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

The Association Between Social Determinants of Health (SDoH) and Mental Health Status in the US

Social determinants of health (SDoH) are considered significant determinants of mental health. This study examines the association between SDoH and mental health status in the United States. We analyzed 2023 Behavioral Risk Factor Surveillance System (BRFSS) data from 183,318 U.S. adults using multinomial logistic regression. Several SDoH were significantly linked to the frequency of poor mental health days. After adjusting for all covariates, individuals facing difficulty paying utility bills had lower odds of experiencing episodic (vs. chronic) poor mental health (AOR = 0.47, p = 0.031). Transportation challenges were associated with lower odds of episodic distress rather than chronic mental health issues (AOR = 0.35, p = 0.026). Individuals who were unable to afford a doctor or who experienced employment loss had significantly lower odds of reporting no poor mental health days compared to reporting chronic poor mental health, with adjusted odds ratios of 0.37 and 0.84, respectively. Non-Hispanic Whites and males were more likely to report chronic poor mental health. Policies that prioritize economic stability and job security, reliable transportation, and equal access to education and healthcare are crucial for promoting mental health equity across diverse populations.

Perceptions and Experiences of Uninsured Latinx Adult Participants in a Community Health Worker-Delivered Intervention to Address Depression

Latinx immigrants have an increased risk of depression and other negative mental health problems. Community health workers (CHWs) have a history of bridging the divide between marginalized communities and health care systems. Since 2019, we have been implementing and evaluating a ten 1-hour-sessions intervention delivered by a CHW and adapted from cognitive behavioral therapy, mindfulness exercises, and behavioral activation to treat mild to severe depressive symptoms and anxiety. There has been little research on the subjective experiences of the participants receiving mental health services delivered by CHW. Our study's purpose was to explore the perceptions and experiences of participants in the intervention. To better understand the experiences of Latinx participants in the intervention, we conducted in-depth 1-hour interviews with participants who completed the 10 intervention sessions. Twenty-nine participants provided responses. Participant discussions about their experience with the intervention centered around three main themes: desperation as a motivator to accept the intervention, changed perceptions of self, and feelings of support. Results show that participants perceived the program as beneficial for their mental health and well-being by influencing their sense of self and self-worth and by feeling supported by the CHW. CHWs have the potential to address gaps in mental health service access experienced among Latinx immigrants. However, more research needs to continue investigating effective engagement strategies for treating depression and anxiety among Latinx immigrant patients.

Health Care Models for Persons with Multiple Chronic Conditions from Populations that Experience Health Disparities: A Scoping Review

Almost half of U.S. adults have multiple chronic conditions (MCC), and the prevalence of MCC has significantly increased for racial and/or ethnic minority groups, especially among those aged 45-64 years. Yet, little is known about evidence-based health care models for managing MCC in these populations. The overall objective of this scoping review was to identify the breadth of literature testing health care delivery models or components of models to improve the management of MCC for populations that experience health disparities. The databases of CINAHL Plus, Embase, PubMed, and Scopus were searched for original articles from 2016 to 2023. Included studies had to assess a health care delivery model, intervention, approach, or strategy for improving the management of two or more chronic conditions among U.S. adults. Using Covidence, each record was independently assessed by two reviewers and relevant data about the study, health care model, population studied, and outcomes were extracted. Out of 9583 initially screened records, 17 met the inclusion criteria, of which 5 (29%) were randomized controlled trials. Most (82%) studies focused on the management of psychiatric and physical chronic conditions. The most cited care model was the Patient-Centered Medical Home (41%). Most studies (82%) were conducted within clinical settings: primary care (n = 9), specialty care (n = 4), and behavioral health (n = 2). All studies documented positive improvements in patient outcomes, including fourteen (82%) studies that measured outcomes related to service utilization and eleven (65%) studies that measured clinical outcomes. Four studies (24%) measured cost-related outcomes. While the Chronic Care Model was developed almost 30 years ago, the applicable evidence for MCC is sparse for populations experiencing health disparities. There is an opportunity for research to develop, adapt, integrate, and implement evidence-based health care models for MCC to improve clinically significant health outcomes that align with the patient goal needs.

Socioeconomic and spatial distribution of depressive symptoms and access to treatment in Peru: A repeated nationwide cross-sectional study from 2014 to 2021

Background

Globally, evidence indicates that poverty and geographical setting influence the prevalence of depressive symptoms and access to treatment. Therefore, this study aimed to evaluate the socioeconomic and spatial distribution of depressive symptoms and treatment in Peru.

Methods

We conducted an observational study based on the analysis of secondary data derived from the Peruvian Demographic and Health Surveys for 2014-2021. Using the Patient Health Questionnaire-9 on depressive symptoms, we estimated the Erreygers concentration index (ECI) to identify socioeconomic inequality in depressive symptoms and access to treatment. Spatial analyses were conducted using Global Moran's I, Kriging interpolation, hotspot analysis (Getis-Ord-Gi∗), and the Bernoulli-based Kulldorff spatial analysis.

Results

The surveys included a total of 113,392 participants. Depressive symptoms exhibited only negative ECI values throughout the 2014-2021 period (pro-poor distribution), whereas access to treatment only displayed positive ECI values (pro-rich distribution). We identified two and four significant clusters in the southeastern areas of Peru in 2014 and 2021, respectively.

Conclusions

Depressive symptoms were concentrated among the poorest, whereas access to treatment was remarkably concentrated among the wealthiest groups. A clustered spatial pattern was observed, and similar high-risk areas were identified. Social policies that address unequal socioeconomic and spatial distribution in depressive symptoms and treatment are required.

A real-world analysis of antidepressant medications in US veterans aged 60 years and older: a comparative analysis

Aim: To compare the safety and efficacy of antidepressants (AD) among older adults with major depressive disorder (MDD) by assessing treatment change, augmentation and hospitalization rates. Methods: This retrospective study analyzed data from the Veterans Affairs (VA) database, including 142,138 patients aged ≥60 years diagnosed with MDD. Patients prescribed bupropion, citalopram, duloxetine, escitalopram, fluoxetine, mirtazapine, paroxetine, sertraline, or venlafaxine were included. Outcomes were treatment change, augmentation and hospitalization rates. Hazard ratios (aHRs) were calculated using sertraline as the reference. Results: Of the patients, 39.6% required augmentation, 18.1% changed antidepressant treatment and 13.3% were hospitalized. The corresponding incidence rate was 544, 124 and 122 events per 1000 person-years. Compared with sertraline, mirtazapine users had the highest AD change risk (aHR 1.34, 95% CI: 1.29-1.40), while duloxetine users had the lowest (aHR 0.87, 95% CI: 0.83-0.92). Duloxetine also had the lowest augmentation risk (aHR 0.89, 95% CI: 0.86-0.92). Mirtazapine users also had the highest risks of augmentation (aHR 1.15, 95% CI: 1.12-1.18) and hospitalization (aHR 1.14, 95% CI: 1.07-1.23). Bupropion had the lowest hospitalization risk (aHR 0.77, 95% CI: 0.71-0.84). Conclusion: Antidepressant choice significantly influences treatment outcomes in older adults with MDD. Duloxetine demonstrated the best profile with the lowest risks of AD change and augmentation, while mirtazapine posed the highest risks of all three outcomes. Personalized treatment strategies are crucial to improving outcomes in this population.

Cost-Effectiveness of Computer-Assisted Cognitive Behavioral Therapy for Depression Among Adults in Primary Care

Importance

Approximately 1 in 5 adults are diagnosed with depression in their lifetime. However, less than half receive help from a health professional, with the treatment gap being worse for individuals with socioeconomic disadvantage. Computer-assisted cognitive behavioral therapy (CCBT) is an effective and convenient strategy to treat depression; however, its cost-effectiveness in a sociodemographically diverse population remains unknown.

Objective

To evaluate the cost-effectiveness of clinician-supported CCBT compared with treatment as usual (TAU) in a primary care population with a substantial number of patients with low income, limited computer or internet access, and lack of college education.

Design, Setting, and Participants

This economic evaluation was a randomized clinical trial-based cost-effectiveness analysis. The trial was conducted at the Departments of Family and Geriatric Medicine and Internal Medicine at the University of Louisville. Enrollment occurred from June 24, 2016, to May 13, 2019. Participants had mild to moderate depression and were followed up for 6 months after treatment completion. The last follow-up assessment was conducted on January 30, 2020. Statistical analysis was performed from August 2023 to August 2024.

Exposure

CCBT intervention was provided for 12 weeks and included 9 modules ranging from behavioral activation and cognitive restructuring to relapse prevention strategies, supported by telephonic sessions with a clinician, in addition to TAU, which included standard clinical management in primary care.

Main Outcomes and Measures

The primary health outcome was quality-adjusted life years (QALYs), estimated using the Short-Form 12 questionnaire (SF-12). The secondary outcome was treatment response, defined as at least 50% improvement in the Patient Health Questionnaire. The intervention cost included sessions with mental health clinicians and the cost of the CCBT software, plus the cost of loaner computer and internet data plan for low-resource households. An incremental cost-effectiveness ratio (ICER) was computed, while adjusting for baseline scores, age, and sex. The cost-effectiveness acceptability curve presented the probability of CCBT being cost-effective for a range of willingness-to-pay values.

Results

Among the 175 primary care patients included in this study, 148 (84.5%) were female; 48 (27.4%) were African American, 2 (1.2%) were American Indian or Alaska Native, 4 (2.5%) were Hispanic, 106 (60.5%) were White, and 15 (8.6%) were multiracial; and the mean (SD) age was 47.03 (13.15) years. CCBT was associated with better quality of life and higher chance of treatment response at the posttreatment and 6-month time points, compared with the TAU group. The ICER for CCBT was $37 295 (95% CI, $22 724-$66 546) per QALY, with a probability of 89.4% of being cost-effective at a willingness-to-pay threshold of $50 000/QALY. The ICER per case of treatment response was $3623 (95% CI, $2617-$5377).

Conclusions and Relevance

In this trial-based economic evaluation, CCBT was found to be cost-effective, compared with TAU, in primary care patients with depression. As this study included individuals with low income and with limited internet access who are underrepresented in cost-effectiveness studies, it has important policy implications for addressing unmet needs in sociodemographically diverse populations.

Health Equity and Perinatal Mental Health

PURPOSE OF REVIEW

Pregnancy and the postpartum period are vulnerable times to experience psychiatric symptoms. Our goal was to describe existing inequities in perinatal mental health, especially across populations, geography, and in the role of childbirth.

RECENT FINDINGS

People of color are at an increased risk for perinatal mental health difficulties and more likely to experience neglect, poor communication, and racial discrimination. LGBTQ + individuals encounter unique challenges, implicating the role of heteronormativity, cisnormativity, and gender dysphoria through pregnancy-related processes. Rural-dwelling women are significantly less likely to seek care, be screened for, or receive treatment for perinatal mental health conditions. Trauma-informed, comprehensive mental health support must be provided to all patients during pregnancy, childbirth, and the postpartum period, especially for racially and ethnically minoritized individuals that have often been omitted from care. Future research needs to prioritize inclusion of perinatal populations not well represented in the literature, including rural-dwelling individuals.

The Relationship of Chronic Disease Burden and Racial-Ethnic Disparities in Depression Treatment

BACKGROUND

Chronic disease and depression are closely related, and depression, if left untreated, can worsen physical disease symptoms. Furthermore, treating depression can improve patient outcomes. Generally, treatment for depression is lower in minority groups.

OBJECTIVE

The aim of this study was to determine the relationship between chronic disease burden and depression treatment and whether that relationship differs between white to non-white patient visits to primary care physicians.

DESIGN

We conducted a quantitative secondary data analysis using data from 2014-2019 National Ambulatory Medical Care Survey (NAMCS).

PARTICIPANTS

Visits by adults with depression to primary care physicians (n = 3832).

MAIN MEASURES

Logistic regressions estimated the odds of medication treatment, mental health counseling treatment, and any treatment.

KEY RESULTS

Visits by patients with 3 or more chronic conditions had 1.39 times the odds of receiving medication treatment (p-value = 0.06). However, when examining treatment by race, visits by white patients with 1-2 chronic conditions had 3.04 times the odds of receiving mental health treatment (p-value = 0.09) compared to visits by non-white patients and 2.09 times the odds of receiving any treatment (p-value = 0.08) compared to visits by non-white patients.

CONCLUSIONS

Although not significant at the p < .05 level, the results suggest that the odds of depression treatment is greater during visits by patients with multiple co-occurring chronic conditions compared to visits by people without chronic conditions. It appears that this effect is larger for visits by white patients compared to visits by non-white patients. Further research is needed to confirm these findings and determine how this association impacts minorities distinctly and what could be the reason behind the disparity. These findings could help physicians be aware of ongoing disparities in depression treatment and provide more equitable depression treatment.

Depressive Symptoms Affect Cognitive Functioning from Middle to Late Adulthood: Ethnoracial Minorities Experience Greater Repercussions

Cognitive deficits, a diagnostic criterion for depressive disorders, may precede or follow the development of depressive symptoms and major depressive disorder. However, an individual can report an increase in depressive symptoms without any change in cognitive functioning. While ethnoracial minority group differences exist, little is known to date about how the relationship between depressive symptoms and cognitive function may differ by ethnoracial minority status. Utilizing data from the Midlife in the United States (MIDUS) study waves II (M2) and III (M3), this study examines the relationship between depressive symptoms and cognitive functioning concurrently and longitudinally in community-dwelling adults, as well as whether the results differed by ethnoracial minority status. Our participants included 910 adults (43.8% male, 80.8% White, 54.4 ± 11.5 years old at M2). Cross-sectionally, depressive symptoms, ethnoracial minority status, and their interaction had significant effects on cognitive function, consistent with previous investigations. Longitudinally, higher M2 depressive symptoms predicted poorer cognitive function at M3 over and above M2 cognitive functioning, but only within the ethnoracial minority sample. Our finding suggests that depressive symptoms predict cognitive functioning both concurrently and across time, and this relationship is moderated by ethnoracial identity, resulting in greater cognitive deficits among ethnoracial minority groups compared to their non-Hispanic White counterparts.

Patient perspectives for improving treatment initiation for new episodes of depression in historically minoritized racial and ethnic groups

OBJECTIVE

Depression is one of the costliest and most prevalent health conditions in the U.S. with 21 million adults having experienced at least one major depressive episode. Despite the availability of evidence-based treatments for depression, a large proportion of people with new diagnoses fail to initiate formal mental health treatment. Although individuals across all racial and ethnic groups fail to initiate treatment for depression, historically minoritized racial/ethnic groups are at even greater risk.

METHOD

Thirty-four participants representing historically underserved racial and ethnic populations from two large health care systems in the U.S. participated in qualitative interviews or focus group to identify factors that impede and facilitate depression treatment initiation in primary care settings.

RESULTS

Participants identified individual and systemic barriers and facilitators of treatment initiation for depression and suggested several ideas for increasing treatment engagement (i.e., increased communication and education from providers, community events, information on social media).

CONCLUSION

Novel interventions are needed to improve treatment initiation following initial diagnosis of depression in primary care settings. Findings from this study offer suggestions for improving treatment initiation in traditionally underserved communities.

Why Culture and Context Matters: Examining Differences in Mental Health Stigma and Social Distance Between Latino Individuals in the United States and Mexico

This study examines the influence of cultural context on social distance and perceptions of stigma towards mental health conditions among Latino populations in Houston, TX, USA and Mexico City, Mexico. We employed a community-based experimental vignette survey to assess perceptions towards individuals experiencing symptoms of alcohol misuse, depression, and psychosis. Participants (n = 513) from Houston and Mexico City were asked about their willingness to accept community members experiencing mental health symptoms in various social roles, their perceptions of stigma related to these symptoms, anticipated danger, possible positive outcomes, and the community member's ability to change. Findings demonstrate significant differences in stigma perceptions between Latino respondents in the US and in Mexico. Houston participants reported lower public stigma and perceived dangerousness of someone with mental health concerns compared to respondents in Mexico City. Furthermore, the cultural context may influence the association between various dimensions of stigma, with some inverse relationships occurring based on location of data collection. Findings illuminate the complex interplay between cultural context, mental health symptoms, and stigma, and underscores the need for culturally nuanced interventions to reduce mental health stigma and promote service utilization in Latino communities.

A classification system for youth outpatient behavioral health services billed to medicaid

Rates of youth behavioral health concerns have been steadily rising. Administrative data can be used to study behavioral health service utilization among youth, but current methods that rely on identifying an associated behavioral health diagnosis or provider specialty are limited. We reviewed all procedure codes billed to Medicaid for youth in one U.S. county over a 10-year period. We identified 158 outpatient behavioral health procedure codes and classified them according to service type. This classification system can be used by health services researchers to better characterize youth behavioral health service utilization.

Racial disparities in emergency department utilization among patients with newly diagnosed depression

OBJECTIVE

To test the hypothesis that racial and ethnic minorities have increased emergency department visit rates, despite being established with a primary care provider.

METHODS

In this retrospective cohort study, ED visits without hospital admission in a 12-month period among patients with a new primary care provider-issued diagnosis of depression were assessed. Electronic medical record (EMR) data was obtained from 47 family medicine clinics in a large Michigan-based healthcare system. General linear regression models with Poisson distribution were used to predict frequency of ED visits.

RESULTS

A total of 4159 patients were included in the analyses. In multivariable analyses, Black / African American race was associated with an additional 0.90 (95% CI 0.64, 1.16) ED visits and American Indian or Alaska Native race was associated with an additional 1.39 (95% CI 0.92, 1.87) ED visits compared to White or Caucasians (null value 0). These risks were only exceeded by patients who received a prescription for a typical antipsychotic drug agent.

CONCLUSION

Despite being established patients at primary care providers and having follow-up encounters, Black / African American and American Indian or Alaska Native patients with depression were considerably more likely to seek ED treatment compared to White/Caucasian patients with depression.

Rising Racial Disparities in Opioid Mortality and Undertreatment of Opioid Use Disorder and Mental Health Comorbidities in Virginia

Introduction

There were more than 100,000 fatal drug overdoses in the U.S. in 2021 alone. In recent years, there has been a shift in opioid mortality from predominantly White rural communities to Black urban communities. This study aimed to identify the Virginia communities disproportionately affected by the overdose crisis and to better understand the systemic factors contributing to disparities in opioid mortality.

Methods

Using the state all-payer claims database, state mortality records, and census data, we created a multivariate model to examine the community-level factors contributing to racial disparities in opioid mortality. We used generalized linear mixed models to examine the associations between socioecologic factors and fatal opioid overdoses, opioid use disorder diagnoses, opioid-related emergency department visits, and mental health diagnoses.

Results

Between 2015 and 2020, racial disparities in mortality widened. In 2020, Black males were 1.5 times more likely to die of an opioid overdose than White males (47.3 vs 31.6 per 100,000; p<0.001). The rate of mental health disorders strongly correlated with mortality (β=0.53, p<0.001). Black individuals are not more likely to be diagnosed with opioid use disorder (β=0.01, p=0.002) or with mental health disorders (β= -0.12, p<0.001), despite higher fatal opioid overdoses.

Conclusions

There are widening racial disparities in opioid mortality. Untreated mental health disorders are a major risk factor for opioid mortality. Findings show pathways to address inequities, including early linkage to care for mental health and opioid use disorders. This analysis shows the use of comprehensive socioecologic data to identify the precursors to fatal overdoses, which could allow earlier intervention and reallocation of resources in high-risk communities.

Race, Healthcare, and Health Disparities: A Critical Review and Recommendations for Advancing Health Equity

An overwhelming body of evidence points to an inextricable link between race and health disparities in the United States. Although race is best understood as a social construct, its role in health outcomes has historically been attributed to increasingly debunked theories of underlying biological and genetic differences across races. Recently, growing calls for health equity and social justice have raised awareness of the impact of implicit bias and structural racism on social determinants of health, healthcare quality, and ultimately, health outcomes. This more nuanced recognition of the role of race in health disparities has, in turn, facilitated introspective racial disparities research, root cause analyses, and changes in practice within the medical community. Examining the complex interplay between race, social determinants of health, and health outcomes allows systems of health to create mechanisms for checks and balances that mitigate unfair and avoidable health inequalities. As one of the specialties most intertwined with social medicine, emergency medicine (EM) is ideally positioned to address racism in medicine, develop health equity metrics, monitor disparities in clinical performance data, identify research gaps, implement processes and policies to eliminate racial health inequities, and promote anti-racist ideals as advocates for structural change. In this critical review our aim was to (a) provide a synopsis of racial disparities across a broad scope of clinical pathology interests addressed in emergency departments-communicable diseases, non-communicable conditions, and injuries-and (b) through a race-conscious analysis, develop EM practice recommendations for advancing a culture of equity with the potential for measurable impact on healthcare quality and health outcomes.

State-Specific Prevalence of Depression Among Adults With and Without Diabetes - United States, 2011-2019

INTRODUCTION

In 2019 among US adults, 1 in 9 had diagnosed diabetes and 1 in 5 had diagnosed depression. Since these conditions frequently coexist, compounding their health and economic burden, we examined state-specific trends in depression prevalence among US adults with and without diagnosed diabetes.

METHODS

We used data from the 2011 through 2019 Behavioral Risk Factor Surveillance System to evaluate self-reported diabetes and depression prevalence. Joinpoint regression estimated state-level trends in depression prevalence by diabetes status.

RESULTS

In 2019, the overall prevalence of depression in US adults with and without diabetes was 29.2% (95% CI, 27.8%-30.6%) and 17.9% (95% CI, 17.6%-18.1%), respectively. From 2011 to 2019, the depression prevalence was relatively stable for adults with diabetes (28.6% versus 29.2%) but increased for those without diabetes from 15.5% to 17.9% (average annual percent change [APC] over the 9-year period = 1.6%, P = .015). The prevalence of depression was consistently more than 10 percentage points higher among adults with diabetes than those without diabetes. The APC showed a significant increase in some states (Illinois: 5.9%, Kansas: 3.5%) and a significant decrease in others (Arizona: -5.1%, Florida: -4.0%, Colorado: -3.4%, Washington: -0.9%). In 2019, although it varied by state, the depression prevalence among adults with diabetes was highest in states with a higher diabetes burden such as Kentucky (47.9%), West Virginia (47.0%), and Maine (41.5%).

CONCLUSION

US adults with diabetes are more likely to report prevalent depression compared with adults without diabetes. These findings highlight the importance of screening and monitoring for depression as a potential complication among adults with diabetes.

Racial and ethnic disparities in time to first antidepressant medication or psychotherapy

Time from first DSM4 major depressive episode (MDE) until treatment in the community was compared across racial/ethnic groups. This secondary analysis used structured baseline data from a depression research clinic (N = 260). Chi-square and survival analyses compared rates and delays to antidepressant medication and psychotherapy. Non-Hispanic Black and Hispanic (any race) participants had lower rates of both antidepressant medication and psychotherapy and longer delays to antidepressant medication compared with non-Hispanic White participants. The results underscore the need to reduce these disparities.

Adapting Mindfulness-Based Cognitive Therapy for Perinatal Depression to Improve Access and Appeal of Preventive Care

Existing and emerging evidence indicates that perinatal depression is a key contributor to preventable morbidity and mortality during and after childbearing. Despite this, there are few effective options for prevention and treatment that are readily accessible for and appealing to pregnant people. Aspects of routine health care systems contribute to this situation. Furthermore, societal and health care systems factors create additional barriers for people of color, people living in rural regions, and people living in poverty. Our interprofessional team of perinatal care providers, mental health providers, community partners, health services scientists, health equity scientists, and business leaders developed and are piloting a perinatal mental health preventive intervention designed to increase access and appeal of a program incorporating mindfulness cognitive behavioral therapy with proven efficacy in preventing perinatal depression. In this article, we briefly summarize key systems barriers to delivering preventive care for perinatal depression in standard prenatal care clinics. We then describe Mindfulness-Based Cognitive Therapy for Perinatal Depression and outline our adaptation of this intervention, Center M. Finally, we identify next steps, challenges, and opportunities for this recent innovation.

The Management of Major Depressive Disorder: Synopsis of the 2022 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline

DESCRIPTION

In February 2022, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved a joint clinical practice guideline (CPG) for the management of major depressive disorder (MDD). This synopsis summarizes key recommendations.

METHODS

Senior leaders within the VA and the DoD assembled a team to update the 2016 CPG for the management of MDD that included clinical stakeholders and conformed to the National Academy of Medicine's tenets for trustworthy CPGs. The guideline panel developed key questions, systematically searched and evaluated the literature, created two 1-page algorithms, and distilled 36 recommendations for care using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. Select recommendations that were identified by the authors to represent key changes from the prior CPG are presented in this synopsis.

RECOMMENDATIONS

The scope of the CPG is diverse; however, this synopsis focuses on key recommendations that the authors identified as important new evidence and changes to prior recommendations on pharmacologic management, pharmacogenomics, psychotherapy, complementary and alternative therapies, and the use of telemedicine.

The US Medicaid Program: Coverage, Financing, Reforms, and Implications for Health Equity

IMPORTANCE

Medicaid is the largest health insurance program by enrollment in the US and has an important role in financing care for eligible low-income adults, children, pregnant persons, older adults, people with disabilities, and people from racial and ethnic minority groups. Medicaid has evolved with policy reform and expansion under the Affordable Care Act and is at a crossroads in balancing its role in addressing health disparities and health inequities against fiscal and political pressures to limit spending.

OBJECTIVE

To describe Medicaid eligibility, enrollment, and spending and to examine areas of Medicaid policy, including managed care, payment, and delivery system reforms; Medicaid expansion; racial and ethnic health disparities; and the potential to achieve health equity.

EVIDENCE REVIEW

Analyses of publicly available data reported from 2010 to 2022 on Medicaid enrollment and program expenditures were performed to describe the structure and financing of Medicaid and characteristics of Medicaid enrollees. A search of PubMed for peer-reviewed literature and online reports from nonprofit and government organizations was conducted between August 1, 2021, and February 1, 2022, to review evidence on Medicaid managed care, delivery system reforms, expansion, and health disparities. Peer-reviewed articles and reports published between January 2003 and February 2022 were included.

FINDINGS

Medicaid covered approximately 80.6 million people (mean per month) in 2022 (24.2% of the US population) and accounted for an estimated $671.2 billion in health spending in 2020, representing 16.3% of US health spending. Medicaid accounted for an estimated 27.2% of total state spending and 7.6% of total federal expenditures in 2021. States enrolled 69.5% of Medicaid beneficiaries in managed care plans in 2019 and adopted 139 delivery system reforms from 2003 to 2019. The 38 states (and Washington, DC) that expanded Medicaid under the Affordable Care Act experienced gains in coverage, increased federal revenues, and improvements in health care access and some health outcomes. Approximately 56.4% of Medicaid beneficiaries were from racial and ethnic minority groups in 2019, and disparities in access, quality, and outcomes are common among these groups within Medicaid. Expanding Medicaid, addressing disparities within Medicaid, and having an explicit focus on equity in managed care and delivery system reforms may represent opportunities for Medicaid to advance health equity.

CONCLUSIONS AND RELEVANCE

Medicaid insures a substantial portion of the US population, accounts for a significant amount of total health spending and state expenditures, and has evolved with delivery system reforms, increased managed care enrollment, and state expansions. Additional Medicaid policy reforms are needed to reduce health disparities by race and ethnicity and to help achieve equity in access, quality, and outcomes.

Willingness to Use Internet-Based Versus Bibliotherapy Interventions in a Representative US Sample: Cross-sectional Survey Study

Background

Self-help interventions have the potential to increase access to evidence-based mental health care. Self-help can be delivered via different formats, including print media or digital mental health interventions (DMHIs). However, we do not know which delivery format is more likely to result in higher engagement.

Objective

The aims of this study were to identify if there is a preference for engaging in print media versus DMHIs and whether there are individual differences in relative preferences.

Methods

Participants were 423 adults between the ages of 18 and 82 years (201/423, 47.5% female) recruited on Prolific as a nationally representative sample of the US population, including non-Hispanic White (293/423, 69.2%), non-Hispanic Black (52/423, 12%), Asian (31/423, 7%), Hispanic (25/423, 6%), and other individuals (22/423, 5%). We provided individuals with psychoeducation in different self-help formats and measured their willingness to use print media versus DMHIs. We also assessed participants’ demographics, personality, and perception of each format’s availability and helpfulness and used these to predict individual differences in the relative preferences.

Results

Participants reported being more willing to engage with print media than with DMHIs (B=0.41, SE 0.08; t₄₂₂=4.91; P<.001; d=0.24, 95% CI 0.05-0.43). This preference appeared to be influenced by education level (B=0.22, SE 0.09; t₄₁₃=2.41; P=.02; d=0.13, 95% CI –0.06 to 0.32), perceived helpfulness (B=0.78, SE 0.06; t₄₁₁=13.66; P<.001; d=0.46, 95% CI 0.27-0.66), and perceived availability (B=0.20, SE 0.58; t₄₁₁=3.25; P=.001; d=0.12, 95% CI 0.07-0.30) of the self-help format.

Conclusions

This study suggests an overall preference for print media over DMHIs. Future work should investigate whether receiving mental health treatment via participants’ preferred delivery format can lead to higher engagement.

Performance Metrics of Substance Use Disorder Care Among Medicaid Enrollees in New York, New York

Importance

There is limited evaluation of the performance of Medicaid managed care (MMC) private plans in covering substance use disorder (SUD) treatment.

Objective

To compare the performance of MMC plans across 19 indicators of access, quality, and outcomes of SUD treatment.

Design Setting and Participants

This cross-sectional study used administrative claims and mandatory assignment to plans of up to 159 016 adult Medicaid recipients residing in 1 of the 5 counties (boroughs) of New York, New York, from January 2009 to December 2017 to identify differences in SUD treatment access, patterns, and outcomes among different types of MMC plans. Data from the latest years were received from the New York State Department of Health in October 2019, and analysis began soon thereafter. Approximately 17% did not make an active choice of plan, and a subset of these (approximately 4%) can be regarded as randomly assigned.

Exposures

Plan assignment.

Main Outcomes and Measures

Percentage of the enrollees achieving performance measures across 19 indicators of access, process, and outcomes of SUD treatment.

Results

Medicaid claims data from 159 016 adults (mean [SD] age, 35.9 [12.7] years; 74 261 women [46.7%]; 8746 [5.5%] Asian, 73 783 [46.4%] Black, and 40 549 [25.5%] White individuals) who were auto assigned to an MMC plan were analyzed. Consistent with national patterns, all plans achieved less than 50% (range, 0%-62.1%) on most performance measures. Across all plans, there were low levels of treatment engagement for alcohol (range, 0%-0.4%) and tobacco treatment (range, 0.8%-7.2%), except for engagement for opioid disorder treatment (range, 41.5%-61.4%). For access measures, 4 of the 9 plans performed significantly higher than the mean on recognition of an SUD diagnosis, any service use for the first time, and tobacco use screening. Of the process measures, total monthly expenditures on SUD treatment was the only measure for which plans differed significantly from the mean. Outcome measures differed little across plans.

Conclusions and Relevance

The results of this cross-sectional study suggest the need for progress in engaging patients in SUD treatment and improvement in the low performance of SUD care and limited variation in MMC plans in New York, New York. Improvement in the overall performance of SUD treatment in Medicaid potentially depends on general program improvements, not moving recipients among plans.

Peer-Led, Remote Intervention to Improve Mental Health Outcomes Using a Holistic, Spirituality-Based Approach: Results from a Pilot Study

In the United States, Black communities face a complex mental health burden, with growing attention on addressing these disparities through the lens of holistic wellbeing. Given the dearth of research on faith-based interventions focused on mental health through the lens of holistic wellbeing, this study evaluates the impact of a spirituality-based, peer-led one-group pre-test post-test pilot intervention in a sample of Black individuals in the Bronx, New York City. The eight-session creating healthy culture curriculum, focused on improving mental health and spiritual wellbeing, was collaboratively developed through community partnerships. Post-intervention results indicated significantly reduced odds of moderate to severe depression (AOR:0.20), and increased sense of community, social support, role of religion in health, flourishing, and reduced trouble sleeping. In-depth interviews with participants further highlighted the interconnected role between psychosocial and mental health indicators. Findings support importance of holistically developing, implementing, and evaluating spirituality-based mental health interventions in Black communities.

Hospital Length of Stay in Patients with and without Serious and Persistent Mental Illness: Evidence of Racial and Ethnic Differences

Background: Prior studies have documented racial and ethnic differences in mental healthcare utilization, and extensively in outpatient treatment and prescription medication usage for mental health disorders. However, limited studies have investigated racial and ethnic differences in length of inpatient stay (LOS) in patients with and without Serious and Persistent Mental Illness. Understanding racial and ethnic differences in LOS is necessary given that longer stays in hospital are associated with adverse health outcomes, which in turn contribute to health inequities. Objective: To examine racial and ethnic differences in length of stay among patients with and without serious and persistent mental illness (SPMI) and how these differences vary in two age cohorts: patients aged 18 to 64 and patients aged 65+. Methods: This study employed a retrospective cohort design to address the research objective, using the 2018 Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample. After merging the 2018 National Inpatient Sample’s Core and Hospital files, Generalized Linear Model (GLM), adjusting for covariates, was applied to examine associations between race and ethnicity, and length of stay for patients with and without SPMI. Results: Overall, patients from racialized groups were likely to stay longer than White patients regardless of severe mental health status. Of all races and ethnicities examined, Asian patients had the most extended stays in both age cohorts: 8.69 days for patients with SPMI and 5.73 days for patients without SPMI in patients aged 18 to 64 years and 8.89 days for patients with SPMI and 6.05 days for patients without SPMI in the 65+ cohort. For individuals aged 18 to 64, differences in length of stay were significantly pronounced in Asian patients (1.6 days), Black patients (0.27 days), and Native American patients/patients from other races (0.76 days) if they had SPMI. For individuals aged 65 and older, Asian patients (1.09 days) and Native American patients/patients from other races (0.45 days) had longer inpatient stays if they had SPMI. Conclusion: Racial and ethnic differences in inpatient length of stay were most pronounced in Asian patients with and without SPMI. Further studies are needed to understand the mechanism(s) for these differences.

The Intergenerational Impact of Structural Racism and Cumulative Trauma on Depression

Depression among individuals who have been racially and ethnically minoritized in the United States can be vastly different from that of non-Hispanic White Americans. For example, African American adults who have depression rate their symptoms as more severe, have a longer course of illness, and experience more depression-associated disability. The purpose of this review was to conceptualize how structural racism and cumulative trauma can be fundamental drivers of the intergenerational transmission of depression. The authors propose that understanding risk factors for depression, particularly its intergenerational reach, requires accounting for structural racism. In light of the profoundly different experiences of African Americans who experience depression (i.e., a more persistent course of illness and greater disability), it is critical to examine whether an emerging explanation for some of these differences is the intergenerational transmission of this disorder due to structural racism.

The impact of electronic health record functions on patterns of depression treatment in primary care

BACKGROUND

Many individuals with depression are not being linked to treatment by their primary care providers. Electronic health records (EHRs) are common in medicine, but their impact on depression treatment is mixed. Because EHRs are diverse, differences may be attributable to differences in functionality. This study examines the relationship between EHR functions, and patterns of depression treatment in primary care.

METHODS

secondary analyses from the 2013-2016 National Ambulatory Medical Care Survey examined adult primary care patients with new or acute depression (n = 5,368). Bivariate comparisons examined patterns of depression treatment by general EHR use, and logistic regression examined the impact of individual EHR functions on treatment receipt.

RESULTS

Half the sample (57%; N = 3,034) was linked to depression treatment. Of this, 98.5% (n = 2,985) were prescribed antidepressants, while 4.3% (n = 130) were linked to mental health. EHR use did not impact mental health linkages, but EHR functions did affect antidepressant prescribing. Medication reconciliation decreased the odds of receiving an antidepressant (OR = .60, p < .05), while contraindication warnings increased the likelihood of an antidepressant prescription (OR = 1.91, p < .001).

CONCLUSIONS

EHR systems did not impact mental health linkages but improved rates of antidepressant prescribing. Optimizing the use of contraindication warnings may be a key mechanism to encourage antidepressant treatment.

Prevalence and Factors Associated With Mental Health Symptoms in Adults Undergoing Covid-19 Testing

Background and objective:

Understanding the mental health impact of the COVID-19 pandemic on persons receiving COVID-19 testing will help guide mental health interventions. We aimed to determine the association between sociodemographic factors and mental health symptoms at 8 weeks (baseline) after a COVID-19 test, and compare prevalence of mental health symptoms at baseline to those at 16-week follow-up.

Materials and Methods:

Prospective cohort study of adults who received outpatient COVID-19 testing at primary care clinics. Logistic regression analyses were used to assess the association between sociodemographic characteristics and COVID-19 test results with mental health symptoms. Mental health symptoms reported at baseline were compared to symptoms at 16 weeks follow-up using conditional logistic regression analyses.

Results:

At baseline, a total of 124 (47.51%) participants reported at least mild depressive symptoms, 110 (42.15%) participants endorsed at least mild anxiety symptoms, and 94 participants (35.21%) endorsed hazardous use of alcohol. Females compared to males were at increased risk of at least mild depressive symptoms at baseline (Adjusted Odds Ratio (AOR): 2.08; 95% CI: 1.14-3.79). The odds of at least mild depressive symptoms was significantly lower among those residing in zip codes within the highest quartile compared to lowest quartile of household income (AOR: 0.37; 95% CI: 0.17-0.81). Also, non-Hispanic Whites had significantly higher odds of reporting hazardous alcohol use compared to non-Whites at baseline (AOR: 1.94; 95% CI: 1.05-3.57). The prevalence of mental health symptoms remained elevated after 16 weeks.

Conclusion and Relevance:

We found a high burden of symptoms of depression and anxiety as well as hazardous alcohol use in a diverse population who received testing for COVID-19 in the primary care setting. Primary care providers need to remain vigilant in screening for symptoms of mental health disorders in patients tested for COVID-19 well after initial testing.

Racial and Ethnic Differences in Psychiatry Resident Prescribing: a Quality Improvement Education Intervention to Address Health Equity

OBJECTIVE

Quality improvement (QI) tools can identify and address health disparities. This paper describes the use of resident prescriber profiles in a novel QI curriculum to identify racial and ethnic differences in antidepressant and antipsychotic prescribing.

METHODS

The authors extracted medication orders written by 111 psychiatry residents over an 18-month period from an electronic medical record and reformatted these into 6133 unique patient encounters. Binomial logistic models adjusted for covariates assessed racial and ethnic differences in antipsychotic or antidepressant prescribing in both emergency and inpatient psychiatric encounters. A multinomial model adjusted for covariates then assessed racial and ethnic differences in primary diagnosis. Models also examined interactions between gender and race/ethnicity.

RESULTS

Black (adjusted OR 0.66; 95% CI, 0.50-0.87; p < 0.01) and Latinx (adjusted OR, 0.65; 95% CI, 0.49-0.86; p < 0.01) patients had lower odds of receiving antidepressants relative to White patients despite diagnosis. Black and Latinx patients were no more likely to receive antipsychotics than White patients when adjusted for diagnosis. Black (adjusted OR 3.85; 95% CI, 2.9-5.2) and Latinx (adjusted OR 1.60; 95% CI, 1.1-2.3) patients were more likely to receive a psychosis than a depression diagnosis when compared to White patients. Gender interactions with race/ethnicity did not significantly change results.

CONCLUSIONS

Our findings suggest that racial/ethnic differences in antidepressant prescription likely result from alternatively higher diagnosis of psychotic disorders and prescription of antipsychotics in Black and Latinx patients. Prescriber profiles can serve as a powerful tool to promote resident QI learning around the effects of structural racism on clinical care.

Current anti-depressant use is associated with cortical bone deficits and reduced physical function in elderly women

BACKGROUND

Anti-depressants, particularly selective serotonin reuptake inhibitors (SSRIs), are associated with an increased risk of fracture. The mechanism is unclear and may be due to effects on bone metabolism, muscle strength, falls or other factors. It is unknown if serotonin norepinephrine reuptake inhibitors (SNRIs) have similar effects.

METHODS

We compared musculoskeletal health in current female anti-depressant users and non-users from a population-based multiethnic (35.6% black, 22.3% white and 42.1% mixed) cohort study of adults ≥65 years old in New York (N = 195) using dual x-ray absorptiometry (DXA), trabecular bone score (TBS), vertebral fracture assessment (VFA), high resolution peripheral quantitative computed tomography (HR-pQCT), body composition, and grip strength.

RESULTS

Current anti-depressant users were more likely to be white than non-white (OR 1.9, 95% CI 1.2-2.9) and were shorter than non-users, but there were no differences in age, weight, BMI, physical activity, calcium/vitamin D intake, falls or self-rated health. There were more pelvic fractures in current vs. non-users (7.1% vs. 0%, p = 0.04). Age- and weight-adjusted T-score by DXA was lower in current users at the 1/3-radius (-1.6 ± 1.1 vs. -1.0 ± 1.4, p = 0.04) site only. There was no difference in TBS, vertebral fractures or fat/lean mass by DXA. Age- and weight-adjusted grip strength was 13.3% lower in current users vs. non-users (p = 0.04). By HR-pQCT, age- and weight-adjusted cortical volumetric BMD (Ct. vBMD) was 4.8% lower in users vs. non-users at the 4% radius site (p = 0.007). A similar cortical pattern was seen at the proximal (30%) tibia. When assessed by anti-depressant class, deteriorated cortical microstructure was present only in SSRI users at the radius and only in SNRI users at the proximal tibia.

CONCLUSIONS

Anti-depressant use is associated with cortical deterioration and reduced physical function, but effects may be class-specific. These findings provide insight into the mechanism by which anti-depressants may contribute to the increased fracture risk in older women.