Learning and Management (CALM) trial.

METHODS

Primary care patients who met study entry criteria (including DSM-IV diagnosis of generalized anxiety disorder, panic disorder, posttraumatic stress disorder, or social anxiety disorder) despite ongoing pharmacotherapy of appropriate type, dose, and duration were classified as medication resistant (n = 227). Logistic regression was used to estimate effects of CALM's CBT program (CALM-CBT; chosen by 104 of 117 medication-resistant patients randomized to CALM) versus usual care (UC; n = 110) on response [≥ 50% reduction of 12-item Brief Symptom Inventory (BSI-12) anxiety and somatic symptom score] and remission (BSI-12 < 6) at 6, 12, and 18 months. Within-group analyses examined outcomes by treatment choice (CBT vs. CBT plus medication management) and CBT dose.

RESULTS

Approximately 58% of medication-resistant CALM-CBT patients responded and 46% remitted during the study. Relative to UC, CALM-CBT was associated with greater response at 6 months (AOR = 3.78, 95% CI 2.02-7.07) and 12 months (AOR = 2.49, 95% CI 1.36-4.58) and remission at 6, 12, and 18 months (AORs = 2.44 to 3.18). Patients in CBT plus medication management fared no better than those in CBT only. Some evidence suggested higher CBT dose produced better outcomes.

CONCLUSIONS

CBT can improve outcomes for patients whose anxiety symptoms are resistant to standard pharmacotherapy.

Racial-Ethnic Differences in Psychiatric Diagnoses and Treatment Across 11 Health Care Systems in the Mental Health Research Network

OBJECTIVE

The objective of this study was to characterize racial-ethnic variation in diagnoses and treatment of mental disorders in large not-for-profit health care systems.

METHODS

Participating systems were 11 private, not-for-profit health care organizations constituting the Mental Health Research Network, with a combined 7,523,956 patients age 18 or older who received care during 2011. Rates of diagnoses, prescription of psychotropic medications, and total formal psychotherapy sessions received were obtained from insurance claims and electronic medical record databases across all health care settings.

RESULTS

Of the 7.5 million patients in the study, 1.2 million (15.6%) received a psychiatric diagnosis in 2011. This varied significantly by race-ethnicity, with Native American/Alaskan Native patients having the highest rates of any diagnosis (20.6%) and Asians having the lowest rates (7.5%). Among patients with a psychiatric diagnosis, 73% (N=850,585) received a psychotropic medication. Non-Hispanic white patients were significantly more likely (77.8%) than other racial-ethnic groups (odds ratio [OR] range .48-.81) to receive medication. In contrast, only 34% of patients with a psychiatric diagnosis (N=548,837) received formal psychotherapy. Racial-ethnic differences were most pronounced for depression and schizophrenia; compared with whites, non-Hispanic blacks were more likely to receive formal psychotherapy for their depression (OR=1.20) or for their schizophrenia (OR=2.64).

CONCLUSIONS

There were significant racial-ethnic differences in diagnosis and treatment of psychiatric conditions across 11 U.S. health care systems. Further study is needed to understand underlying causes of these observed differences and whether processes and outcomes of care are equitable across these diverse patient populations.

Illness perception, help-seeking attitudes, and knowledge related to obsessive-compulsive disorder across different ethnic groups: a community survey

PURPOSE

Despite similar prevalence rates across ethnicities, ethnic minorities with obsessive-compulsive disorder (OCD) are under-represented in research and clinical settings. The reasons for this disproportion have been sparsely studied. We explored potential differences in illness perception, help-seeking attitudes, illness knowledge, and causal attributions that could help explain the lower uptake of treatment for OCD amongst ethnic minorities.

METHODS

Two-hundred and ninety-three parents (139 White British, 61 Black African, 46 Black Caribbean, and 47 Indian) were recruited from the general population in South-East London, UK. Using a text vignette methodology, participants completed a survey including questions on illness perception, help-seeking attitudes, OCD knowledge, and causal attributions.

RESULTS

The groups did not differ in socio-demographic characteristics and family history of OCD. White British parents perceived that the OCD difficulties would have more negative impact on their children and that treatment would be more helpful, compared to the ethnic minorities; the largest differences were observed between White British and Indian parents. Ethnic minorities were more prone to say that would seek help from their religious communities. Black African parents were more in favor of not seeking help for the described difficulties and, in general, perceived more treatment barriers. White British parents seemed to be better informed about OCD than ethnic minority parents.

CONCLUSIONS

The results offer some plausible explanations for the large inequalities in access to services amongst ethnic minorities with OCD. Clinicians and policy-makers need to be aware of these socio-cultural factors when designing strategies to encourage help-seeking behaviors in these populations.

Ethnic inequalities in the use of secondary and tertiary mental health services among patients with obsessive-compulsive disorder

BACKGROUND

Obsessive-compulsive disorder (OCD) has similar prevalence rates across ethnic groups. However, ethnic minorities are underrepresented in clinical trials of OCD. It is unclear whether this is also the case in clinical services.

AIMS

To explore whether ethnic minorities with OCD are underrepresented in secondary and tertiary mental health services in the South London and Maudsley (SLaM) NHS Foundation Trust.

METHOD

The ethnic distribution of patients with OCD seen between 1999 and 2013 in SLaM (n = 1528) was compared with that of the general population in the catchment area using census data. A cohort of patients with depression (n = 22 716) was used for comparative purposes.

RESULTS

Ethnic minorities with OCD were severely underrepresented across services (-57%, 95% CI -62% to -52%). The magnitude of the observed inequalities was significantly more pronounced than in depression (-29%, 95% CI -31% to -27%).

CONCLUSIONS

There is a clear need to understand the reasons behind such ethnic inequalities and implement measures to reduce them.

Screening for depression in the primary care population

Despite strong efforts, the diagnosis and treatment of depression bring many challenges in the primary care setting. Screening for depression has been shown to be effective only if reliable systems of care are in place to ensure appropriate treatment by clinicians and adherence by patients. New evidence-based models of care for depression exist, but spread has been slow because of inadequate funding structures and conflicts within current clinical culture. The Affordable Care Act introduces potential opportunities to reorganize funding structures, conceivably leading to increased adoption of these collaborative care models. Suicide screening remains controversial.

Screening for depression in the primary care population

Despite strong efforts, the diagnosis and treatment of depression bring many challenges in the primary care setting. Screening for depression has been shown to be effective only if reliable systems of care are in place to ensure appropriate treatment by clinicians and adherence by patients. New evidence-based models of care for depression exist, but spread has been slow because of inadequate funding structures and conflicts within current clinical culture. The Affordable Care Act introduces potential opportunities to reorganize funding structures, conceivably leading to increased adoption of these collaborative care models. Suicide screening remains controversial.