Patients talked about the importance of being able to tell their story without being interrupted by the provider asking repeated questions. A brief excerpt illustrates the experience of providers when they tried to use an actuarial approach in the clinical intake:
I got the sense that he wanted to, you know, have to kind of like tell his story and that just wasn't in the cards for today, `cause we needed to fill out the intake, so, I could tell that he was unpleased that, you know, I would be interrupting him and asking him all these questions. You know, he said at the end that he didn't feel that he could really talk to me, that sometimes he didn't think I was listening. [450CN]*
Repeatedly, providers stated the tension they experienced in trying to fulfill multiple roles in the intake process: understanding what brought the patient in; completing a diagnostic assessment; establishing a good working alliance; planning treatment; addressing questions for the referral source; and completing intake forms. They described how achieving these multiple goals required using time efficiently.
Concordance in diagnoses
Comparing the diagnosis given during the intake session and the one given by the clinician coder (data not shown), we found greater levels of agreement for substance-related disorders (κ = 0.70), lower levels for anxiety disorders (κ = 0.35) and depressive disorders (κ = 0.33), and very low agreement for most specific disorders except drug abuse/dependence (κ = 0.80), obsessive-compulsive disorder (κ = 0.66), and panic disorder (κ = 0.64).*
These kappa coefficients would support the contention that clinicians weigh information differently.
We also observed two major patterns (data not shown). First, cases for which there is agreement between intake clinician and clinician coder on the presence of a particular disorder (eg, concordant positive) are more likely to exhibit more symptom information linked to the observed disorder, whereas cases in which they agree that the patient does not have the disorder (eg, concordant negative) or they do not agree on the patient's diagnosis (eg, discordant) have substantially less information collected. For example, in 94 percent of concordant-positive cases of depressive disorder there was discussion of depression; in 73 percent of these cases suicide was brought up. For discordant cases in which the intake clinician defined the case as positive for depression but the clinician coder evaluated the case as negative, we see that depressed mood (73%) or depression (64%) was raised in the majority of these cases. However, when we look at the frequency of discussing specific symptoms of depression, in only about a third of cases were sleep disturbance or weight loss talked about during the intake. In cases where the clinician coder regarded the case as positive for depression but the intake clinician did not, the opposite pattern was seen, with symptoms of depression being more likely to be mentioned (72.7% discussed sleep disturbance, 63.6% brought forth poor appetite, 54.5% mentioned of loss of energy) but apparently disregarded by the intake clinician.
Omission of diagnostic information in intake was more common for anxiety and substance disorders. Most criteria for anxiety and substance disorders were not assessed, according to the clinician coders who evaluated what items were discussed during the clinical interview. Again, for discordant cases, anxiety and exposure to traumatic events were discussed in approximately half of these cases, but specific symptoms of anxiety were generally not discussed. A similar pattern was observed for substance use disorders, where only in concordant-positive cases do we see specific symptoms linked to substance abuse or dependence criteria as part of the intake in comparison with negative or discordant cases. shows that most cases, independently of race or ethnicity, were screened with general probes for mood, anxiety, and substance disorders. However, except for major depressive disorder (64.9%), most criteria to fulfill a diagnosis were not assessed in actual practice for patients belonging to any of the racial and ethnic groups (see ). Compared with Latino and Black patients, Whites had more criteria assessed for alcohol disorder (26.9%) and for drug abuse disorder (44.8%).
Discussion rates of symptom screeners across racial/ethnic groups
Percent of cases assessed for most diagnostic criteria
Factor analyses to identify latent symptom clusters
The factors included the following: (1) a depression factor (eg, with items on diminished interest or pleasure in activities, weight change, sleep disturbance, fatigue or loss of energy, worthlessness, excessive guilt, diminished ability to think, suicidality, hopelessness, and poor functioning; range of factor scores = [-1.827, 1.465]); (2) an anxiety factor (eg, with items on any mention of anxiety, anxiety in places where escape will be difficult, recurrent and unexpected panic attacks, somatic symptoms of anxiety, marked and persistent fear of objects/situations; obsessions; or being worried, nervous, or tense; range of factor scores = [-0.99, 2.261]); (3) a trauma factor (eg, with items on exposure to a traumatic event, traumatic event persistently experienced or persistent symptoms of increased arousal; range of factor scores = [-0.787, 1.793]); (4) substance history, life stressor, and mental health history factor (eg, lifetime substance abuse treatment, current substance abuse treatment, history of respondent and/or family substance use, availability of substances, history of mental disorder, current psychiatric hospitalization, problems with physical health, relationship conflict, academic failure in school, trouble with police, history of driving under the influence; range of factor scores = [-0.247, 2.481]); (5) family history of abuse/victimization and disability factor that describes other symptoms (eg, respondent or family member victim of a crime, family member perpetrator, history of physical, sexual or emotional abuse; and general role difficulties/disability; range of factor scores = [-0.382, 2.126]); (6) an alcohol use factor (eg, any information on alcohol use, symptoms of alcohol abuse and/or dependence; range of factor scores = [-1.511, 1.705]); and (7) a drug use factor (eg, any information on substance use, symptoms of substance abuse and/or dependence; range of factor scores = [-1.21, 1.804])
Rates of discussing symptoms and topics by race/ethnicity
In this next set of analyses, we look at what information factors are actually collected during the diagnostic interview and whether the rate of discussion of different topic areas (factors) differs by patients' race/ethnicity. displays the rates of discussion for the items related to the latent factors that have factor loadings greater than 0.40 and also the P values for testing differences in discussion rates for each item between Whites and Latinos. Examining the discussion rates, we found that although marked dysfunction with depression was more likely to be discussed with Latinos than with Whites, having depressed mood was more frequently discussed with Whites than with Latinos (P < .01). For anxiety items, any mention of anxiety and obsession was more likely to be discussed with Whites than with Latinos (P < .05), whereas exposure to traumatic events was more likely to be discussed with Latinos than with White patients (P < .05). Most alcohol factor symptoms, drug factor symptoms, substance history, and life stressor factor symptoms were substantially more frequently discussed with White patients than with Latino patients, as shown in .
Discussion rates of symptoms linked to specific factors by race/ethnicity
Association of race/ethnicity and latent symptom factors with diagnosis
Female sex and information on trauma were associated with increased likelihood of giving a depression diagnosis by the clinician doing the intake, whereas discussion of anxiety symptoms decreased the likelihood of depression diagnosis (). Being female and discussion of exposure to trauma increased the odds of receiving a diagnosis of depression but not ethnicity. There was a significant interaction between Latino ethnicity and discussion of family history of abuse/victimization and disability. Latinos who had more discussion of family history of abuse/victimization and disability with the provider were more likely to be given a depression diagnosis than non-Latino Whites who also had the same discussions. Symptoms of anxiety (anxiety factor) and being Latino (as compared with White) were found to be associated with increased likelihood of receiving an anxiety diagnosis (). There were no significant interactions between race/ethnicity and the latent factor scores associated with anxiety disorder diagnosis. Being female and being Latino were associated with a decreased risk of substance use diagnosis, whereas discussing symptoms of the drug abuse/dependence factors was related to augmented odds of receiving a substance use disorder diagnosis. Because of low event rates, we were unable to examine the race/ethnicity and latent factor interactions for diagnoses of substance use disorders.
Odds ratios (95% confidence intervals) from estimated logistic regression models based on 107 subjects assessed at 8 clinics