A longitudinal study of the use of mental health services by persons with serious mental illness: do Spanish-speaking Latinos differ from English-speaking Latinos and Caucasians?

Perspectives of Individuals With Serious Mental Illness on a Reverse-Colocated Care Model: A Qualitative Study

OBJECTIVE

Individuals with serious mental illness experience excess mortality related to general medical comorbidities. Reverse-integrated and reverse-colocated models of care have been proposed as a system-level solution. Such models integrate primary care services within behavioral health settings. Further understanding of consumer perspectives on these models is needed to ensure that models adequately engage consumers on the basis of their expressed needs. This qualitative study examined the perspectives of English- and Spanish-speaking individuals with serious mental illness on their current experience with the management of their medical care and on a hypothetical reverse-colocated care model.

METHODS

Semistructured interviews were conducted in a purposive sample of 30 individuals with serious mental illness recruited from two outpatient mental health clinics affiliated with a comprehensive community-based program. The interview assessed the participant's current experience with the management of their health care, followed by a vignette describing a reverse--colocated care model and questions to elicit the participant's reaction to the vignette. An inductive thematic analysis was employed.

RESULTS

Consumers expressed positive views of the potential for working with trusted staff, increased communication, and access to care through reverse colocation. Reflections on current health management experience were notable for an emphasis on self-efficacy and receipt of support for self-management strategies from mental health clinicians.

CONCLUSIONS

Study findings add to prior literature indicating support for assistance with management of general medical health in the mental health setting among individuals with serious mental illness. Key themes similar to those in previous studies generate hypotheses for further evaluation.

Qualitative Evaluation of a Peer Navigator Program for Latinos with Serious Mental Illness

Peer navigator programs (PNP) may help reduce physical health disparities for ethnic minorities with serious mental illness (SMI). However, specific aspects of PNP that are important to peer navigators and their clients are under-researched. A qualitative study explored the perspectives of service users (n = 15) and peer navigators (n = 5) participating in a randomized controlled trial of a PNP for Latinos with SMI. Results show PN engagement with service users spans diverse areas and that interactions with peers, trust, and accessibility are important from a service user perspective. PNs discussed needs for high-quality supervision, organizational support, and additional resources for undocumented Latinos.

The Healthcare Needs of Latinos with Serious Mental Illness and the Potential of Peer Navigators

Latinos with serious mental illness get sick and die much younger than other adults. In this paper, we review findings of a community based participatory research project meant to identify important healthcare needs, barriers to these needs, solutions to the barriers, and the promise of peer navigators as a solution. Findings from focus groups reflected general concerns of people with mental illness (e.g., insurance, engagement, accessibility) and Latinos with serious mental illness (e.g., immigration, language, and family). Feedback and analyses especially focused on the potential of peer navigators. Implications of these findings for integrated care of Latinos with serious mental illness are discussed.

Prioritizing the healthcare needs of Latinos with mental illness

Latinos with serious mental illness have higher morbidity and mortality rates than same age peers. In this paper, we review findings of a community based participatory research project meant to identify important health needs of this group, barriers to these needs, solutions to the barriers and the promise of peer navigators as a solution. Findings from a prior qualitative study yielded 84 themes related to needs, barriers and solutions. These findings were transposed into individual items, to which 122 Latino participants with mental illness responded using a 7-point importance scale. Results showed item importance means ranging from 4.34 to 5.47, with counseling/therapy services and mental health treatment topping the list for healthcare needs. Analyses also examined differences between those born in the USA versus those born elsewhere. Latinos who were native to the USA differed significantly from those born abroad in over one quarter of importance ratings. Implications of these findings for integrated care of Latinos with serious mental illness are discussed.

Examining patient race and area predictors of inpatient admission for schizophrenia among hospital users in California

According to international research African-Caribbean and Black African populations have increased risk of hospitalization for schizophrenia, compared to Whites. Less is known about admission risk for other racial-ethnic groups. This study investigated racial-ethnic differences in hospital admission for schizophrenia in California. It also investigated the influence of area social factors (racial-ethnic neighborhood composition, and per capita income) and health service factors (presence of primary care clinics). The study sample included individuals admitted to a California hospital during 1990-2005 with a primary appendicitis related diagnosis, and without a prior or concurrent indication of schizophrenia. The adjusted logistic model examined how patient racial-ethnicity (White, Black, Hispanic, Other), other personal, area social characteristics and presence of primary care clinics influenced hospital admissions for schizophrenia. Black individuals were almost twice as likely as Whites to be admitted while Hispanics and Other race individuals were less to be admitted. In addition, male sex, having more comorbidities and living in areas with greater proportions of non-Whites increased risk. The increased risk for Blacks compared to Whites was consistent with the existing literature. However, this is among the first studies to report that Hispanics had a reduced risk of admission for schizophrenia, compared to Whites. Future studies may want to include a broader range of health services to better understand patterns of care use among individuals with schizophrenia.

Disparities in Treatment and Service Utilization Among Hispanics and Non-Hispanic Whites with Bipolar Disorder

OBJECTIVES

Due to the serious and recurrent nature of bipolar disorder, continuous long-term medication treatment is typically recommended. Little is known about whether these treatment recommendations are effectively implemented for Hispanics. This study examined differences in mood stabilizer use and mental health service utilization between adult English-speaking Hispanic and non-Hispanic white respondents with bipolar disorder.

METHODS

The sample included 163 participants with lifetime bipolar I and II disorders in the National Comorbidity Survey Replication. Demographics, symptom presentation, and acculturation were examined as covariates.

RESULTS

None of the 26 Hispanic respondents were taking mood-stabilizing medication, compared to 21 % of non-Hispanic whites, and Hispanics were less likely to receive medications for emotional problems, see a professional for manic episodes, or attend psychotherapy. Even after accounting for differences in symptom profiles and sociodemographics, ethnicity continued to be a significant predictor of mood stabilizer use and psychotherapy attendance. There was a non-significant trend toward lower acculturation among Hispanics being associated with even poorer service utilization.

CONCLUSIONS

No Hispanics were receiving minimally adequate treatment for their bipolar disorder. Future research should focus on identifying the barriers that lead to these stark ethnic disparities in treatment.

Depression, Help-Seeking and Self-Recognition of Depression among Dominican, Ecuadorian and Colombian Immigrant Primary Care Patients in the Northeastern United States

Latinos, the largest minority group in the United States, experience mental health disparities, which include decreased access to care, lower quality of care and diminished treatment engagement. The purpose of this cross-sectional study of 177 Latino immigrants in primary care is to identify demographic factors, attitudes and beliefs, such as stigma, perceived stress, and ethnic identity that are associated with depression, help-seeking and self-recognition of depression. Results indicated that 45 participants (25%) had depression by Patient Health Questionnaire (PHQ-9) criteria. Factors most likely to be associated with depression were: poverty; difficulty in functioning; greater somatic symptoms, perceived stress and stigma; number of chronic illnesses; and poor or fair self-rated mental health. Fifty-four people endorsed help-seeking. Factors associated with help-seeking were: female gender, difficulty in functioning, greater somatic symptoms, severity of depression, having someone else tell you that you have an emotional problem, and poor or fair self-rated mental health. Factors most likely to be associated with self-recognition were the same, but also included greater perceived stress. This manuscript contributes to the literature by examining attitudinal factors that may be associated with depression, help-seeking and self-recognition among subethnic groups of Latinos that are underrepresented in research studies.

Predisposing, enabling and need correlates of mental health treatment utilization among homeless men

There is significant unmet need for mental health treatment among homeless men, but little is known about the correlates of treatment utilization in this population. Within the framework of the Behavioral Model for Vulnerable Populations, this study examines predisposing, enabling and need factors that may be associated with mental health care utilization. Participants were a representative sample of 305 heterosexually active homeless men utilizing meal programs in the Skid Row region of LA. Logistic regression examined the association between predisposing, enabling and need factors and past 30 day mental health service utilization on Skid Row. Results indicated that while need, operationalized as positive screens for posttraumatic stress disorder or depression, was associated with recent mental health care utilization, predisposing and enabling factors were also related to utilization. African-American homeless men, and those men who also reported substance abuse treatment and drop-in center use, had increased odds of reporting mental health care utilization.

The efficacy of a behavioral activation intervention among depressed US Latinos with limited English language proficiency: study protocol for a randomized controlled trial

Background

Major depressive disorder is highly prevalent among Latinos with limited English language proficiency in the United States. Although major depressive disorder is highly treatable, barriers to depression treatment have historically prevented Latinos with limited English language proficiency from accessing effective interventions. The project seeks to evaluate the efficacy of behavioral activation treatment for depression, an empirically supported treatment for depression, as an intervention that may address some of the disparities surrounding the receipt of efficacious mental health care for this population.

Methods/design

Following a pilot study of behavioral activation treatment for depression with 10 participants which yielded very promising results, the current study is a randomized control trial testing behavioral activation treatment for depression versus a supportive counseling treatment for depression. We are in the process of recruiting 60 Latinos with limited English language proficiency meeting criteria for major depressive disorder according to the Diagnostic and Statistical Manual of Mental Disorders 4^th and 5^th Edition for participation in a single-center efficacy trial. Participants are randomized to receive 10 sessions of behavioral activation treatment for depression (n = 30) or 10 sessions of supportive counseling (n = 30). Assessments occur prior to each session and at 1 month after completing treatment. Intervention targets include depressive symptomatology and the proposed mechanisms of behavioral activation treatment for depression: activity level and environmental reward. We will also examine other factors related to treatment outcome such as treatment adherence, treatment satisfaction, and therapeutic alliance.

Discussion

This randomized controlled trial will allow us to determine the efficacy of behavioral activation treatment for depression in a fast-growing, yet highly underserved population in US mental health services. The study is also among the first to examine the effect of the proposed mechanisms of change of behavioral activation treatment for depression (that is, activity level and environmental reward) on depression over time. To our knowledge, this is the first randomized controlled trial to compare an empirical-supported treatment to a control supportive counseling condition in a sample of depressed, Spanish-speaking Latinos in the United States.

Trial registration

Clinical Trials Register: NCT01958840; registered 8 October 2013.

Health of elderly Mexican American adults and family caregiver distress

Using newly available data on family caregivers from a large epidemiological study of elderly Mexican-origin adults (Hispanic Established Population for the Epidemiologic Study of the Elderly [HEPESE], 2010/2011), we identify which types of impairment (functional, psychological, and cognitive) in the elderly individual are associated with family caregiver depressive symptoms. Results from ordinary least squares regressions using 626 caregiver-care recipient dyads demonstrate that more severe mobility limitations (Performance-Oriented Mobility Assessment), social disability (instrumental activities of daily living), neuropsychiatric disturbances related to cognitive decline (Neuropsychiatric Inventory), and depressive symptoms in the elderly subject are positively associated with caregiver psychological distress. Perceived social stress partially accounts for these associations. We also identify certain segments of this caregiver population that are especially vulnerable to burden when caring for a family member with high levels of impairment, namely female and low-income caregivers. These vulnerabilities should be the focus of intervention efforts to reduce stress and improve the emotional and psychological well-being of Mexican-origin caregivers.

Pilot of the brief behavioral activation treatment for depression in latinos with limited english proficiency: preliminary evaluation of efficacy and acceptability

Latinos with limited English proficiency (LEP) experience multiple barriers to accessing efficacious mental health treatments. Using a stage model of behavior therapy research, this Stage I investigation evaluated the Brief Behavioral Activation Treatment for Depression (BATD), an intervention that may be well equipped to address existing treatment barriers. A sample of 10 Latinos with LEP and depressive symptomatology participated in a 10-session, direct (i.e., literal) Spanish-language translation of BATD, with no other cultural modifications. Participants were assessed at each session for depressive symptomatology and for the proposed BATD mechanisms: activity engagement and environmental reward. One month after treatment, participants were reassessed and interviewed to elicit feedback about BATD. Hierarchical linear model analyses were used to measure BATD outcomes. Results showed depressive symptomatology decreased (p<.001), while both activation (p=.04) and environmental reward (p=.02) increased over the course of BATD. Increases in activation corresponded concurrently with decreases in depression (p=.01), while environmental reward preceded decreases in depressive symptomatology (all p's ≤ .04). Follow-up analyses revealed sustained clinical gains in depression and activation, and an increase in environmental reward at follow-up. Participant interviews conducted 1 month after treatment conclusion indicated that BATD is an acceptable treatment for our sample of interest. Despite the limitations inherent in a study restricted to a sample of 10, preliminary outcomes of this Stage I research suggest that members of this otherwise underserved group showed improvements in depressive symptomatology and are willing to participate in and adhere to BATD. The study's positive outcomes suggest that a Stage II randomized clinical trial is a logical next step.

Disordered eating and body image in Chinese and Caucasian students in the United States

OBJECTIVE

This study evaluated the roles of exposure to Western culture and language choice and gender differences in disordered eating symptoms in Chinese and Caucasian students.

METHOD

796 Caucasian and 194 Chinese students completed measures of eating disorder symptoms, body image, and body esteem. Participants chose their survey language (English or Chinese).

RESULTS

Caucasian women had higher levels of body dissatisfaction than Chinese women. Women of both ethnicities reported more disordered eating symptoms and body dissatisfaction than men; these differences were smaller for the Chinese group. Differences emerged on certain dimensions of body esteem between Chinese women who responded in Chinese and those who responded in English.

CONCLUSIONS

There were few differences between ethnicities, suggesting that mechanisms other than Western culture play a role. Cultural variables may account for the degree of intra-ethnic gender differences. Individuals who complete studies in their native language may differ from their English-responding counterparts in areas of body esteem.

Official language minority communities in Canada: is linguistic minority status a determinant of mental health?

OBJECTIVES

Language has been identified as a determinant of mental health. Within Canada, individuals may speak an official language and still belong within the linguistic minority (Francophones outside Quebec and Anglophones within Quebec). The objectives of this study were to compare mental health problems between minority and majority official language communities, and examine the association between official language minority and mental health problems.

METHODS

Data from the Canadian Community Health Survey, Cycle 1.2 were used to make two comparisons: Francophones to Anglophones within Quebec, and Francophones to Anglophones outside Quebec. Twelve-month and lifetime prevalences of mental disorders (major depressive episode, anxiety disorders, and alcohol/substance abuse/dependence) and mental health indices were compared. Logistic regression analysis examined whether official language minority status was a determinant of mental health.

RESULTS

Mental health between minority and majority language groups was similar. Official language minority status was not a significant determinant of mental health. Self-rated mental health indices varied between groups. In some cases, minority language groups reported lower levels of life satisfaction (minority Anglophones versus majority Francophones), while in other cases more majority Anglophones reported poor life satisfaction and mental health (majority Anglophones versus minority Francophones).

CONCLUSIONS

Overall, few differences were found between language groups, though variations in self-rated mental health indices were observed. In order to better understand the role of context in determining health outcomes, future research should examine mental health problems among official language minority groups provincially to help stakeholders in directing resources and programs to populations in most need.

Crisis visits and psychiatric hospitalizations among patients attending a community clinic in rural Southern California

Ethnic minorities from disadvantaged socioeconomic backgrounds report increased utilization of mental health emergency services; however findings have been inconsistent across ethnic/racial groups. In this study we describe patients who present to a rural crisis unit in Southern California, examine rates of psychiatric hospitalizations across ethnic/racial groups, and investigate factors that are associated with increased psychiatric hospitalizations in this sample. This is a retrospective study of 451 racially and ethnically diverse patients attending a crisis unit in Imperial County, California. Chart review and data abstraction methods were used to characterize the sample and identify factors associated with psychiatric crises and subsequent hospitalizations. The sample was predominantly Latino/Hispanic (58.5%). Based on chart review, common psychosocial stressors which prompted a crisis center visit were: (a) financial problems; (b) homelessness; (c) partner or family conflict; (d) physical and health problems; (e) problems at school/work; (f) medication compliance; (g) aggressive behavior; (h) delusional behavior; (i) addiction and (j) anxiety/depression. Bivariate analyses revealed that Hispanics had a disproportionately lower rate of psychiatric hospitalizations while African Americans had a higher rate. Multivariate analyses which included demographic, clinical and psychosocial stressor variables revealed that being African American, having a psychotic disorder, and presenting as gravely disabled were associated with a higher likelihood of hospitalization while partner/family conflict was associated with a lesser likelihood in this rural community. These data elucidate the need for longitudinal studies to understand the interactions between psychosocial stressors, ethnicity and social support as determinants of psychiatric hospitalizations.

Racial Disparities in Mental Health Outcomes After Psychiatric Hospital Discharge Among Individuals With Severe Mental Illness

Racial disparities in mental health outcomes have been widely documented in non-institutionalized community psychiatric samples, but few studies have specifically examined the effects of race among individuals with the most severe mental illnesses. A sample of 925 individuals hospitalized for severe mental illness were followed for a year after hospital discharge to examine the presence of disparities in mental health outcomes between African American and White individuals diagnosed with a severe psychiatric condition. Results from a series of individual growth curve models indicated that African American individuals with severe mental illness experienced significantly less improvement in global functioning, activation and anergia symptoms, and were less likely to return to work in the year following hospitalization. Racial disparities persisted after adjustment for sociodemographic and diagnostic confounders, and were largely consistent across gender, socioeconomic status, and psychiatric diagnosis. Implications for social work research and practice with minorities with severe mental illness are discussed.

Factors associated with use of community mental health services by schizophrenia patients using multilevel analysis

Background

Persons with schizophrenia and related disorders may be particularly sensitive to a number of determinants of service use, including those related with illness, socio-demographic characteristics and organizational factors. The objective of this study is to identify factors associated with outpatient contacts at community mental health services of patients with schizophrenia or related disorders.

Methods

This cross-sectional study analyzed 1097 patients. The main outcome measure was the total number of outpatient consultations during one year. Independent variables were related to socio-demographic, clinical and use of service factors. Data were collected from clinical records.

Results

The multilevel linear regression model explained 46.35% of the variance. Patients with significantly more contacts with ambulatory services were not working and were receiving welfare benefits (p = 0.02), had no formal education (p = 0.02), had a global level of severity of two or three (four being the most severe) (p < 0.001), with one or more inpatient admissions (p < 0.001), and in contact with both types of professional (nurses and psychiatrists) (p < 0.001). The patients with the fewest ambulatory contacts were those with diagnoses of persistent delusional disorders (p = 0.04) and those who were attended by four of the 13 psychiatrists (p < 0.001).

Conclusions

As expected, the variables that explained the use of community service could be viewed as proxies for severity of illness. The most surprising finding, however, was that a group of four psychiatrists was also independently associated with use of ambulatory services by patients with schizophrenia or related disorders. More research is needed to carefully examine how professional support networks interact to affect use of mental health.

Risk for maternal harsh parenting in high-risk families from birth to age three: does ethnicity matter?

Child maltreatment prevention programs typically identify at-risk families by screening for risk with limited consideration of how risk might vary by ethnicity. In this study, longitudinal data from mothers who participated in a randomized clinical trial of a home-visitation, child maltreatment prevention program (N = 262) were examined to determine whether risk for harsh parenting differed among mothers who identified themselves as Spanish-speaking Latinas (n = 64), English-speaking Latinas (n = 102), or non-Latina Caucasians (n = 96). The majority of the participants were first-time mothers (58.4%), and the average age of all participants was 23.55 years (SD = 6.04). At the time of their infants' births, the Spanish-speaking Latina mothers demonstrated higher SES risk, whereas the English-speaking Latina and non-Latina Caucasian mothers demonstrated higher psychosocial risk. Three years later, the English-speaking Latina and non-Latina Caucasian mothers reported harsher parenting behaviors than the Spanish-speaking Latina mothers. The need for prevention programs to consider how risk and protective factors differ by ethnic group membership when identifying at-risk mothers is discussed.

Telephone depression care management for Latino Medicaid health plan members: a pilot randomized controlled trial

The objective of this pilot study was to provide a preliminary test of feasibility, acceptability, and efficacy of telephone depression care management among Latino Medicaid health plan members. Thirty-eight depressed primary care patients were enrolled in a pilot randomized trial of telephone depression care management + treatment as usual (TAU) versus TAU only. Bilingual care managers conducted care management for 3 months following an antidepressant prescription. For 1 year, research staff attempted to contact 929 potentially eligible members and enrolled 38. Qualitative analyses suggested that, of the participants we interviewed, most expressed satisfaction with the program. Participants suggested ways to improve recruitment, such as face-to-face contact. When compared with the group receiving TAU, there was a trend for the intervention group to experience less depression in time. This pilot study suggests that this program may be promising; however, there is need to investigate ways to better reach those who might find the program helpful.

Utilization of psychiatric services among low-income HIV-infected patients with psychiatric comorbidity

INTRODUCTION

HIV-infected individuals face a tremendous burden of psychiatric comorbidity. This study evaluates a community health care system's effort to screen for psychiatric disorders among patients at an HIV clinic and evaluate adherence to psychiatric service utilization.

METHODS

Standardized screening measures were used to identify participants who met diagnostic symptom criteria for post-traumatic stress disorder (PTSD), acute stress disorder (ASD) and depression. All participants who screened positive were referred for psychiatric follow-up. Rates of utilization were measured and barriers to adherence were investigated.

RESULTS

Of the 210 participants, 118 patients met screening criteria for PTSD, ASD, and/or depression, and 116 of these had medical records available for review. Of the 116 patients with psychiatric comorbidity, 46.6% saw a psychiatrist and/or were prescribed a psychiatric medication. Thirty-two percent of Latinos, 40.5% of African Americans, and 38.5% of heterosexuals utilized referred psychiatric services, and these rates were significantly less than their counterparts. One hundred patients were seen by a social worker.

DISCUSSION

While a large burden of psychiatric comorbidity exists among this population of HIV-positive patients, only half adhered to recommended psychiatric services referrals. Further research is warranted to examine cost-effective interventions to maximize psychiatric screening, referral, and follow-up with mental health services in this vulnerable population.

Community-based mental health service utilization among low-income Latina immigrants

Latina immigrants may be at increased risk for mental illnesses, but have less access to and seek mental health services less often than Black and White counterparts. Guided by the Andersen Behavioral Model of service utilization, the current study employed a medical chart review to elucidate factors associated with use of mental health services at a community health center. Of the clients referred for mental health services, only 36% followed through on the referral. Older age, use of case management services, and depressive symptomatology were predictors of attending mental health services. These findings have implications for community health and mental health providers.

Depression treatment preferences of Hispanic individuals: exploring the influence of ethnicity, language, and explanatory models

PURPOSE

there is uncertainty regarding Hispanic individuals' depression treatment preferences, particularly regarding antidepressant medication, the most available primary care option. We assessed whether this uncertainty reflected heterogeneity among subgroups of Hispanic persons and investigated possible mechanisms. Specifically, we examined factors associated with medication preferences in non-Hispanic white and Spanish-speaking and English-speaking Hispanic persons.

METHODS

we analyzed data from a follow-up telephone interview of 839 non-Hispanic white and 139 Hispanic respondents originally surveyed via the 2008 California Behavioral Risk Factor Surveillance System. Measures included treatment preferences (for treatment plans including vs not including antidepressants); depression history and current symptoms; sociodemographics; and psychological measures.

RESULTS

compared with non-Hispanic white respondents (adjusting for age, sex, history of depression diagnosis, and current depression symptoms), Spanish-speaking Hispanic (adjusted odds ratio [AOR] 0.41; 95% CI, 0.19-0.90) but not English-speaking Hispanic (AOR, 1.18; 95% CI, 0.60-2.33) respondents had a lower preference for antidepressant inclusive options. Endorsing a biomedical explanation of depression was associated with a preference for antidepressant inclusive options (AOR, 4.76; 95% CI, 3.13-7.14) for all respondents and accounted for the effect of Spanish-language interview. Accounting for other factors did not change these relationships, although older age and history of depression diagnosis remained significant predictors of antidepressant inclusive treatment preference for all respondents.

CONCLUSIONS

Spanish-language interview and less belief in a biomedical explanation for depression were associated with Hispanic respondents' lower preferences for pharmacologic treatment of depression; ethnicity was not. Understanding treatment preferences and illness beliefs could help optimize depression treatment in primary care.

English language proficiency and mental health service use among Latino and Asian Americans with mental disorders

OBJECTIVE

The impact of language proficiency as a potential contributor to ethnic disparities in mental health care has received less attention than other factors. Data from the National Latino and Asian American Study were examined to assess the impact of limited English proficiency (LEP) on access to and quality of mental health care for community-dwelling Latino and Asian Americans with mental disorders.

METHODS

English-proficient (EP) and LEP individuals with mental disorders were compared on lifetime use of healthcare services for a mental disorder, duration of untreated disorders, receipt of minimally adequate care, and barriers to treatment (eg, lack of identification of need for treatment, language barriers, and embarrassment or discomfort related to treatment).

RESULTS

Compared with EP individuals, LEP individuals with mental disorders were significantly less likely to identify a need for mental health services, experience longer duration of untreated disorders, and use fewer healthcare services for mental disorders, particularly specialty mental health care. Receipt of minimally adequate care did not differ significantly by language proficiency. Embarrassment and discomfort were not more common among LEP individuals. Perceived need for treatment predicted lifetime mental healthcare use, whereas embarrassment and discomfort did not.

CONCLUSIONS

Among Latino and Asian Americans with mental disorders, LEP contributes to disparities in access to care and longer duration of untreated disorders. Potential disparities in quality of care were difficult to detect in the context of low overall rates of mental healthcare use and quality of care among both LEP and EP individuals.

Acculturation and depressive symptoms among Mexican American elders new to the caregiving role: results from the Hispanic-EPESE

OBJECTIVE

The purpose of this study was to identify characteristics associated with becoming a caregiver among Mexican American (MA) elders and to examine predictors of depressive symptoms among the new caregivers 2 years later.

METHOD

Drawn from the Hispanic Established Populations for Epidemiologic Studies of the Elderly (H-EPESE), 152 MA recent caregivers and 2,023 other MAs were compared. Residualized change regression analysis was conducted.

RESULTS

At baseline, MAs who had recently become caregivers exhibited a significantly greater number of depressive symptoms compared to those who had not. Controlling for background characteristics, physical health, social support, and baseline depressive symptoms, regression analysis revealed that 2 years later higher acculturation was related to a greater number of depressive symptoms among those who at baseline were new caregivers.

DISCUSSION

Better knowledge of the within-group differences among MA elderly caregivers, especially with respect to acculturation, may better inform interventions for this at-risk group.

Differences in prevalence and treatment of bipolar disorder among immigrants: results from an epidemiologic survey

OBJECTIVE

To add to the limited data on the prevalence, clinical characteristics, and treatment of bipolar disorder (BD) among immigrants.

METHOD

Data were obtained from a large epidemiologic survey, the Canadian Community Health Survey-Mental Health and Well-Being (CCHS 1.2). Lifetime prevalence rates of BD were compared between immigrant and nonimmigrant respondents. Among BD subjects (n = 831), sociodemographic, clinical, and mental health treatment use variables were compared based on immigrant status. Logistic regression was used to determine the correlates of lifetime contact with a mental health professional and 12-month psychotropic medication use.

RESULTS

Lifetime prevalence rate of CCHS 1.2-defined BD was significantly lower among immigrant, compared with nonimmigrant, participants (1.50% and 2.27%, P = 0.01). There were few sociodemographic or clinical differences, yet immigrants with BD were significantly less likely to report any lifetime contact with mental health professionals (OR = 0.25, 95% CI 0.13 to 0.50, P < 0.001). Past-year psychotropic medication use was numerically lower among immigrants with BD (24.5% and 41.0%); however, this did not reach statistical significance when controlling for other factors (OR = 0.49, 95% CI 0.24 to 1.01, P = 0.05).

CONCLUSIONS

Based on the results of this study, there are in the range of 56 000 to 104 000 immigrants with BD in Canada. Further efforts are needed to better understand and address the barriers to mental health treatment use among immigrants who have BD.

Effect of racial and ethnic composition of neighborhoods in San Francisco on rates of mental health-related 911 calls

OBJECTIVE

This study investigated the association between the racial and ethnic residential composition of San Francisco neighborhoods and the rate of mental health-related 911 calls.

METHODS

A total of 1,341,608 emergency calls (28,197 calls related to mental health) to San Francisco's 911 system were made from January 2001 through June 2003. Police sector data in the call records were overlaid onto U.S. census tracts to estimate sector demographic and socioeconomic characteristics. Negative binomial regression was used to estimate the association between the percentage of black, Asian, Latino, and white residents and rates of mental health-related calls.

RESULTS

A one-point increase in a sector's percentage of black residents was associated with a lower rate of mental health-related calls (incidence rate ratio=.99, p<.05). A sector's percentage of Asian and Latino residents had no significant effect.

CONCLUSIONS

The observed relationship between the percentage of black residents and mental health-related calls is not consistent with known emergency mental health service utilization patterns.

Examining Latino differences in mental healthcare use: the roles of acculturation and attitudes towards healthcare

Latinos are less likely to use mental health services compared to non-Latino whites, but little research has examined the relative contribution of acculturation and attitudes towards healthcare. In the current study, we analyze data from a nationally representative sample of Mexicans, Cubans, Puerto Ricans and non-Latino whites from the 2002-2003 Medical Expenditure Panel Survey (n = 30,234). Findings show different utilization patterns in use of specialty, non-specialty, and any type of mental healthcare across the three Latino subgroups. The predictive efficacy of acculturation variables on ethnic group differences varies by subgroup. Self-reliant attitudes towards healthcare are associated with lower use, but these attitudes do not explain the ethnic gaps in use.

Adherence to antipsychotics among Latinos and Asians with schizophrenia and limited English proficiency

OBJECTIVES

The authors examined data for 7,784 Latino, Asian, and non-Latino white Medi-Cal beneficiaries with schizophrenia to determine the relationship between patients' preferred language for mental health services--English, Spanish, or an Asian language--and their adherence to treatment with antipsychotic medications.

METHODS

Data reflected 31,560 person-years from 1999 to 2004. Pharmacy records were analyzed to assess medication adherence by use of the medication possession ratio (MPR). Clients were defined as nonadherent (MPR<.5), partially adherent (MPR=.5-<.8), or adherent (MPR=.8-1.1) or as an excess filler of prescriptions (MPR<1.1). Regression models were used to examine adherence, hospitalization, and costs by race-ethnicity and language status.

RESULTS

Latinos with limited English proficiency were more likely than English-proficient Latinos to be medication adherent (41% versus 36%; p<.001) and less likely to be excess fillers (15% versus 20%; p<.001). Asians with limited English proficiency were less likely than English-proficient Asians to be adherent (40% versus 45%; p=.034), more likely to be nonadherent (29% versus 22%; p<.001), and less likely to be excess fillers (13% versus 17%; p=.004). When analyses controlled for adherence and comorbidities, clients with limited English proficiency had lower rates of hospitalization and lower health care costs than English-proficient and white clients.

CONCLUSIONS

Adherence to antipsychotic medications varied by English proficiency among and within ethnic groups. Policies supporting the training of bilingual and multicultural providers from ethnic minority groups and interventions that capitalize on patients' existing social support networks may improve adherence to treatment in linguistically diverse populations.

Toward an adaptation of interpersonal psychotherapy for Hispanic patients with DSM-IV major depressive disorder

BACKGROUND

Spanish-speaking individuals comprise a growing percentage of the United States population. They have greater difficulty than most in accessing and remaining in psychiatric treatments, including psychotherapy, their stated preference. The literature on cultural competence in treating Hispanic patients provides few details of psychotherapeutic adaptations.

OBJECTIVE

This article, based on interpersonal psychotherapy (IPT) supervision for a low-socioeconomic sample of monolingual Spanish-speaking New York City patients, describes culturally specific psychotherapy.

METHOD

In conducting IPT for Spanish-speaking patients with DSM-IV major depressive disorder, we reviewed cases in weekly supervision over 3 years (January 2005 to January 2008) to explore treatment themes and evaluate the congruence of IPT in addressing them. Important themes are illustrated by case example.

RESULTS

Key themes include (1) the centrality of family, (2) conflicts due to migration and acculturation, (3) gender roles, (4) need to avoid humiliating or irrevocable social confrontation, and (5) equanimity in facing an unpredictable environment.

CONCLUSIONS

IPT appears a compatible intervention, focusing on and adaptable to these important issues for Hispanic patients.

Psychotropic medication nonadherence among United States Latinos: a comprehensive literature review

OBJECTIVE

Psychotropic medication nonadherence is a major public health problem, but few studies have focused on Latinos. The authors systematically reviewed the literature on rates of and factors influencing antipsychotic, antidepressant, and mood stabilizer nonadherence among U.S. Latinos.

METHODS

MEDLINE and PsycINFO were searched by using the keywords adherence, compliance, Latino, Hispanic, psychotropic, and related terms; bibliographies from relevant reviews and studies were also searched. Twenty-one studies met inclusion criteria: published since 1980 in English or Spanish and measured psychotropic medication nonadherence rates among U.S. Latino adults. Information was extracted about study design and objective, location, population, medication type, participant demographic characteristics, adherence measures, adherence rates, and factors related to adherence.

RESULTS

In the 17 studies that included Latinos and other minority groups, mean nonadherence rates were 41%, 31%, and 43%, respectively, among Latinos, Euro-Americans, and African Americans, with an overall effect size of .64 between Latinos and Euro-Americans. In the four studies that included only Latinos, the mean nonadherence rate was 44%. Ten of 16 studies found that Latinos had significantly lower adherence rates than Euro-Americans. Risk factors for nonadherence included being a monolingual Spanish speaker, lacking health insurance, experiencing access barriers to high-quality care, and having lower socioeconomic status. Protective factors included family support and psychotherapy.

CONCLUSIONS

Rates of nonadherence to psychotropic medications were found to be higher for Latinos than for Euro-Americans. Further investigation is needed to understand the potentially modifiable individual and society-level mechanisms of this discrepancy. Clinical and research interventions to improve adherence should be culturally appropriate and incorporate identified factors.

The level of non-Western immigrants' use of acute psychiatric care compared with ethnic Norwegians over an 8-year period

Immigrants are assumed by many to have more mental health problems than the population in the countries they have emigrated to, and clinicians have the impression that an increasing number of non-Western immigrants are referred to acute psychiatric care. Patients referred over an 8-year period to an acute care facility, responsible for a catchment area of close to 100,000 inhabitants in Oslo, Norway, were scrutinized to study the latter assumption. In total 792 men and 701 women (47.0%) were referred. There were 168 men and 59 women among the non-Western immigrants, i.e. 26.0% of the non-Western immigrants were women, whereas 50.2% or 611 out of 1217 ethnic Norwegians were women. Non-Western immigrants were referred twice as often in 2007, n=40, as in 2000, n=19. Non-Western immigrants as a percentage of the other referred patients increased from 15.2% to 16.0% in 2006, which was lower than the representation in the general population. Mean age was lower for non-Western immigrants, 34.6 (standard deviation, s=14.7) than for ethnic Norwegians 39.5 (s=11.6). Mean length of stay was lower for ethnic Norwegians. If the prevalence of mental disorders is the same or higher in immigrants than in the original population, this study indicates that they are under-represented among referred patients from the catchment area population. This seems to be the case especially for women.

Antidepressant use in a nationally representative sample of community-dwelling US Latinos with and without depressive and anxiety disorders

BACKGROUND

Antidepressant drugs are among the most widely prescribed drugs in the United States; however, little is known about their use among major ethnic minority groups.

METHOD

Collaborative Psychiatric Epidemiology Surveys (CPES) data were analyzed to calculate nationally representative estimates of Latino and non-Latino White adults antidepressant use.

SETTING

The 48 coterminous United States was the setting.

PARTICIPANTS

Household residents aged 18 years and older (N=9,250).

MAIN OUTCOME

Past year antidepressant use.

RESULTS

Compared to non-Latino Whites, few Latinos, primarily Mexican Americans, with 12-month depressive and/or anxiety disorders reported past year antidepressant use. Mexican Americans (OR=0.48; 95%CI=0.30-0.77) had significantly lower odds of use compared to non-Latino Whites, which were largely unaffected by factors associated with access to care. Over half of antidepressant use was by respondents not meeting 12-month criteria for depressive or anxiety disorders. Lifetime depressive and anxiety disorders explained another 21% of past year antidepressant use, leaving another 31% of drug use unexplained.

DISCUSSION

We found a disparity in antidepressant use for Mexican Americans compared to non-Latino Whites that was not accounted for by differences in need and factors associated with access to care. About one third of antidepressant use was by respondents not meeting criteria for depressive or anxiety disorders. Our findings underscore the importance of disaggregating Latino ethnic groups. Additional work is needed to understand the medical and economic value of antidepressant use beyond their primary clinical targets.

Evaluation of a generic brief acculturation scale in a sample of male enlisted naval personnel

This study examined the reliability and validity of the 3-item Generic Brief Acculturation Scale (GBAS). The GBAS was administered as a part of a larger Navy Health Behavior Survey of male enlisted personnel deployed on aircraft carriers. Analyses are reported here for the subsample for whom English was a second language (n = 529, 15% of original sample). Generic Brief Acculturation Scale reliability was assessed with internal consistency. Validity was assessed using t test and correlation. Results supported reliability and validity: Cronbach alpha was .81, mean GBAS scores for US-born participants were significantly higher than that for foreign born (P < .05), and GBAS scores were positively correlated with generation (r = 0.34). Additional research with civilian populations is needed, but these findings suggest that the GBAS could be useful either as a quick screen in clinical practice to determine when a translator may be needed or to guide decision making regarding health promotion programming.

The need for culture sensitive diagnostic procedures: a study among psychotic patients in Morocco

OBJECTIVE

We examine the procedural validity of a standardized instrument for the diagnosis of psychotic disorders in Morocco.

METHOD

Twenty-nine patients from Casablanca, Morocco, with a psychotic or mood disorder were examined using the Comprehensive Assessment of Symptoms and History (CASH) an adapted version using cultural formulation to make the instrument more culturally sensitive (CASH-CS). Chance corrected agreement was calculated between diagnoses based on these two versions of CASH and independent clinical diagnoses according to local psychiatrists.

RESULTS

Agreement for traditional CASH versus clinical diagnosis and for CASH versus CASH-CS was low (kappa = -0.19; SD 0.16 and kappa = 0.21; SD 0.16, respectively). De CASH-CS, showed good agreement with clinical diagnosis (kappa = 0.79; SD 0.11).

CONCLUSION

Standardized instruments for the assessment of psychosis such as the CASH may be liable to cultural misinterpretations. This may be relevant to the interpretation of the high incidence rates of schizophrenia among immigrants.

SIGNIFICANT OUTCOMES

Agreement between a culturally naïve version of a standardized diagnostic instrument for the assessment of psychosis and clinical diagnosis by Moroccan psychiatrists is poor. Adding additional probes and decision rules based on cultural formulation improves agreement with clinical diagnosis significantly.

LIMITATIONS

The study was conducted in a small sample. Both versions of CASH were administered by the same interviewer in a single interview session.