Depression and substance use disorders (SUDs) are among the most common and debilitating psychiatric problems, but their impact is unevenly distributed . Mental health care disparities may be defined as “a difference in treatment provided to members of different racial or ethnic groups that is not justified by the underlying health conditions or treatment preferences of patients” [1
]. For example, members of ethnic minority groups in the United States (African American, Latinos) are more likely than Whites to have depressive disorders under-identified or under-treated [2
]. Compared to Whites with depression, African Americans and Latinos are less likely to fill an antidepressant prescription (indicating that treatment preferences as well as actual disparities in care may play a role in the utilization differences observed) [4
]. Asian Americans may also receive inadequate depression care relative to Whites, but have been studied much less than African Americans and Latinos [7
]. Such ethnic (and socio-economic) disparities in care are of significant concern to providers and policy-makers around the world.
Compared with depression, less is known about the extent to which race-ethnic disparities exist in SUD treatment. Higher lifetime prevalence of drug use disorders has been found for Whites than for African Americans, Latinos, or Asian Americans [9
]. Yet African Americans and Latinos have disproportionate alcohol-related morbidity and mortality [10
]. Two general population studies found that African Americans [11
] and Latinos [12
] were more likely to enter SUD treatment than Whites, but a Medicaid managed care study had mixed findings on treatment access based on type of service examined, with Whites more likely to access inpatient treatment [13
]. African Americans and Latinos have been over-represented in treatment relative to their proportions in the population [14
]. However, a survey of public programs found that African Americans had lower completion rates than Whites after controlling for other factors [15
]. This variability in the literature, and lack of attention to Asian Americans, indicates that further work is needed to determine the extent of SUD service disparities such as accessing treatment.
Both patient and system factors potentially contribute to disparities in health care, including socioeconomic status, stigma, distrust of providers, poor identification, and lack of culturally competent services [16
]. In the United States, inequities in having insurance contribute, but disparities have also been found in private systems and in nations with universal coverage systems. In a private managed care health plan, African Americans and Latinos were less likely to use outpatient mental health services [17
]. In a U.S. study of Medicare managed care plans, African Americans were less likely than Whites to receive follow-up after psychiatric hospitalization [18
]. It is therefore important to continue to investigate disparities within systems where lack of insurance is not a barrier to care.
Few prior studies have examined behavioral health disparities separately by gender, yet there are several reasons to do so. Women have higher depression prevalence [19
] and lower SUD prevalence than men. Women are more likely to receive depression services than men [20
], yet face additional SUD treatment barriers and are less likely to seek these services [22
]. Men are more likely than women to prefer antidepressant treatment to counseling [23
]. Ethnic differences in SUD treatment initiation [25
] and retention [26
] may vary by gender, with implications for improving services. Examining men and women together could obscure these effects [26
]. For these reasons we explore ethnic differences and factors associated with accessing depression and SUD treatment separately by gender.
The present study investigated race-ethnic disparities in accessing treatment for depression and SUD among members of a large Northern California health plan with an integrated health care delivery system. Primary outcomes examined in multivariate analysis included accessing antidepressant medication (for patients diagnosed with depression) and accessing chemical dependency programs (for patients diagnosed with SUD) because these are the main treatment modalities in the health plan. Factors hypothesized to impact accessing treatment were based on the behavioral model of service utilization [28
] used in prior studies of ethnic disparities [8
] that may help to explain effects of ethnicity on accessing treatment. Studies of adults under age 65 have found that age, income, and education have been predisposing factors associated with treatment utilization for depression [8
] and SUD [9
]. Having a co-occurring condition (both depression and SUD) is a marker of psychiatric severity and treatment need [11
], and has been associated with SUD treatment initiation [9
]. Having a regular health care provider is a facilitating factor that may vary by ethnicity and could increase likelihood that patients receive specialty care [13
]. The study hypothesized that these factors might predict accessing treatment independent of ethnicity.
As secondary outcomes for patients diagnosed with depression, in bivariate analysis we examined ethnic differences in accessing psychiatry and psychological counseling or therapy. These outcomes are less clearly indicative than medication of receiving depression care, since psychiatric services or counseling might be sought for problems other than depression. But because of the literature that ethnic minorities are less likely to use antidepressant medication [4
], these outcomes were tested to explore whether minorities might compensate for lack of antidepressant utilization with other types of services.
This investigation potentially makes several contributions to the literature on health care disparities. It investigated differences in accessing medication, psychiatry clinics, and chemical dependency programs in an integrated health system in which all patients have coverage for this care, and in which services are provided internally rather than contracted with other agencies. Patient services were measured using a combination of electronic specialty care clinic records, pharmacy records, and self-report survey measures. We examined both depression and SUD in the same sample, as well as the impact on accessing treatment of having both disorders. The study includes Asian Americans, who have been particularly under-investigated. It is anticipated that the findings will contribute to understanding health care disparities and contributing factors, and identify areas for improvement in service delivery.