Reducing health disparities in depressive disorders outcomes between non-Hispanic Whites and ethnic minorities: a call for pragmatic strategies over the life course

Mining the health disparities and minority health bibliome: A computational scoping review and gap analysis of 200,000+ articles

Without comprehensive examination of available literature on health disparities and minority health (HDMH), the field is left vulnerable to disproportionately focus on specific populations or conditions, curtailing our ability to fully advance health equity. Using scalable open-source methods, we conducted a computational scoping review of more than 200,000 articles to investigate major populations, conditions, and themes as well as notable gaps. We also compared trends in studied conditions to their relative prevalence using insurance claims (42 million Americans). HDMH publications represent 1% of articles in Medical Literature Analysis and Retrieval System Online (MEDLINE). Most studies are observational in nature, although randomized trial reporting has increased fivefold in the past 20 years. Half of HDMH articles concentrate on only three disease groups (cancer, mental health, and endocrine/metabolic disorders), while hearing, vision, and skin-related conditions are among the least well represented despite substantial prevalence. To support further investigation, we present HDMH Monitor, an interactive dashboard and repository generated from the HDMH bibliome.

Primary care-based screening and recruitment for an adolescent depression prevention trial: Contextual considerations during a youth mental health crisis

Background

Rising rates of adolescent depression in the wake of COVID-19 and a youth mental health crisis highlight the urgent need for accessible mental healthcare and prevention within primary care. Digital mental health interventions (DMHIs) may increase access for underserved populations. However, these interventions are not well studied in adolescents, nor healthcare settings. The purpose of this study was to identify barriers and facilitators to screening and recruitment activities for PATH 2 Purpose (P2P): Primary Care and Community-Based Prevention of Mental Disorders in Adolescents, a multi-site adolescent depression prevention trial comparing two digital prevention programs within four diverse health systems in two U.S. states.

Method

This qualitative study is a component of a larger Hybrid Type I trial. We conducted semi-structured key informant interviews with clinical and non-clinical implementers involved with screening and recruitment for the P2P trial. Informed by the Consolidated Framework for Implementation Research (CFIR), interviews were conducted at the midpoint of the trial to identify barriers, facilitators, and needed adaptations, and to gather information on determinants that may affect future implementation.

Findings

Respondents perceived the P2P trial as valuable, well aligned with the mission of their health systems. However, several barriers were identified, many of which stemmed from influences outside of the healthcare settings. Universal and site-specific outer setting influences (COVID-19 pandemic, youth mental health crisis, local community conditions) interacted with Inner Setting and Innovation domains to create numerous challenges to the implementation of screening and recruitment.

Conclusion

Our findings emphasize the need for ongoing, comprehensive assessment of dynamic inner and outer setting contexts prior to and during implementation of clinical trials, as well as flexibility for adaptation to unique clinical contexts. The CFIR is useful for assessing determinants during times of rapid inner and outer setting change, such as those brought on by the COVID-19 pandemic, youth mental health crisis, and the corresponding exacerbation of resource strain within healthcare settings.

Clinical trial registration

PATH 2 Purpose: Primary Care and Community-Based Prevention of Mental Disorders in Adolescents https://www.clinicaltrials.gov/study/NCT04290754.

Socio-demographic differences in access to psychological treatment services: evidence from a national cohort study

BACKGROUND

Since 2008, the Improving Access to Psychological Therapies (IAPT) programme has offered adults in England evidence-based psychological treatments for common mental disorders (CMDs) such as depression and anxiety disorders. However, inequalities in access have not been explored at the national level.

METHODS

Using a unique individual patient dataset that linked 2011 Census information of English residents to national IAPT data collected between April 2017 and March 2018, we estimated the rate of access by a wide range of socio-demographic characteristics that are not routinely available. A large household survey was used to estimate the prevalence of probable CMDs by these socio-demographic characteristics. We estimated the probability of access to IAPT amongst people with CMDs by comparing the rates of access from IAPT data and the estimates of prevalence of CMDs from the household survey. Both unadjusted and adjusted (for important patient characteristics) access rates were estimated in logistic regression models.

RESULTS

As a proportion of those with a probable CMD, access to IAPT varied markedly by socio-demographic characteristics. Older adults, males, people born outside of the UK, people with religious beliefs, people from Asian ethnic backgrounds, people reporting a disability and those without any academic or professional qualifications were underrepresented in IAPT services nationally, in adjusted models.

CONCLUSIONS

The identification of patients who may be underrepresented in IAPT provides an opportunity for services to target outreach and engagement with these groups. Further understanding of barriers to access should help increase equity in access.

Mining the Health Disparities and Minority Health Bibliome: A Computational Scoping Review and Gap Analysis of 200,000+ Articles

Without comprehensive examination of available literature on health disparities and minority health (HDMH), the field is left vulnerable to disproportionately focus on specific populations or conditions, curtailing our ability to fully advance health equity. Using scalable open-source methods, we conducted a computational scoping review of more than 200,000 articles to investigate major populations, conditions, and themes in the literature as well as notable gaps. We also compared trends in studied conditions to their relative prevalence in the general population using insurance claims (42MM Americans). HDMH publications represent 1% of articles in MEDLINE. Most studies are observational in nature, though randomized trial reporting has increased five-fold in the last twenty years. Half of all HDMH articles concentrate on only three disease groups (cancer, mental health, endocrine/metabolic disorders), while hearing, vision, and skin-related conditions are among the least well represented despite substantial prevalence. To support further investigation, we also present HDMH Monitor, an interactive dashboard and repository generated from the HDMH bibliome.

Elements of Integrated Behavioral Health Associated with Primary Care Provider Confidence in Managing Depression at Community Health Centers

BACKGROUND

Depression is most often treated by primary care providers (PCPs), but low self-efficacy in caring for depression may impede adequate management. We aimed to identify which elements of integrated behavioral health (BH) were associated with greater confidence among PCPs in identifying and managing depression.

DESIGN

Mailed cross-sectional surveys in 2016.

PARTICIPANTS

BH leaders and PCPs caring for adult patients at community health centers (CHCs) in 10 midwestern states.

MAIN MEASURES

Survey items asked about depression screening, systems to support care, availability and integration of BH, and PCP attitudes and experiences. PCPs rated their confidence in diagnosing, assessing severity, providing counseling, and prescribing medication for depression on a 5-point scale. An overall confidence score was calculated (range 4 (low) to 20 (high)). Multilevel linear mixed models were used to identify factors associated with confidence.

KEY RESULTS

Response rates were 60% (N=77/128) and 52% (N=538/1039) for BH leaders and PCPs, respectively. Mean overall confidence score was 15.25±2.36. Confidence was higher among PCPs who were satisfied with the accuracy of depression screening (0.38, p=0.01), worked at CHCs with depression tracking systems (0.48, p=0.045), had access to patients' BH treatment plans (1.59, p=0.002), and cared for more patients with depression (0.29, p=0.003). PCPs who reported their CHC had a sufficient number of psychiatrists were more confident diagnosing depression (0.20, p=0.02) and assessing severity (0.24, p=0.03). Confidence in prescribing was lower at CHCs with more patients living below poverty (-0.66, p<0.001). Confidence in diagnosing was lower at CHCs with more Black/African American patients (-0.20, p=0.03).

CONCLUSIONS

PCPs who had access to BH treatment plans, a system for tracking patients with depression, screening protocols, and a sufficient number of psychiatrists were more confident identifying and managing depression. Efforts are needed to address disparities and support PCPs caring for vulnerable patients with depression.

Strategic COVID-19 vaccine distribution can simultaneously elevate social utility and equity

Balancing social utility and equity in distributing limited vaccines is a critical policy concern for protecting against the prolonged COVID-19 pandemic and future health emergencies. What is the nature of the trade-off between maximizing collective welfare and minimizing disparities between more and less privileged communities? To evaluate vaccination strategies, we propose an epidemic model that explicitly accounts for both demographic and mobility differences among communities and their associations with heterogeneous COVID-19 risks, then calibrate it with large-scale data. Using this model, we find that social utility and equity can be simultaneously improved when vaccine access is prioritized for the most disadvantaged communities, which holds even when such communities manifest considerable vaccine reluctance. Nevertheless, equity among distinct demographic features may conflict; for example, low-income neighbourhoods might have fewer elder citizens. We design two behaviour-and-demography-aware indices, community risk and societal risk, which capture the risks communities face and those they impose on society from not being vaccinated, to inform the design of comprehensive vaccine distribution strategies. Our study provides a framework for uniting utility and equity-based considerations in vaccine distribution and sheds light on how to balance multiple ethical values in complex settings for epidemic control.

Trauma-informed Collaborative Care for African American Primary Care Patients in Federally Qualified Health Centers: A Pilot Randomized Trial

BACKGROUND

African Americans have nearly double the rate of posttraumatic stress disorder (PTSD) compared with other racial/ethnic groups.

OBJECTIVE

To understand whether trauma-informed collaborative care (TICC) is effective for improving PTSD among African Americans in New Orleans who receive their care in Federally Qualified Health Centers (FQHCs).

DESIGN AND METHOD

In this pilot randomized controlled trial, we assigned patients within a single site to either TICC or to enhanced usual care (EUC). We performed intent to treat analysis by nonparametric exact tests for small sample sizes.

PARTICIPANTS

We enrolled 42 patients from October 12, 2018, through July 2, 2019. Patients were eligible if they considered the clinic their usual source of care, had no obvious physical or cognitive obstacles that would prevent participation, were age 18 or over, self-identified as African American, and had a provisional diagnosis of PTSD.

MEASURES

Our primary outcome measures were PTSD measured as both a symptom score and a provisional diagnosis based on the PTSD Checklist for DSM-5 (PCL-5).

KEY RESULTS

Nine months following baseline, both PTSD symptom scores and provisional PTSD diagnosis rates decreased substantially more for patients in TICC than in EUC. The decreases were by 26 points in EUC and 36 points in TICC for symptoms (P=0.08) and 33% in EUC and 57% in TICC for diagnosis rates (P=0.27). We found no effects for mediator variables.

CONCLUSIONS

TICC shows promise for addressing PTSD in this population. A larger-scale trial is needed to fully assess the effectiveness of this approach in these settings.

Psychometric Properties of Three Measures of Stigma Among Hispanics with Depression

While many measures of mental illness stigma have been developed, few have been validated in Hispanic populations. This study examined the psychometric properties of three stigma measures (Stigma Concerns about Mental Health Care [SCMHC], Social Distance Scale [SDS], and Latino Scale for Antidepressant Stigma [LSAS]) among a depressed, Hispanic sample. Data were collected during baseline assessments for two studies taking place in primary care settings (N = 500). Psychometric and factor validity were tested for each measure. Confirmatory factor analyses indicated adequate model fit, and adequate internal consistency reliability was found for all three measures. Stigma scores significantly differed by education level and gender. Findings from this analysis provide support for the use of the SCMHC, SDS, and LSAS in a depressed, Hispanic population. Assessing barriers to depression treatment, including stigma, are critical in engaging Hispanics in care and eliminating disparities for the population.

Cross-sectional mixed-methods study protocol exploring the enablers and barriers for people with severe and enduring mental illness in Jamaica when accessing healthcare for chronic physical illness

INTRODUCTION

Extant international research suggests that people with severe and enduring mental illness (PWSEMI) experience increased rates of chronic physical illness (CPI), reduced life expectancy and higher mortality than those in the general population. The high prevalence of CPI among PWSEMI is associated with a number of barriers that this population experiences when accessing physical healthcare. Although substantial research has been conducted in North America, Europe and Australia, there appears to be a paucity of research exploring CPI among PWSEMI in the Caribbean region, although this region has reported very high rates of non-communicable diseases within its populations. The current study will be situated in Jamaica and will explore the enablers and barriers to PWSEMI accessing healthcare for CPI.

METHODS AND ANALYSIS

A convergent mixed-method design will explore the enablers and barriers to accessing healthcare for CPI among PWSEMI. This cross-sectional study will collect data from PWSEMI, caregivers and family members, community health aides, primary care physicians, psychiatrists and health policymakers.

ETHICS AND DISSEMINATION

The study findings will provide baseline data describing the prevalence of CPI among PWSEMI in Jamaica and will identify enablers for, and barriers to, PWSEMI accessing CPI care. Findings will be disseminated widely in Jamaica and internationally to key stakeholders through publications and conferences. Institutional ethical approval was granted from Jamaica's Ministry of Health and Wellness Medico-legal Ethics Review Panel (# 2019/49), the Curtin University Human Research and Ethics Committee (HRE 2020-0022) and the University of the West Indies FMS Ethics Committee (ECP 101, 19/20).

A Qualitative Inquiry Addressing the Experience of Depression in Impoverished Ethnically Diverse Women: Implications for Developing a Community-Based Model

BACKGROUND

Literature suggests that a disparity exists relative to the higher prevalence of depression among the population of impoverished ethnically diverse women, the services available, and care received resulting in a significant health issue for women.

OBJECTIVES

An exploratory-descriptive qualitative study explored the experiences of depression among the population and key stakeholders to inform the development of a community-based program to reduce depression and improve the quality of life of ethnically diverse women residing in an urban community.

DESIGN

Data were collected using focus groups and individual interviews with members of the population and key community representatives, transcribed verbatim, reviewed for accuracy, coded, and analyzed for themes.

RESULTS

Compassion, ease, and hope emerged as the three overarching foundational themes.

CONCLUSION

An intentional infrastructure and strategies to create an experience of compassion, ease, and hope appear to be essential core components of a successful community mental health program model for impoverished women experiencing depression.

Effect of Internet-based Cognitive Behavioral Humanistic and Interpersonal Training vs. Internet-based General Health Education on Adolescent Depression in Primary Care: A Randomized Clinical Trial

IMPORTANCE

Although 13-20% of American adolescents experience a depressive episode annually, no scalable primary care model for adolescent depression prevention is currently available.

OBJECTIVE

To study whether CATCH-IT (Competent Adulthood Transition with Cognitive Behavioral Humanistic and Interpersonal Training) reduces the hazard for depression in at-risk adolescents identified in primary care, as compared to a general health education attention control (HE).

DESIGN

The Promoting AdolescenT Health (PATH) study compares CATCH-IT and HE in a phase 3 single-blind multicenter randomized attention control trial. Participants were enrolled from 2012 to 2016 and assessed at 2, 6, 12, 18, and 24 months post-randomization.

SETTING

Primary care.

PARTICIPANTS

Eligible adolescents were 13-18 years with subsyndromal depression and/or history of depression and no current depression diagnosis or treatment. Of 2,250 adolescents screened for eligibility, 446 participants completed the baseline interview and 369 were randomized into CATCH-IT (n=193) and HE (n=176).

INTERVENTIONS

CATCH-IT is a 20-module (15 adolescent modules, 5 parent modules) online psychoeducation course that includes a parent program, supported by three motivational interviews.

MAIN OUTCOMES AND MEASURES

Time-to-event for depressive episode; depressive symptoms at 6 months.

RESULTS

Mean age was 15.4 years, and 68% were female; 28% had both a past episode and subsyndromal depression; 12% had a past episode only, 59% had subsyndromal depression only, and 1% had borderline subsyndromal depression. The outcome of time-to-event favored CATCH-IT but was not significant with intention-to-treat analyses (N=369; unadjusted HR=0.59; 95% CI 0.27, 1.29; p=0.18; adjusted HR=0.53; 95% CI 0.23, 1.23, p=0.14). Adolescents with higher baseline CES-D₁₀ scores showed a significantly stronger effect of CATCH-IT on time-to-event relative to those with lower baseline scores (p=0.04). For example, for a CES-D₁₀ score of 15 (significant sub-syndromal depression), HR=0.20 (95% CI 0.05, 0.77), compared to CES-D₁₀ of 5 (no sub-syndromal depression), HR=1.44 (95% CI, 0.41, 5.03). In both CATCH-IT and HE groups, depression symptoms declined and functional scores increased.

CONCLUSIONS AND RELEVANCE

CATCH-IT may be better than HE for preventing depressive episodes for at-risk adolescents with sub-syndromal depression. CATCH-IT may be a scalable approach to prevent depressive episodes in adolescents in primary care.

A Little Effort Can Withstand the Hardship: Fielding an Internet-Based Intervention to Prevent Depression among Urban Racial/Ethnic Minority Adolescents in a Primary Care Setting

BACKGROUND

This study explored the implementation of Chicago Urban Resiliency Building (CURB), a randomized clinical trial designed as an Internet-based primary care depression prevention intervention for urban African American and Latino adolescents.

METHODS

We utilized a mixed methods analysis to explore four aims. First, we estimated the percent of at-risk adolescents that were successfully screened. Second, we examined clinic site factors and performance. Third, primary care providers (n = 10) and clinic staff (n = 18) were surveyed to assess their knowledge and attitudes about the intervention. Fourth, clinic staff (nursing and medical assistant) interviews were analyzed using thematic analysis to gather perspectives of the implementation process.

RESULTS

We found that the estimated percent of at-risk adolescents who were successfully screened in each clinic varied widely between clinics with a mean of 14.48%. Daily clinic communication was suggestive of greater successful screening. Feasibility of screening was high for both primary care providers and clinic staff. Clinic staff exit interviews indicated the presence of community barriers that inhibited successful implementation of the intervention.

CONCLUSION

This study shares the challenges and successes for depression screening and implementing Internet-based mental health interventions for urban racial/ethnic minority adolescents in primary care settings.

Pain and Function in Home Care: A Need for Treatment Tailoring to Reduce Disparities?

OBJECTIVES

To describe racial/ethnic group differences in pain presentation and the prevalence of psychosocial factors among patients admitted to home health care, and to determine the extent of racial/ethnic group differences in the association of psychosocial factors with pain intensity and pain-related disability.

METHODS

We analyzed cross-sectional data on 588 patients with activity-limiting pain admitted to home care for physical therapy. Three psychosocial factors were assessed: depressive symptoms, pain self-efficacy, and health literacy. Statistical methods included estimation of general linear models of pain intensity and pain-related disability.

RESULTS

Hispanics and non-Hispanic blacks report a greater number of pain sites, worse pain intensity, and higher levels of pain-related disability than non-Hispanic whites and others. Racial/ethnic minority group patients also have a higher prevalence of adverse psychosocial factors than others, with evidence that race/ethnicity interacts with pain self-efficacy and depressive symptoms in their association with mean pain intensity and pain-related disability, respectively.

DISCUSSION

The substantial racial/ethnic difference in the psychosocial profiles of older adults with activity-limiting pain highlights the importance of screening for these modifiable risk factors and tailoring interventions accordingly. Direct attention to the psychosocial needs of patients could help to address racial/ethnic disparities in pain outcomes.

Individual and contextual-level factors associated with continuity of care for adults with schizophrenia

This retrospective cohort study examined rates of conformance to continuity of care treatment guidelines and factors associated with conformance for persons with schizophrenia. Subjects were 8,621 adult Ohio Medicaid recipients, aged 18-64, treated for schizophrenia in 2004. Information on individual-level (demographic and clinical characteristics) and contextual-level variables (county socio-demographic, economic, and health care resources) were abstracted from Medicaid claim files and the Area Resource File. Outcome measures captured four dimensions of continuity of care: (1) regularity of care; (2) transitions; (3) care coordination, and (4) treatment engagement. Multilevel modeling was used to assess the association between individual and contextual-level variables and the four continuity of care measures. The results indicated that conformance rates for continuity of care for adults with schizophrenia are below recommended guidelines and that variations in continuity of care are associated with both individual and contextual-level factors. Efforts to improve continuity of care should target high risk patient groups (racial/ethnic minorities, the dually diagnosed, and younger adults with early onset psychosis), as well as community-level risk factors (provider supply and geographic barriers of rural counties) that impede access to care.

Development of a technology-based behavioral vaccine to prevent adolescent depression: A health system integration model

Efforts to prevent depression have become a key health system priority. Currently, there is a high prevalence of depression among adolescents, and treatment has become costly due to the recurrence patterns of the illness, impairment among patients, and the complex factors needed for a treatment to be effective. Primary care may be the optimal location to identify those at risk by offering an Internet-based preventive intervention to reduce costs and improve outcomes. Few practical interventions have been developed. The models for Internet intervention development that have been put forward focus primarily on the Internet component rather than how the program fits within a broader context. This paper describes the conceptualization for developing technology based preventive models for primary care by integrating the components within a behavioral vaccine framework. CATCH-IT (Competent Adulthood Transition with Cognitive-behavioral, Humanistic and Interpersonal Training) has been developed and successfully implemented within various health systems over a period of 14 years among adolescents and young adults aged 13-24.

An internet-based adolescent depression preventive intervention: study protocol for a randomized control trial

BACKGROUND

The high prevalence of major depressive disorder in adolescents and the low rate of successful treatment highlight a pressing need for accessible, affordable adolescent depression prevention programs. The Internet offers opportunities to provide adolescents with high quality, evidence-based programs without burdening or creating new care delivery systems. Internet-based interventions hold promise, but further research is needed to explore the efficacy of these approaches and ways of integrating emerging technologies for behavioral health into the primary care system.

METHODS/DESIGN

We developed a primary care Internet-based depression prevention intervention, Competent Adulthood Transition with Cognitive Behavioral Humanistic and Interpersonal Training (CATCH-IT), to evaluate a self-guided, online approach to depression prevention and are conducting a randomized clinical trial comparing CATCH-IT to a general health education Internet intervention. This article documents the research framework and randomized clinical trial design used to evaluate CATCH-IT for adolescents, in order to inform future work in Internet-based adolescent prevention programs. The rationale for this trial is introduced, the current status of the study is reviewed, and potential implications and future directions are discussed.

DISCUSSION

The current protocol represents the only current, systematic approach to connecting at-risk youth with self-directed depression prevention programs in a medical setting. This trial undertakes the complex public health task of identifying at-risk individuals through mass screening of the general primary care population, rather than solely relying on volunteers recruited over the Internet, and the trial design provides measures of both symptomatic and diagnostic clinical outcomes. At the present time, we have enrolled N = 234 adolescents/expected 400 and N = 186 parents/expected 400 in this trial, from N = 6 major health systems. The protocol described here provides a model for a new generation of interventions that blend substantial computer-based instruction with human contact to intervene to prevent mental disorders such as depression. Because of the potential for broad generalizability of this model, the results of this study are important, as they will help develop the guidelines for preventive interventions with youth at-risk for the development of depressive and other mental disorders.

TRIAL REGISTRATION

CLINICAL TRIAL REGISTRY

NCT01893749 date 6 May 2012.

Risk and Protective Factors for Three Major Mental Health Problems Among Latino American Men Nationwide

The present study investigated psychosocial predictors for major depressive disorder (MDD), general anxiety disorder (GAD), and suicidal ideation (SI) of Latino American men identified in the first national mental health epidemiological survey of Latinos. Three separate sets of logistic regression analyses were performed for 1,127 Latinos, following preplanned two steps (Model 1—Known Demographic and Acculturation Predictors as controls, Model 2—Psychosocial Risk and Protective Factors). Results show that Negative Interactions with family members significantly predicted the likelihood of both MDD and SI, while SI was also associated with Discrimination. Acculturation Stress was associated with that of GAD (alongside more Income, Education of 12 years, and Years in the United States for less than 11 years). Other potential protective factors (social support, racial/ethnic identity, religious involvement) were not influential. The differential predictors for mental health issues among Latino men imply that assessment and intervention for them may need certain gender-specific foci in order to improve mental health disparities in this population.

Racial/Ethnic disparities in depression and its theoretical perspectives

The purpose of this review is to look at racial/ethnic disparities in the diagnosis of depression and its treatment and to explain the dynamics and causes of these racial/ethnic disparities in depression by looking at several theories, such as perceived racism, cultural competency, and other theories. Perceived racism is that the perceptions of an environmental stimulus as being racist affects the coping responses of ethnic/racial minorities, which alters psychological and physiological stress responses, and finally affects health outcomes negatively. A lower level of cultural competence can lead to health disparities. In addition, lower socioeconomic status and health care providers' beliefs and behaviors about patients' race/ethnicity and class can affect depressive symptoms as well as diagnosis and treatment. In order to reduce these racial/ethnic disparities in depression, diverse interventions should be developed to improve depression outcomes for ethnic minority populations based on these theoretical perspectives.

Enhancing Hispanic participation in mental health clinical research: development of a Spanish-speaking depression research site

BACKGROUND

Hispanics, particularly those with limited English proficiency, are underrepresented in psychiatric clinical research studies. We developed a bilingual and bicultural research clinic dedicated to the recruitment and treatment of Spanish-speaking subjects in the Predictors of Remission in Depression to Individual and Combined Treatments (PReDICT) study, a large clinical trial of treatment-naïve subjects with major depressive disorder (MDD).

METHODS

Demographic and clinical data derived from screening evaluations of the first 1,174 subjects presenting for participation were compared between the Spanish-speaking site (N = 275) and the primary English-speaking site (N = 899). Reasons for ineligibility (N = 888) for the PReDICT study were tallied for each site.

RESULTS

Compared to English speakers, Spanish speakers had a lower level of education and were more likely to be female, uninsured, and have uncontrolled medical conditions. Clinically, Spanish speakers demonstrated greater depression severity, with higher mean symptom severity scores, and a greater number of previous suicide attempts. Among the subjects who were not randomized into the PReDICT study, Spanish-speaking subjects were more likely to have an uncontrolled medical condition or refuse participation, whereas English-speaking subjects were more likely to have bipolar disorder or a non-MDD depressive disorder.

CONCLUSION

Recruitment of Hispanic subjects with MDD is feasible and may enhance efforts at signal detection, given the higher severity of depression among Spanish-speaking participants presenting for clinical trials. Specific approaches for the recruitment and retention of Spanish-speaking participants are required.

Evaluation of a fotonovela to increase depression knowledge and reduce stigma among Hispanic adults

Fotonovelas-small booklets that portray a dramatic story using photographs and captions-represent a powerful health education tool for low-literacy and ethnic minority audiences. This study evaluated the effectiveness of a depression fotonovela in increasing depression knowledge, decreasing stigma, increasing self-efficacy to recognize depression, and increasing intentions to seek treatment, relative to a text pamphlet. Hispanic adults attending a community adult school (N = 157, 47.5 % female, mean age = 35.8 years, 84 % immigrants, 63 % with less than high school education) were randomly assigned to read the fotonovela or a low-literacy text pamphlet about depression. They completed surveys before reading the material, immediately after reading the material, and 1 month later. The fotonovela and text pamphlet both produced significant improvements in depression knowledge and self-efficacy to identify depression, but the fotonovela produced significantly larger reductions in antidepressant stigma and mental health care stigma. The fotonovela also was more likely to be passed on to family or friends after the study, potentially increasing its reach throughout the community. Results indicate that fotonovelas can be useful for improving health literacy among underserved populations, which could reduce health disparities.

Factors contributing to depressive symptoms among Mexican Americans and Latinos

Survey results from 90 Mexican Americans and Latinos found that individuals who experienced social and economic challenges were more likely to self-report depressive symptoms. The prevalence of depressive symptoms among this sample was 30 percent. Results from a logistic regression analysis identified three significant predictors for depressive symptoms: (1) Individuals concerned about discrimination were twice as likely to self-report depressive symptoms; (2) individuals with concerns about access to medical care had a greater likelihood of having depressive symptoms by 94.8 percent; and (3) those who had experienced a dramatic loss of income were 1.1 times more likely to have depressive symptoms than those who had not experienced income loss. Results from the study also confirmed that the majority of Mexican Americans and Latinos prefer to seek assistance for mental health issues from a medical doctoral or from indigenous community resources, such as family members, friends, and religious consultation. Strategies for overcoming barriers to receive adequate and culturally competent mental health care and for coping with dramatic loss of income may help to alleviate depressive symptoms among the Mexican American and Latino populations.

Pilot Study of Implementation of an Internet-Based Depression Prevention Intervention (CATCH-IT) for Adolescents in 12 US Primary Care Practices: Clinical and Management/Organizational Behavioral Perspectives

OBJECTIVE

To explore the implementation of CATCH-IT (Competent Adulthood Transition with Cognitive-behavioral Humanistic and Interpersonal Training), an Internet-based depression intervention program in 12 primary care sites, occurring as part of a randomized clinical trial comparing 2 versions of the intervention (motivational interview + Internet program versus brief advice + Internet program) in 83 adolescents aged 14 to 21 years recruited from February 1, 2007, to November 31, 2007.

METHOD

The CATCH-IT intervention model consists of primary care screening to assess risk, a primary care physician interview to encourage participation, and 14 online modules of Internet training to teach adolescents how to reduce behaviors that increase vulnerability to depressive disorders. Specifically, we evaluated this program from both a management/organizational behavioral perspective (provider attitudes and demonstrated competence) and a clinical outcomes perspective (depressed mood scores) using the RE-AIM model (Reach, Efficacy, Adoption, Implementation, and Maintenance of the intervention).

RESULTS

While results varied by clinic, overall, clinics demonstrated satisfactory reach, efficacy, adoption, implementation, and maintenance of the CATCH-IT depression prevention program. Measures of program implementation and management predicted clinical outcomes at practices in exploratory analyses.

CONCLUSION

Multidisciplinary approaches may be essential to evaluating the impact of complex interventions to prevent depression in community settings. Primary care physicians and nurses can use Internet-based programs to create a feasible and cost-effective model for the prevention of mental disorders in adolescents in primary care settings.

TRIAL REGISTRATION

ClinicalTrials.gov identifiers: NCT00152529 and NCT00145912.

Thirty years of disparities intervention research: what are we doing to close racial and ethnic gaps in health care?

BACKGROUND

A systematic scan of the disparities intervention literature will allow researchers, providers, and policymakers to understand which interventions are being evaluated to improve minority health and which areas require further research.

METHODS

We systematically categorized 391 disparities intervention articles published between 1979 and 2011, covering 11 diseases. We developed a taxonomy of disparities interventions using qualitative theme analysis. We identified the tactic, or what was done to intervene; the strategy, or a group of tactics with common characteristics; and the level, or who was targeted by the effort.

RESULTS

The taxonomy included 44 tactics, 9 strategies, and 6 levels. Delivering education and training was the most common strategy (37%). Within education and training, the most common tactics were education about disease (14%) and self-management (11%), whereas communication skills training (3%) and decision-making aids (1%) were less frequent. The strategy of actively engaging the community through tactics such as community health workers and outreach efforts accounted for 6.5% of tactics. Interventions most commonly targeted patients (50%) and community members who were not established patients of the intervening organization (32%). Interventions targeting providers (7%), the microsystem (immediate care team) (9%), organizations (3%), and policies (0.1%) were less common.

CONCLUSIONS

Disparities researchers have predominantly focused on the patient as the target for change; future research should also investigate how to improve the system that serves minority patients. Areas for further study include interventions that engage the community, educational interventions that address communication barriers, and the impact of policy reform on disparities in care.

Identification of and beliefs about depressive symptoms and preferred treatment approaches among community-living older African Americans

OBJECTIVE

To examine older African American's recognition of and beliefs about depressive symptoms, preferred symptom management strategies, and factors associated with willingness to use mental health treatments. Differences between the depressed and nondepressed and men and women were examined.

DESIGN

Cross-sectional survey.

SETTING

Home, senior center.

PARTICIPANTS

A total of 153 senior center members (56 male, 97 female) 55 years and older.

MEASUREMENTS

Using a depression vignette, participants indicated if the person was depressed and their endorsement of items reflecting beliefs, stigma, symptom management, and willingness to use treatments (yes/no). A 9-item Patient Health Questionnaire assessed current symptomatology.

RESULTS

Overall, 24.2% reported depressive symptoms (≥5); 88.2% correctly identified the person in the vignette as depressed. Most (≥75%) endorsed active symptom management strategies, preference for treatment in physician and therapist offices, and willingness to take medications, seek therapy, see doctor, and attend support groups; less than 33% viewed depression as stigmatizing, whereas 48% viewed depression as normal aging. Logistic regressions revealed lower education, higher physical function, and feeling okay if community knew of depression diagnosis were associated with willingness to see physician if feeling depressed; being married and believing antidepressant medications are beneficial were related to willingness to use medications. Different associations emerged for depressed/nondepressed and men and women.

CONCLUSIONS

Overall, this older African American sample had positive attitudes and beliefs and endorsed traditional treatment modalities suggesting that beliefs alone are unlikely barriers to underutilization of mental health services. Because different factors were associated with willingness to seek physician help and use medications and factors differed for depressed/nondepressed and by sex, interventions should be tailored.

Development and pilot study of a marketing strategy for primary care/internet-based depression prevention intervention for adolescents (the CATCH-IT intervention)

BACKGROUND

Adolescent depression is both common and burdensome, and while evidence-based strategies have been developed to prevent adolescent depression, participation in such interventions remains extremely low, with less than 3% of at-risk individuals participating. To promote participation in evidence-based preventive strategies, a rigorous marketing strategy is needed to translate research into practice.

OBJECTIVE

To develop and pilot a rigorous marketing strategy for engaging at-risk individuals with an Internet-based depression prevention intervention in primary care targeting key attitudes and beliefs.

METHOD

A marketing design group was constituted to develop a marketing strategy based on the principles of targeting, positioning/competitor analysis, decision analysis, and promotion/distribution and incorporating contemporary models of behavior change. We evaluated the formative quality of the intervention and observed the fielding experience for prevention using a pilot study (observational) design.

RESULTS

The marketing plan focused on "resiliency building" rather than "depression intervention" and was relayed by office staff and the Internet site. Twelve practices successfully implemented the intervention and recruited a diverse sample of adolescents with > 30% of all those with positive screens and > 80% of those eligible after phone assessment enrolling in the study with a cost of $58 per enrollee. Adolescent motivation for depression prevention (1-10 scale) increased from a baseline mean value of 7.45 (SD = 2.05) to 8.07 poststudy (SD = 1.33) (P = .048).

CONCLUSIONS

Marketing strategies for preventive interventions for mental disorders can be developed and successfully introduced and marketed in primary care.

A roadmap and best practices for organizations to reduce racial and ethnic disparities in health care

Over the past decade, researchers have shifted their focus from documenting health care disparities to identifying solutions to close the gap in care. Finding Answers: Disparities Research for Change, a national program of the Robert Wood Johnson Foundation, is charged with identifying promising interventions to reduce disparities. Based on our work conducting systematic reviews of the literature, evaluating promising practices, and providing technical assistance to health care organizations, we present a roadmap for reducing racial and ethnic disparities in care. The roadmap outlines a dynamic process in which individual interventions are just one part. It highlights that organizations and providers need to take responsibility for reducing disparities, establish a general infrastructure and culture to improve quality, and integrate targeted disparities interventions into quality improvement efforts. Additionally, we summarize the major lessons learned through the Finding Answers program. We share best practices for implementing disparities interventions and synthesize cross-cutting themes from 12 systematic reviews of the literature. Our research shows that promising interventions frequently are culturally tailored to meet patients' needs, employ multidisciplinary teams of care providers, and target multiple leverage points along a patient's pathway of care. Health education that uses interactive techniques to deliver skills training appears to be more effective than traditional didactic approaches. Furthermore, patient navigation and engaging family and community members in the health care process may improve outcomes for minority patients. We anticipate that the roadmap and best practices will be useful for organizations, policymakers, and researchers striving to provide high-quality equitable care.

Identification and treatment of depression in minority populations

Depression is a common condition, representing close to 6% of visits to primary care providers. Although minorities are more likely to have chronic depression, they are more likely to be incorrectly diagnosed and less likely to receive treatment when compared to the mainstream population. Screening and appropriate treatment within primary care is recommended in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow-up. This recommendation is especially relevant for treatment of minority populations, as they are more likely to seek care for mental health problems from primary care providers rather than specialists. A number of self-report screening tools that simplify screening are available. Treatment modalities that are supported by evidence are psychotherapy, prescription medications, and electroconvulsive therapy for severe depression. Selective serotonin reuptake inhibitors (SSRIs) have become the cornerstone of therapy for depression since the Food and Drug Administration (FDA) approval of fluoxetine in 1987. No substantial differences in efficacy of SSRIs have been found, although data suggest differences with respect to onset of action and adverse effects that may be relevant in the choice of one medicine over another. Common side effects of serotonin reuptake inhibitors include nausea, diarrhea, insomnia, somnolence and dizziness, akathisia, and sexual dysfunction. While most of these symptoms tend to subside within several weeks of use, sexual dysfunction appears to be a long-term side effect that typically reverses within a few days after discontinuation of the causative medication. Selective norepinephrine reuptake inhibitors (SNRIs), bupropion, mirtazapine, and tricyclic antidepressants (TCAs) are other commonly used medications. Complementary and alternative treatments, such as St. John's wort (Hypericum perforatum), exercise, acupuncture, music therapy, and relaxation, have limited data supporting their efficacy.

Racial and ethnic disparities in depression care in community-dwelling elderly in the United States

OBJECTIVES

We investigated racial/ethnic disparities in the diagnosis and treatment of depression among community-dwelling elderly.

METHODS

We performed a secondary analysis of Medicare Current Beneficiary Survey data (n = 33,708) for 2001 through 2005. We estimated logistic regression models to assess the association of race/ethnicity with the probability of being diagnosed and treated for depression with either antidepressant medication or psychotherapy.

RESULTS

Depression diagnosis rates were 6.4% for non-Hispanic Whites, 4.2% for African Americans, 7.2% for Hispanics, and 3.8% for others. After we adjusted for a range of covariates including a 2-item depression screener, we found that African Americans were significantly less likely to receive a depression diagnosis from a health care provider (adjusted odds ratio [AOR] = 0.53; 95% confidence interval [CI] = 0.41, 0.69) than were non-Hispanic Whites; those diagnosed were less likely to be treated for depression (AOR = 0.45; 95% CI = 0.30, 0.66).

CONCLUSIONS

Among elderly Medicare beneficiaries, significant racial/ethnic differences exist in the diagnosis and treatment of depression. Vigorous clinical and public health initiatives are needed to address this persisting disparity in care.

Are patient characteristics associated with quality of depression care and outcomes in collaborative care programs for depression?

OBJECTIVE

To determine whether demographic or clinical characteristics of primary care patients are associated with depression treatment quality and outcomes within a collaborative care model.

METHODS

Collaborative depression care, based on principles from the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) trial, was implemented in six community health organizations serving disadvantaged patients. Over 3 years, 2821 patients were treated. Outcomes were receipt of quality treatment and depression improvement.

RESULTS

Logistic regression analyses revealed that patients who were older, more depressed or more anxious were more likely to be retained in treatment and to receive appropriate pharmacotherapy. Whereas gender and depression severity were unrelated to depression outcomes, significantly more patients who preferred Spanish (59.1%) than English (48.5%, P<.01) improved within 12 weeks in multivariate analyses. High baseline anxiety was associated with a lower probability of improvement, and older age showed a similar trend. Survival analyses demonstrated that patients who preferred Spanish or were less anxious improved significantly more rapidly than their counterparts (P<.001).

CONCLUSIONS

Patients with more anxiety received higher quality care but experienced worse depression outcomes than less anxious patients. Spanish language preference was strongly associated with depression improvement. This collaborative care program attained admirable outcomes among disadvantaged Spanish-speaking patients without extensive cultural tailoring of care.

Attitudes toward depression among a sample of Muslim adolescents in the Midwestern United States

BACKGROUND

Little is known about how Muslim youth in non-Muslim countries perceive depression and its treatment and prevention.

OBJECTIVE

We investigated the barriers and suggest treatment models for depressive disorders in Muslim adolescents and young adults residing in the United States.

METHODS

We conducted a thorough literature review to identify previous study on the beliefs of American Muslim adolescents about depression and its treatment. We identified the gaps and developed a survey to ascertain this information from American Muslim adolescents.

RESULTS

The survey was administered to a convenience sample of 125 Muslim subjects (60.0% males) aged 14-21 years. The sample was ethnically diverse with Pakistani (44.8%) encompassing the majority of the sample. Most responders believed that recitation from the Koran relieves mental distress. Multiple linear regression analysis revealed that those who reported strong emotional support from parents or a greater acceptance of taking depression medication prescribed from a physician were more likely to accept a physician's diagnosis, whereas believing in prayer to heal depression was associated with a lower likelihood of the same. Youth were accepting of Internet and preventive approaches.

CONCLUSION

Planning of culturally sensitive mental health services is useful to accommodate the needs of Muslim youth served by primary care physicians and mental health practitioners in the United States. Muslim adolescents tend to be more traditional with family, social, and religious values. This value system plays an important role in their likelihood of seeking and accepting professional help for depression.

Adolescent and parent experiences with a primary care/Internet-based depression prevention intervention (CATCH-IT)

This article describes a mixed-methods approach to understand the experience of adolescents involved in the Internet-based intervention for depression, Competent Adulthood Transition with Cognitive Behavioral Humanistic and Interpersonal Training (CATCH-IT), as well as the experiences of their parents while they were involved. Qualitative analysis was done with grounded theory-based categorization of interview comments and typed program responses (adolescents only) into themes. Quantitative analysis was done with self-report surveys. The article describes the nine themes reflecting the adolescent experience and the three themes reflecting the parent experience. The article also describes the results of the quantitative surveys of helpfulness and attitudes change, which were favorable of the Internet-based intervention. Separate models explaining the psychological transformation of the adolescents and the experience of the parents are proposed. The positive experience of the adolescents and parents involved in CATCH-IT is discussed in the context of growing interest in how best to utilize Internet-based interventions for mental illness, and suggestions are made for future investigation.

A study of a culturally focused psychiatric consultation service for Asian American and Latino American primary care patients with depression

BACKGROUND

Ethnic minorities with depression are more likely to seek mental health care through primary care providers (PCPs) than mental health specialists. However, both provider and patient-specific challenges exist. PCP-specific challenges include unfamiliarity with depressive symptom profiles in diverse patient populations, limited time to address mental health, and limited referral options for mental health care. Patient-specific challenges include stigma around mental health issues and reluctance to seek mental health treatment. To address these issues, we implemented a multi-component intervention for Asian American and Latino American primary care patients with depression at Massachusetts General Hospital (MGH).

METHODS/DESIGN

We propose a randomized controlled trial to evaluate a culturally appropriate intervention to improve the diagnosis and treatment of depression in our target population. Our goals are to facilitate a) primary care providers' ability to provide appropriate, culturally informed care of depression, and b) patients' knowledge of and resources for receiving treatment for depression. Our two-year long intervention targets Asian American and Latino American adult (18 years of age or older) primary care patients at MGH screening positive for symptoms of depression. All eligible patients in the intervention arm of the study who screen positive will be offered a culturally focused psychiatric (CFP) consultation. Patients will meet with a study clinician and receive toolkits that include psychoeducational booklets, worksheets and community resources. Within two weeks of the initial consultation, patients will attend a follow-up visit with the CFP clinicians. Primary outcomes will determine the feasibility and cost associated with implementation of the service, and evaluate patient and provider satisfaction with the CFP service. Exploratory aims will describe the study population at screening, recruitment, and enrollment and identify which variables influenced patient participation in the program.

DISCUSSION

The study involves an innovative yet practical intervention that builds on existing resources and strives to improve quality of care for depression for minorities. Additionally, it complements the current movement in psychiatry to enhance the treatment of depression in primary care settings. If found beneficial, the intervention will serve as a model for care of Asian American and Latino American patients.

Factors associated with antidepressant adherence for Medicaid-enrolled children and adolescents

BACKGROUND

Antidepressants have been shown to be efficacious for the treatment of pediatric depression. However, many youths do not receive an adequate duration of treatment, and factors associated with nonadherence in this population remain poorly understood.

OBJECTIVE

To examine rates of antidepressant adherence for depressed youth and identify factors associated with adherence during the acute and continuation phases of treatment.

METHODS

A retrospective cohort analysis was conducted using claims data from a state Medicaid-enrolled population of 1650 youths (aged 5-17 years) with new episodes of depression between January 1, 2005, and December 30, 2007. These patients were treated with selective serotonin reuptake inhibitors or newer antidepressants and followed for 6 months from the first prescription fill date. Adherence measures were derived from the Health Plan Employer Data and Information Set (HEDIS) quality indicators on antidepressant management (3 months of continuous treatment for the acute phase and 6 months for the continuation phase) and assessed using the medication possession ratio. Multivariate logistic regression analyses evaluated the association between demographic, clinical, medication, and treatment factors, and adherence.

RESULTS

About half (49.5%) of the youths were adherent to antidepressant medication during the acute phase, and 42% of these were adherent during the continuation phase; 21% were adherent across both treatment phases. Optimal follow-up visits and adequate antidepressant dosing was associated with better adherence during both treatment phases, as was use of other psychotropic medications. Youths prescribed trazodone for sleep had higher adherence rates during the acute phase. Minority youths and adolescents had lower adherence rates during the acute phase. Youths in foster care had higher adherence rates during both treatment phases.

CONCLUSIONS

Nonadherence with antidepressant medications is common among Medicaid-covered children and adolescents. Study findings underscore the need for clinicians to deliver guideline-concordant care, assess adherence, and develop interventions that improve adherence, particularly for vulnerable subgroups.

Racial and ethnic service use disparities among homeless adults with severe mental illnesses receiving ACT

OBJECTIVE

Case management-based interventions aimed at improving quality of care have the potential to narrow racial and ethnic disparities among people with chronic illnesses. The aim of this study was to assess the equity effects of assertive community treatment (ACT), an evidence-based case management intervention, among homeless adults with severe mental illness.

METHODS

This study used baseline, three-, and 12-month data for 6,829 black, Latino, and white adults who received ACT services through the ACCESS study (Access to Community Care and Effective Services and Support). Zero-inflated Poisson random regression models were used to estimate the adjusted probability of use of outpatient psychiatric services and, among service users, the intensity of use. Odds ratios and rate ratios (RRs) were computed to assess disparities at baseline and over time.

RESULTS

No disparities were found in probability of use at baseline or over time. Compared with white users, baseline intensity of use was lower for black users (RR=.89; 95% confidence interval [CI]=.83-.96) and Latino users (RR=.65; CI=.52-.81]). Intensity did not change over time for whites, but it did for black and Latino users. Intensity increased for blacks between baseline and three months (RR=1.11, CI=1.06-1.17]) and baseline and 12 months (RR=1.17, CI=1.11-1.22]). Intensity of use dropped for Latinos between baseline and three months (RR=.83, CI=.70-.98).

CONCLUSIONS

Receipt of ACT was associated with a reduction in service use disparities for blacks but not for Latinos. Findings suggest that ACT's equity effects differ depending on race-ethnicity.

Internet-based depression prevention over the life course: a call for behavioral vaccines

Technology-based approaches for the prevention of depression offer considerable benefits including easy access, patient autonomy, and "nonconsumable" services that are autonomous from traditional (face-to-face) interventions. The authors have previously worked to develop Internet interventions based on the frameworks for conventional, face-to-face effective community-based interventions, and propose to integrate these models into a "behavioral vaccine model" aptly applicable to technology-based delivery. This article reviews the literature on Internet-based depression prevention programs using this behavioral vaccine development model, reviewing literature relevant to each component of the model in turn.

Telemental Health and Web-based Applications in Children and Adolescents

The authors conducted a review of the literature with regard to child and adolescent mental health intervention, from which they identified 20 unique publications and 12 separate interventions. These interventions encompassed depression, anxiety, substance abuse, eating disorders, and mental health promotion. Studies were heterogeneous, with a wide range of study designs and comparison groups creating some challenges in interpretation. However, modest evidence was found that Internet interventions showed benefits compared with controls and preintervention symptom levels. Interventions had been developed for a range of settings, but tended to recruit middle-class participants of European ethnicity. Internet interventions showed a range of approaches toward engaging children and incorporating parents and peers into the learning process.

Retention in depression treatment among ethnic and racial minority groups in the United States

BACKGROUND

Premature discontinuation of psychiatric treatment among ethnic-racial minorities is a persistent concern. Previous research on identifying factors associated with ethnic-racial disparities in depression treatment has been limited by the scarcity of national samples with adequate representation of minority groups and especially non-English speakers. In this article, we aim to identify variations in the likelihood of retention in depression treatment among ethnic-racial minority groups in the United States as compared to non-Latino whites. Second, we aim to identify the factors that are related to treatment retention.

METHODS

We use data from the Collaborative Psychiatric Epidemiology Surveys to examine differences and correlates of depression treatment retention among a representative sample (n=564) of non-Latino whites, Latinos, African-American, and Asian respondents with last 12-month depressive disorder and who report receiving formal mental health treatment in the last year. We define retention as attending at least four visits or remaining in treatment during a 12-month period.

RESULTS

Being seen by a mental health specialist as opposed to being seen by a generalist and having received medication are correlates of treatment retention for the entire sample. However, after adjusting for demographics, clinical factors including number of co-occurring psychiatric disorders and level of disability, African-Americans are significantly less likely to be retained in depression treatment as compared to non-Latino whites.

CONCLUSIONS

Availability of specialized mental health services or comparable treatment within primary care could improve treatment retention. Low retention suggests persistent problems in the delivery of depression treatment for African-Americans.

Differences in vulnerability factors for depressive episodes in African American and European American adolescents

BACKGROUND

Although intervention tailoring could lower the burden of adolescent depression, few studies have examined differences in vulnerability factors between African American and European American youth.

METHODS

We determined and compared the prevalence, relative risk, and population-attributable risk (PAR) of baseline vulnerability factors predicting depressive episodes at 1-year follow-up in a nationally representative sample of African American and European American adolescents.

RESULTS

The leading (highest PAR) vulnerability factors for African American adolescents were demographics, while the top vulnerability factors for European American youth were current depressed affect and low perceived family connectedness. Unique vulnerability factors for African American youth were (1) neither parent finished high school, (2) believing oneself unintelligent, and (3) running away from home. Avoidant problem solving, divorce, poor residential father relationship, sexual relationships, and delinquent behaviors did not predict depressive episodes in African American adolescents but did in European American. Low family and peer connectedness were important common vulnerability factors for both groups.

CONCLUSIONS

Differing patterns of vulnerability suggest that alternative strategies may be better suited to preventing depression among African American youth. A first step may lie in understanding what mediates the effect of low parental educational status on future depression risk.

Demands of Immigration, Health Literacy, and Depression in Recent Latino Immigrants

Latino immigrants have unique stressors that can influence mental health. The challenges of adapting to a new society include language barriers, separation from family, and feelings of loss, which can lead to depression. Low health literacy may make it difficult to obtain health care services, and depression may then go untreated. This secondary data analysis examined the relationships of immigration demands, health literacy, and depression in a sample of recent Latino immigrants. Depressive symptoms were a significant problem; 26% of the participants reported symptoms that were suggestive of depression. Furthermore, low health literacy and greater immigration demands predicted higher depression scores. The study suggests that recent Latino immigrants would benefit from health literacy training, education on depressive symptoms, and better access to mental health services. Latinos who do access health care services need to be screened for depression; furthermore, home health care nurses can promote access to support and health care services.

Health care quality-improvement approaches to reducing child health disparities

Relatively few quality-improvement efforts have been aimed at reducing differences in children's care and outcomes across race and ethnicity, socioeconomic status, and insurance status. To inform quality-improvement efforts to reduce child health disparities, we summarize lessons learned from the adult disparities-intervention literature, identify interventions that have reduced disparities in pediatric asthma outcomes and immunization rates, and outline special considerations for child disparity interventions. Key recommendations for providers, health care organizations, and researchers include: (1) examine your performance data stratified according to insurance status, race/ethnicity, language, and socioeconomic status; (2) measure and improve childhood health-related quality of life, development, and condition-specific targets (such as asthma and immunizations); (3) measure and improve anticipatory guidance for early prevention of conditions (such as injuries, violence, substance abuse, and sexually transmitted diseases) and efforts to promote positive growth (such as readership programs to improve low literacy); (4) measure and improve structural aspects of care that affect child health outcomes and can reduce disparities, such as patient-centered medical-home elements; (5) incorporate families into interventions; (6) use multidisciplinary teams with close tracking and follow-up of patients; (7) integrate non-health care partners into quality-improvement interventions; and (8) culturally tailor quality improvement. A key recommendation for payers is to align financial incentives to reduce disparities. The National Institutes of Health and other funders should support (1) disparity-intervention studies on these recommendations that analyze clinical outcomes, intervention-implementation processes, and costs, and (2) creation of new child health services researchers who can find effective quality-improvement approaches for reducing disparities.

Racial and ethnic disparities in police-reported intimate partner violence and risk of hospitalization among women

OBJECTIVES

We sought to examine racial and ethnic disparities in police-reported intimate partner violence (IPV) and hospitalization rates and rate ratios among women with police-reported IPV relative to those without such reports.

METHODS

This retrospective cohort study linked adult male-to-female IPV police records of non-Hispanic Black, Hispanic, and non-Hispanic White women residing in a south central US city with regional hospital discharge data. Rates and incidence rate ratios (IRR) were calculated and age-adjusted where the data allowed.

RESULTS

Police-reported IPV rates were 2-3 times higher among Black and Hispanic women compared with White women. Overall, hospitalization rates were higher among Black and White victims and lower among Hispanic victims than their counterparts in the comparison group (age-adjusted IRR [aIRR], 1.23; 95% confidence interval [CI], 1.08-1.41; aIRR, 1.46; 95% CI, 1.19-1.79; and aIRR, 0.68; 95% CI, 0.54-0.86, respectively). Rate ratios were significant for victims among 1) White women for any mental disorder (aIRR, 2.02; 95% CI, 1.30-3.13) and for episodic mood/depressive disorders in particular (aIRR, 2.18; 95% CI, 1.33-3.59); 2) Black and White women for any injury-related diagnosis (aIRR, 2.46; 95% CI, 1.48-4.10 and aIRR, 3.20; 95% CI, 1.65-6.19, respectively); and 3) all women for intentional injury (IRR, 10.45; 95% CI, 3.56-30.69) and self-inflicted injury (IRR, 4.91; 95% CI, 2.12-11.37).

CONCLUSIONS

Exposure to IPV as reported to police increases the rate of hospital utilization among Black and White women, but lowers the rate for Hispanic women. Screening for IPV in hospitals may identify a substantial number of IPV-exposed women. Primary and secondary prevention efforts related to IPV should be culturally informed and specific.

The Effects of Integrative Reminiscence on Depressive Symptoms in Older African Americans

The purpose of this pilot study was to evaluate the effect of integrative reminiscence on depressive symptoms in older African Americans. Fifty-six community-dwelling participants from a northeast urban setting were randomized into a reminiscence intervention group ( n = 19), attention control group (health education; n = 19), or true control group ( n = 18). Data were collected pre- and posttest using the Center for Epidemiological Studies Depression Scale. Significant differences were found between groups, F(2, 52) = 8.6, p = .001, η2 = .10. Using Holm’s method of post hoc analysis, the mean score for the reminiscence group was 6.8 ( SD = 4.7), significantly different from the control group 14.6 ( SD = 10.1) and the health education group 11.7 ( SD = 7.1). Findings demonstrate that integrative reminiscence has a positive effect on decreasing depressive symptoms in older African Americans.

Interventions to reduce racial and ethnic disparities in health care

In 2005, the Robert Wood Johnson Foundation created Finding Answers: Disparities Research for Change, a program to identify, evaluate, and disseminate interventions to reduce racial and ethnic disparities in the care and outcomes of patients with cardiovascular disease, depression, and diabetes. In this introductory paper, we present a conceptual model for interventions that aim to reduce disparities. With this model as a framework, we summarize the key findings from the six other papers in this supplement on cardiovascular disease, diabetes, depression, breast cancer, interventions using cultural leverage, and pay-for-performance and public reporting of performance measures. Based on these findings, we present global conclusions regarding the current state of health disparities interventions and make recommendations for future interventions to reduce disparities. Multifactorial, culturally tailored interventions that target different causes of disparities hold the most promise, but much more research is needed to investigate potential solutions and their implementation.