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1.  The Relationship between Obesity and Psychiatric Disorders across Ethnic and Racial Minority Groups in the United States 
Eating behaviors  2010;12(1):1-8.
Context
Epidemiologic studies of obesity have not examined the prevalence and relationship of mental-health conditions with obesity for diverse ethnic and racial populations in the United States.
Objective
(1) To assess whether obesity was associated with diverse psychiatric diagnoses across a representative sample of non-Latino whites, Latinos, Asians, African-Americans, and Afro-Caribbeans; and (2) to test whether physical health status, smoking, sociodemographic characteristics, and psychiatric comorbidities mediate any of the observed associations.
Design
Our analyses used pooled data from the NIMH Collaborative Psychiatric Epidemiology Surveys (CPES). Analyses tested the association between obesity and psychiatric disorders in a diverse sample of Americans (N=13,837), while adjusting for factors such as other disorders, age, gender, socioeconomic status, smoking and physical health status (as measured by chronic conditions and WHO-DAS scores) in different models.
Results
The relationship between obesity and last-year psychiatric disorders varied by ethnicity/race. The likelihood of having mood or anxiety disorder was positively associated with obesity for certain racial/ethnic groups, but was moderated by differences in physical health status. Substance-use disorders were associated with decreased odds for obesity in African-Americans.
Conclusions
The role of physical health status (as measured by chronic conditions and WHO-DAS scores) dramatically changes the pattern of associations between obesity and psychiatric disorders, suggesting the important role it plays in explaining differential patterns of association across racial and ethnic groups.
doi:10.1016/j.eatbeh.2010.08.008
PMCID: PMC3052947  PMID: 21184966
obesity; depression; anxiety; ethnic/racial minority groups
2.  Psychiatric Disorders and Labor Market Outcomes: Evidence from the National Latino and Asian American Study 
Health economics  2007;16(10):1069-1090.
This paper investigates to what extent psychiatric disorders and mental distress affect labor market outcomes in two rapidly growing populations that have not been studied to date – ethnic minorities of Latino and Asian descent, most of whom are immigrants. Using data from the National Latino and Asian American Study (NLAAS), we examine the labor market effects of having any psychiatric disorder in the past 12 months as well as the effects of experiencing psychiatric distress in the past 12 months. The labor market outcomes analyzed are current employment status, the number of weeks worked in the past year among those who are employed, and having at least one work absence in the past month among those who are employed. Our results show that among Latinos, psychiatric disorders and mental distress are associated with large, detrimental effects on employment and absenteeism, similar to effects found in analyses of mostly white, American born populations. Among Asians, we find more mixed evidence that psychiatric disorders and mental distress detract from labor market outcomes.
doi:10.1002/hec.1210
PMCID: PMC2675701  PMID: 17294497
mental illness; psychiatric disorders; mental distress; labor market outcomes; ethnicity; Latino and Asian Americans
3.  Prevalence of Psychiatric Illnesses among Ethnic Minority Elderly 
OBJECTIVES
To compare lifetime and 12-month prevalence of DSM-IV psychiatric disorders among a national representative sample of older Latinos, Asians, African-Americans, and Afro-Caribbean to non-Latino Whites.
DESIGN
Cross-sectional study conducted in 2001 through 2004.
SETTING
Urban and rural households in the contiguous United States.
PARTICIPANTS
A total of 4,245 community-dwelling residents aged 50 and older living in non-institutional settings. Data are from the NIMH Collaborative Psychiatric Epidemiology Surveys.
METHODS
The World Health Organization Composite International Diagnostic Interview assessed lifetime and 12-month psychiatric disorders. Interviewers matched the cultural background and language preference of participants. Bayesian estimates compared psychiatric disorder prevalence rates among ethnic/racial groups.
RESULTS
After gender adjustments, older non-Latino Whites had higher lifetime rates of any depressive disorder than African-Americans but were no different than older Latinos. Older Asians and Afro-Caribbean had significantly lower lifetime rates of any depressive, anxiety, and substance use disorders than non-Latino Whites. Immigrant Asians had higher lifetime rates of GAD than the U.S.-born Asians and immigrant Latinos had higher lifetime rates of dysthymia and GAD than U. S.-born Latinos. U.S. born Latinos had higher lifetime rates of substance abuse, especially alcohol abuse, than immigrant Latinos. There were no significant differences in the rates of 12-month psychiatric disorders between non-Latino whites and ethnic/racial minorities, except that older African-Americans had higher 12-month rates of any substance use disorder compared to non-Latino Whites.
CONCLUSION
Prevalence rates vary considerably by ethnicity and race as well as by nativity for older minorities, suggesting different patterns of illness and risk.
doi:10.1111/j.1532-5415.2009.02685.x
PMCID: PMC2854540  PMID: 20374401
ethnicity; prevalence; psychiatric illness; older adults
4.  Prevalence, Patterns, and Correlates of Co-Occurring Substance Use and Mental Disorders in the US: Variations by Race/Ethnicity 
Comprehensive Psychiatry  2011;53(6):657-665.
Objective
This study examines racial/ethnic differences in the prevalence, patterns, and correlates of co-occurring substance use and mental disorders (COD) among Whites, Blacks, Latinos, and Asians using data from the Collaborative Psychiatric Epidemiology Studies.
Method
We first estimated the prevalence of various combinations of different co-occurring depressive and anxiety disorders among respondents with alcohol, drug, and any substance use (alcohol or drug) disorders in each racial/ethnic group. We then estimated the prevalence of different patterns of onset and different psychosocial correlates among individuals with COD of different racial/ethnic groups. We used weighted linear and logistic regression analysis controlling for key demographics to test the effect of race/ethnicity. Tests of differences between specific racial/ethnic subgroups were only conducted if the overall test of race was significant.
Results
Rates of COD varied significantly by race/ethnicity. Approximately 8.2% of Whites, 5.4% of Blacks, 5.8% of Latinos, 2.1% of Asians met criteria for lifetime COD. Whites were more likely than persons in each of the other groups to have lifetime COD. Irrespective of race/ethnicity, the majority of those with COD reported that symptoms of mental disorders occurred before symptoms of substance use disorders. Only rates of unemployment and history of psychiatric hospitalization among individuals with COD were found to vary significantly by racial/ethnic group.
Conclusions
Our findings underscore the need to further examine the factors underlying differences between minority and non-minority individuals with COD as well as how these differences might affect help seeking and utilization of substance abuse and mental health services.
doi:10.1016/j.comppsych.2011.10.002
PMCID: PMC3327759  PMID: 22152496
Substance abuse; mental disorders; co-occurring disorders; comorbidity; dual diagnosis; minorities; health disparities; CPES
5.  Retention in Depression Treatment among Ethnic and Racial Minority Groups in the United States 
Depression and anxiety  2010;27(5):485-494.
Background
Premature discontinuation of psychiatric treatment among ethnic-racial minorities is a persistent concern. Prior 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 US as compared to non-Latino whites. Secondly, we aim to identify factors which are related to treatment retention.
Methods
We use data from the Collaborative Psychiatric Epidemiology Surveys (CPES) 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 over 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.
doi:10.1002/da.20685
PMCID: PMC2927223  PMID: 20336808
Depression; Retention in Care; Ethnic-Racial Minorities
6.  Prevalence of Lifetime DSM-IV Affective Disorders among Older African Americans, Black Caribbeans, Latinos, Asians and Non-Hispanic Whites 
Objectives
The purpose of this study is to estimate lifetime prevalence of 7 psychiatric affective disorders for older non-Hispanic Whites, African Americans, Caribbean Blacks, Latinos and Asian Americans and examine demographic, socioeconomic, and immigration correlates of those disorders.
Design
Data are taken from the older sub-sample of the Collaborative Psychiatric Epidemiology Surveys. Selected measures of lifetime DSM-IV psychiatric disorders were examined (i.e., panic disorder, agoraphobia, social phobia, generalized anxiety disorder, post-traumatic stress disorder, major depressive disorder, and dysthymia).
Setting
Community epidemiologic survey.
Participants
Nationally representative sample of adults aged 55 and older (n=3,046).
Measurements
Disorders were assessed using the DSM-IV World Mental Health Composite International Diagnostic Interview (WMH-CIDI).
Results
Major depressive disorder and social phobia were the two most prevalent disorders among the 7 psychiatric conditions. Overall, non-Hispanic Whites and Latinos consistently had higher prevalence rates of disorders, African Americans had lower prevalence of major depression and dysthymia, and Asian Americans were typically less likely to report affective disorders than their counterparts. There is variation across groups in the association of demographic, socioeconomic, and immigration variables with disorders.
Conclusions
This study furthers our understanding of the racial and ethnic differences in the prevalence of DSM-IV disorders among older adults and the correlates of those disorders. It highlights the importance of examining both between-and within-group differences in disorders and the complexity of the mechanisms associated with differences across groups. Findings from this study underscores the need for future research that more clearly delineates subgroup differences and similarities.
doi:10.1002/gps.2790
PMCID: PMC3391316  PMID: 21987438
Depression; anxiety; elderly; race; ethnicity
7.  Prevalence, Risk, and Correlates of Posttraumatic Stress Disorder across Ethnic and Racial Minority Groups in the U.S 
Medical care  2013;51(12):1114-1123.
Objectives
We assess whether posttraumatic stress disorder (PTSD) varies in prevalence, diagnostic criteria endorsement, and type and frequency of traumatic events (PTEs) among a nationally representative U.S. sample of 5071 non-Latino whites, 3264 Latinos, 2178 Asians, 4249 African Americans, and 1476 Afro-Caribbeans.
Methods
PTSD and other psychiatric disorders were evaluated using the World Mental Health-Composite International Diagnostic Interview (WMH-CIDI) in a national household sample that oversampled ethnic/racial minorities (n=16,238) but was weighted to produce results representative of the general population.
Results
Asians have lower prevalence rates of probable lifetime PTSD while African Americans have higher rates as compared to non-Latino whites, even after adjusting for type and number of exposures to traumatic events, and for sociodemographic, clinical and social support factors. Afro-Caribbeans and Latinos seem to demonstrate similar risk to non-Latino whites, adjusting for these same covariates. Higher rates of probable PTSD exhibited by African Americans and lower rates for Asians, as compared to non-Latino whites, do not appear related to differential symptom endorsement, differences in risk or protective factors or differences in types and frequencies of PTEs across groups.
Conclusions
There appears to be marked differences in conditional risk of probable PTSD across ethnic/racial groups. Questions remain about what explains risk of probable PTSD. Several factors that might account for these differences are discussed as well as the clinical implications of our findings. Uncertainty of the PTSD diagnostic assessment for Latinos and Asians requires further evaluation.
doi:10.1097/MLR.0000000000000007
PMCID: PMC3922129  PMID: 24226308
Posttraumatic Stress Disorders across racial and ethnic minority groups; diagnosis
8.  Comparative Prevalence, Correlates of Impairment, and Service Utilization for Eating Disorders across U.S. Ethnic Groups: Implications for Reducing Ethnic Disparities in Health Care Access for Eating Disorders 
Objective
The study compared the prevalence, correlates of functional impairment, and service utilization for eating disorders across Latinos, Asians, and African Americans living in the U.S. to non-Latino Whites.
Method
Pooled data from the NIMH Collaborative Psychiatric Epidemiological Studies (CPES; [1]) were used.
Results
The prevalence of anorexia nervosa (AN) and binge-eating disorder (BED) were similar across all groups examined, but bulimia nervosa (BN) was more prevalent among Latinos and African Americans than non-Latino whites. Despite similar prevalence of BED among ethnic groups examined, lifetime prevalence of ABE was greater among each of the ethnic minority groups in comparison to non-Latino Whites. Mental health service utilization was lower among ethnic minority groups studied than for non-Latino whites for respondents with a lifetime history of any eating disorder.
Discussion
These findings suggest the need for clinician training and health policy interventions to achieve optimal and equitable care for eating disorders across all ethnic groups in the U.S.
doi:10.1002/eat.20787
PMCID: PMC3011052  PMID: 20665700
Anorexia Nervosa; Bulimia Nervosa; Binge-eating disorder; Ethnicity
9.  Role of Referrals in Mental Health Service Disparities for Racial and Ethnic Minority Youth 
Objective
To investigate racial/ethnic differences in teachers’ and other adults’ identification and/or encouragement of parents to seek treatment for psychiatric problems in their children and to evaluate if and whether identification/encouragement is associated with service use.
Method
Data on identification/encouragement to seek treatment for externalizing disorders (i.e., attention-deficit/hyperactivity disorder, oppositional-defiant disorder, and/or conduct disorder) and internalizing disorders (i.e., major depressive episode/dysthymia and/or separation anxiety disorder) and services used were obtained for 6,112 adolescents (13–17 years of age) in the National Comorbidity Survey Adolescent Supplement. Racial/ethnic differences were examined for Latinos, non-Latino blacks, and non-Latino whites.
Results
There were few racial/ethnic differences in rates of youth identification/encouragement and how identification/encouragement related to service use. Only non-Latino black youth with low severity internalizing disorders were less likely to be identified/encouraged to seek services compared with non-Latino white youth with the same characteristics (odds ratio [OR] = 0.4, 95% confidence interval [CI] = [0.2–0.7]). Identification/encouragement increased the likelihood of seeking services for externalizing and internalizing disorders for all youth. However, compared with their non-Latino white counterparts, non-Latino black youth who met criteria for internalizing disorders appeared less likely to have used any services (OR = 0.4, 95%, CI = 0.2–;0.7), after adjusting for identification/encouragement, clinical, and sociodemographic characteristics. Non-Latino black youth with internalizing disorders and without identification/encouragement were less likely to use the specialty care sector than their non-Latino white counterparts.
Conclusions
In this study of a nationally representative sample of adolescents, almost no ethnic/racial differences in identification/encouragement were found. However, identification/encouragement may increase service use for all youth.
doi:10.1016/j.jaac.2012.05.005
PMCID: PMC3652396  PMID: 22721593
referral; disparities; ethnic; minority; services
10.  Neighborhood Context and Substance Use Disorders: A Comparative Analysis of Racial and Ethnic Groups in the United States 
Drug and alcohol dependence  2012;125(Suppl 1):S35-S43.
Background
There is evidence that ethnic/racial minorities are conferred differential risk for substance use problems based on where they live. Despite a burgeoning of research focusing on the role of neighborhood characteristics on health, limited findings are available on substance use. Our study uses nationally representative data (N= 13, 837) to examine: (1) What neighborhood characteristics are associated with risk of substance use disorders?; (2) Do the associations between neighborhood characteristics and substance use disorders remain after adjusting for individual-level factors?; and (3) Do neighborhood characteristics associated with substance use disorders differ by race/ethnicity after adjusting for individual-level factors?
Methods
Data were drawn from the Collaborative Psychiatric Epidemiology Studies (CPES-Geocode file) with 836 Census tracts. Analyses included African Americans, Asians, Caribbean Blacks, Latinos, and non-Latino whites. Separate logistic regression models were fitted for any past-year substance use disorder, alcohol use disorder, and drug use disorder.
Results
Living in more affluent and residentially unstable census tracts was associated with decreased risk of past-year substance use disorder, even after adjusting for individual-level factors. However, when we investigated the interaction of race/ethnicity and census latent factors with past-year substance use disorders, we found different associations for the different racial/ethnic groups. We also found different associations between neighborhood affluence, residential instability and any past-year substance use and alcohol disorders by nativity.
Conclusions
Characteristics of the environment might represent differential risk for substance disorders depending on a person’s ethnicity/race and nativity status.
doi:10.1016/j.drugalcdep.2012.05.027
PMCID: PMC3488110  PMID: 22699095
neighborhood context; substance use disorders; alcohol; drugs; racial/ethnic minorities; nativity
11.  Childhood Trauma and Psychiatric Disorders as Correlates of School Dropout in a National Sample of Young Adults 
Child development  2011;82(3):982-998.
The effect of childhood trauma, psychiatric diagnoses, and mental health services on school dropout among U.S. born and immigrant youth is examined using data from the Collaborative Psychiatric Epidemiology Surveys (CPES), a nationally representative probability sample of African Americans, Afro-Caribbeans, Asians, Latinos, and non-Latino Whites, including 2532 young adults, ages 21 to 29. The dropout prevalence rate was 16% overall, with variation by childhood trauma, childhood psychiatric diagnosis, race/ethnicity, and nativity. Childhood substance and conduct disorders mediated the relationship between trauma and school dropout. Likelihood of dropout was decreased for Asians, and increased for African Americans and Latinos, compared to non-Latino Whites as a function of psychiatric disorders and trauma. Timing of U.S. immigration during adolescence increased risk of dropout.
doi:10.1111/j.1467-8624.2010.01534.x
PMCID: PMC3089672  PMID: 21410919
DROPOUT; TRAUMA; MENTAL HEALTH; MINORITY YOUTH; IMMIGRATION
12.  The Impact of Insurance Coverage in Diminishing Racial and Ethnic Disparities in Behavioral Health Services 
Health services research  2012;47(3 0 2):1322-1344.
Objective
To estimate whether racial/ethnic behavioral health service disparities are likely to be reduced through insurance expansion coverage expected through the Affordable Health Care Act.
Data Sources
Pooled data from the nationally representative NIMH Collaborative Psychiatric Epidemiological Studies (2001–2003).
Study Design
We employ a novel reweighting method to estimate service disparities in the presence and absence of insurance coverage.
Data Collection
Access to care was assessed by whether any behavioral health treatment was received in the past year. Need was determined by presence of prior year psychiatric disorder, psychiatric diagnoses, physical comorbidities, gender, and age.
Principal Findings
Improving patient education and availability of community clinics, combined with insurance coverage reduces service disparities across racial/ethnic groups. However, even with expanded insurance coverage, approximately 10 percent fewer African Americans with need for behavioral health services are likely to receive services compared to non-Latino whites while Latinos show no measurable disparity.
Conclusions
Expansion of insurance coverage might have different effects for racial/ethnic groups, requiring additional interventions to reduce disparities for all groups.
doi:10.1111/j.1475-6773.2012.01403.x
PMCID: PMC3418830  PMID: 22568675
. Disparities; minorities; expanding insurance; behavioral health; mechanisms
13.  The Impact of Insurance Coverage in Diminishing Racial and Ethnic Disparities in Behavioral Health Services 
Health Services Research  2012;47(3 Pt 2):1322-1344.
Objective
To estimate whether racial/ethnic behavioral health service disparities are likely to be reduced through insurance expansion coverage expected through the Affordable Health Care Act.
Data Sources
Pooled data from the nationally representative NIMH Collaborative Psychiatric Epidemiological Studies (2001–2003).
Study Design
We employ a novel reweighting method to estimate service disparities in the presence and absence of insurance coverage.
Data Collection
Access to care was assessed by whether any behavioral health treatment was received in the past year. Need was determined by presence of prior year psychiatric disorder, psychiatric diagnoses, physical comorbidities, gender, and age.
Principal Findings
Improving patient education and availability of community clinics, combined with insurance coverage reduces service disparities across racial/ethnic groups.However, even with expanded insurance coverage, approximately 10 percent fewer African Americans with need for behavioral health services are likely to receive services compared to non-Latino whites while Latinos show no measurable disparity.
Conclusions
Expansion of insurance coverage might have different effects for racial/ethnic groups, requiring additional interventions to reduce disparities for all groups.
doi:10.1111/j.1475-6773.2012.01403.x
PMCID: PMC3418830  PMID: 22568675
Disparities; minorities; expanding insurance; behavioral health; mechanisms
14.  Race/Ethnicity and Measurement Equivalence of the Everyday Discrimination Scale 
Psychological assessment  2014;26(3):892-900.
The present study examines the effect of race/ethnicity on measurement equivalence of the Everyday Discrimination Scale (EDS). Drawn from the Collaborative Psychiatric Epidemiology Surveys (CPES), adults aged 18 and older from four racial/ethnic groups were selected for analyses: 884 non-Hispanic Whites, 4,950 Blacks, 2,733 Hispanics/Latinos, and 2,089 Asians. Multiple-group confirmatory factor analyses were conducted. After adjusting for age and gender, the underlying construct of the EDS was invariant across four racial/ethnic groups, with Item 7 (“People act as if they’re better than you are”) associated with lower intercepts for the Hispanic/Latino and Asian groups relative to the non-Hispanic White and Black groups. In terms of latent factor differences, Blacks tended to score higher on the latent construct compared to other racial/ethnic groups, whereas Asians tended to score lower on the latent construct compared to Whites and Hispanics/Latinos. Findings suggest that although the EDS in general assesses the underlying construct of perceived discrimination equivalently across diverse racial/ethnic groups, caution is needed when Item 7 is used among Hispanics/Latinos or Asians. Implications are discussed in cultural and methodological contexts.
doi:10.1037/a0036431
PMCID: PMC4152383  PMID: 24708076
Perceived Discrimination; Measurement Equivalence; Race/Ethnicity; Everyday Discrimination Scale (EDS); Health Disparities; Culture
15.  Depression Care in the United States 
Archives of general psychiatry  2010;67(1):37-46.
Objective:
To determine the prevalence and adequacy of depression care among different ethnic and racial groups in the United States.
Design:
Collaborative Psychiatric Epidemiology Surveys (CPES) data were analyzed to calculate nationally representative estimates of depression care.
Setting:
The 48 coterminous United States.
Participants:
Household residents 18 years and older (N=15 762) participated in the study.
Main Outcome Measures:
Past-year depression pharmacotherapy and psychotherapy using American Psychiatric Association guideline-concordant therapies. Depression severity was assessed with the Quick Inventory of Depressive Symptomatology Self-Report. Primary predictors were major ethnic/racial groups (Mexican American, Puerto Rican, Caribbean black, African American, and non-Latino white) and World Mental Health Composite International Diagnostic Interview criteria for 12-month major depressive episode.
Results:
Mexican American and African American individuals meeting 12-month major depression criteria consistently and significantly had lower odds for any depression therapy and guideline-concordant therapies despite depression severity ratings not significantly differing between ethnic/racial groups. All groups reported higher use of any past-year psychotherapy and guideline-concordant psychotherapy compared with pharmacotherapy; however, Caribbean black and African American individuals reported the highest proportions of this use.
Conclusions:
Few Americans with recent major depression have used depression therapies and guideline-concordant therapies; however, the lowest rates of use were found among Mexican American and African American individuals. Ethnic/racial differences were found despite comparable depression care need. More Americans with recent major depression used psychotherapy over pharmacotherapy, and these differences were most pronounced among Mexican American and African American individuals. This report underscores the importance of disaggregating ethnic/racial groups and depression therapies in understanding and directing efforts to improve depression care in the United States.
doi:10.1001/archgenpsychiatry.2009.168
PMCID: PMC2887749  PMID: 20048221
16.  Disparity in Depression Treatment among Racial and Ethnic Minority Populations in the United States 
Objective:
Prior work on racial/ethnic disparities in depression treatment has been limited by the scarcity of national samples that include an array of diagnostic and quality indicators and substantial non-English speaking minorities. Using nationally representative data (n=8762), we evaluate differences in access to and quality of depression treatments between ethnic/racial minority patients and non-Latino whites.
Method:
Access to mental health care was assessed by whether or not any mental health treatment was received in the past year. Quality treatment for acute depression was defined as four or more specialty/general health provider visits in the past year plus antidepressant use for 30 days or more; or eight or more specialty mental health provider visits of at least 30 minutes in length, with no antidepressant use.
Results:
For those with last year depressive disorder, 63.7% of Latinos, 68.7% of Asians and 58.8% of African Americans, vs. 40.2% of non-Latino whites, did not access any last year mental health treatment (significantly different at p<0.001). We also found that the disparities in the likelihood of both having access and receiving quality care for depression are significantly different for all minority groups as contrasted to non-Latino whites, except Latinos (marginally significant).
Conclusion:
Simply relying on present healthcare systems without considering the unique barriers to quality care that apply for ethnic and racial minorities is unlikely to affect the pattern of disparities observed. Populations reluctant to come to the clinic for depression care may have correctly anticipated the limited quality available in usual care.
doi:10.1176/appi.ps.59.11.1264
PMCID: PMC2668139  PMID: 18971402
17.  Differential Impact of Isolated Psychotic Symptoms on Treatment Outcome of Major Depressive Disorder in the STAR*D cohort of Whites, Blacks and Latinos 
Journal of affective disorders  2013;150(2):578-584.
Objective
To determine whether isolated psychotic symptoms are more likely to be endorsed by depressed Latinos as opposed to other ethnic-racial groups; whether these symptoms affect Latinos similarly to other ethnic-racial groups in terms of treatment response; and whether they are more likely to be associated with anxiety disorders in depressed Latinos.
Methods
We analyzed data from STAR*D subjects who self identified as White, Black, or Latino. Rates of isolated psychotic symptoms were assessed by the self-rated Psychiatric Diagnostic Screening Questionnaire (PDSQ) and compared between ethnic-racial groups. Depressive remission outcomes were compared within each ethnic-racial group between subjects who endorsed psychotic symptoms versus no psychotic symptoms. Associations between isolated psychotic symptoms and anxiety disorders were also examined.
Results
Among 2,597 eligible subjects with at least one post-baseline assessment and available PDSQ data excluding first-rank symptoms, the prevalence of auditory-visual hallucination was 2.5% in Whites (n=49 /1,928), 11.3% in Blacks (n=45 /398) 6.3% in Latinos (n=17 /270) (χ2=64.9; df=2; p<.001). Prevalence of paranoid ideation was 15.5% in Whites (n=299 /1927), 31.5% in Blacks (n=126 /400), and 21.1% in Latinos (n=57 /270) (χ2=57.3; df=2; p<.001). Among Whites and Blacks but not Latinos, depressive remission rates were worse in subjects with auditory-visual hallucinations compared to those without them. Paranoid ideation had a significant negative impact on remission in Whites only. In all ethnic-racial groups, a significant association was found between auditory-visual hallucinations and PTSD and panic disorder.
Limitations
the STAR*D study did not include any structured clinician-based assessment of psychotic symptoms.
Conclusion
Latinos do not appear to have worse outcomes when treated for MDD with auditory-visual hallucinations, differently from Whites and Blacks.
doi:10.1016/j.jad.2013.02.012
PMCID: PMC3749257  PMID: 23489398
Latinos; Hispanic; Major Depressive Disorder; Psychosis-like Symptoms; Antidepressants; Remission
18.  Valuing health in a racially and ethnically diverse community sample: an analysis using the valuation metrics of money and time 
Purpose
Limited research in health valuation analyzes samples with high proportions of racial/ethnic minorities within the United States. The primary objective was to explore patterns of health valuation across race/ethnicity using the Collaborative Psychiatric Epidemiology Surveys. A secondary objective was to analyze whether mental health disorder and immigrant status were associated with these estimates.
Methods
Health valuation questions using different metrics (time and money) were analyzed. Ordered logit models stratified across poor and moderate health tested differences by race/ethnicity, with mental health disorder and immigrant status as covariates.
Results
Asians in moderate health and Latinos were willing to pay more for health than non-Latino whites. Asians in moderate health were willing to trade more time for health. Latinos in poor health were less willing to trade time and gave disproportionate zero-trade responses. Lifetime history of anxiety disorder was positively associated with both metrics. Immigrant status confounded money valuation for Asians in moderate health, and time valuation for Latinos in poor health.
Conclusions
Health valuation estimates vary across race/ethnicity depending upon the metric. Time valuation scenarios appear less feasible for Latinos in poor health. More research is necessary to understand these differences and the role of immigrant status in health valuation.
doi:10.1007/s11136-010-9713-6
PMCID: PMC3596787  PMID: 20680690
Health valuation; Utilities; Racial/ethnic minorities; Mental health
19.  ANTIDEPRESSANT USE IN A NATIONALLY REPRESENTATIVE SAMPLE OF COMMUNITY-DWELLING US LATINOS WITH AND WITHOUT DEPRESSIVE AND ANXIETY DISORDERS 
Depression and anxiety  2009;26(7):674-681.
Background:
Antidepressant drugs are among the most widely prescribed drugs in the United States; however, little is known about their use among major ethnic minority groups.
Method:
Collaborative Psychiatric Epidemiology Surveys (CPES) data were analyzed to calculate nationally representative estimates of Latino and non-Latino White adults antidepressant use.
Setting:
The 48 coterminous United States was the setting.
Participants:
Household residents aged 18 years and older (N=9,250).
Main outcome:
Past year antidepressant use.
Results:
Compared to non-Latino Whites, few Latinos, primarily Mexican Americans, with 12-month depressive and/or anxiety disorders reported past year antidepressant use. Mexican Americans (OR=0.48; 95%CI=0.30–0.77) had significantly lower odds of use compared to non-Latino Whites, which were largely unaffected by factors associated with access to care. Over half of antidepressant use was by respondents not meeting 12-month criteria for depressive or anxiety disorders. Lifetime depressive and anxiety disorders explained another 21% of past year antidepressant use, leaving another 31% of drug use unexplained.
Discussion:
We found a disparity in antidepressant use for Mexican Americans compared to non-Latino Whites that was not accounted for by differences in need and factors associated with access to care. About one third of antidepressant use was by respondents not meeting criteria for depressive or anxiety disorders. Our findings underscore the importance of disaggregating Latino ethnic groups. Additional work is needed to understand the medical and economic value of antidepressant use beyond their primary clinical targets.
doi:10.1002/da.20561
PMCID: PMC2882071  PMID: 19306305
Latinos; Hispanics; Cubans; Mexicans; Puerto Ricans; major depressive disorder; depression; anxiety disorders; antidepressive agents
20.  Crisis Visits and Psychiatric Hospitalizations Among Patients Attending a Community Clinic in Rural Southern California 
Community Mental Health Journal  2010;48(2):133-137.
Ethnic minorities from disadvantaged socioeconomic backgrounds report increased utilization of mental health emergency services; however findings have been inconsistent across ethnic/racial groups. In this study we describe patients who present to a rural crisis unit in Southern California, examine rates of psychiatric hospitalizations across ethnic/racial groups, and investigate factors that are associated with increased psychiatric hospitalizations in this sample. This is a retrospective study of 451 racially and ethnically diverse patients attending a crisis unit in Imperial County, California. Chart review and data abstraction methods were used to characterize the sample and identify factors associated with psychiatric crises and subsequent hospitalizations. The sample was predominantly Latino/Hispanic (58.5%). Based on chart review, common psychosocial stressors which prompted a crisis center visit were: (a) financial problems; (b) homelessness; (c) partner or family conflict; (d) physical and health problems; (e) problems at school/work; (f) medication compliance; (g) aggressive behavior; (h) delusional behavior; (i) addiction and (j) anxiety/depression. Bivariate analyses revealed that Hispanics had a disproportionately lower rate of psychiatric hospitalizations while African Americans had a higher rate. Multivariate analyses which included demographic, clinical and psychosocial stressor variables revealed that being African American, having a psychotic disorder, and presenting as gravely disabled were associated with a higher likelihood of hospitalization while partner/family conflict was associated with a lesser likelihood in this rural community. These data elucidate the need for longitudinal studies to understand the interactions between psychosocial stressors, ethnicity and social support as determinants of psychiatric hospitalizations.
doi:10.1007/s10597-010-9350-0
PMCID: PMC3157591  PMID: 20924788
Hospitalization; Rural mental health; Ethnic minorities; Underserved
21.  Crisis visits and psychiatric hospitalizations among patients attending a community clinic in rural Southern California 
Community Mental Health Journal  2010;48(2):133-137.
Background
Ethnic minorities from disadvantaged socioeconomic backgrounds report increased utilization of mental health emergency services; however findings have been inconsistent across ethnic/racial groups. In this study we describe patients who present to a rural crisis unit in Southern California, examine rates of psychiatric hospitalizations across ethnic/racial groups, and investigate factors that are associated with increased psychiatric hospitalizations in this sample.
Methods
This is a retrospective study of 451 racially and ethnically diverse patients attending a crisis unit in Imperial County, California. Chart review and data abstraction methods were used to characterize the sample and identify factors associated with psychiatric crises and subsequent hospitalizations.
Results
The sample was predominantly Latino/Hispanic (58.5%). Based on chart review, common psychosocial stressors which prompted a crisis center visit were: a) financial problems; b) homelessness; c) partner or family conflict; d) physical and health problems; e) problems at school/work; f) medication compliance; g) aggressive behavior; h) delusional behavior; i) addiction and j) anxiety/depression. Bivariate analyses revealed that Hispanics had a disproportionately lower rate of psychiatric hospitalizations while African Americans had a higher rate. Multivariate analyses which included demographic, clinical and psychosocial stressor variables revealed that being African American, having a psychotic disorder, and presenting as gravely disabled were associated with a higher likelihood of hospitalization while partner/family conflict was associated with a lesser likelihood in this rural community.
Discussion
These data elucidate the need for longitudinal studies to understand the interactions between psychosocial stressors, ethnicity and social support as determinants of psychiatric hospitalizations.
doi:10.1007/s10597-010-9350-0
PMCID: PMC3157591  PMID: 20924788
hospitalization; rural mental health; ethnic minorities; underserved
22.  Measuring Disparities across the Distribution of Mental Health Care Expenditures 
Background
Previous mental health care disparities studies predominantly compare mean mental health care use across racial/ethnic groups, leaving policymakers with little information on disparities among those with a higher level of expenditures.
Aims of the Study
To identify racial/ethnic disparities among individuals at varying quantiles of mental health care expenditures. To assess whether disparities in the upper quantiles of expenditure differ by insurance status, income and education.
Methods
Data were analyzed from a nationally representative sample of white, black and Latino adults 18 years and older (n=83,878). Our dependent variable was total mental health care expenditure. We measured disparities in any mental health care expenditures, disparities in mental health care expenditure at the 95th, 97.5th, and 99th expenditure quantiles of the full population using quantile regression, and at the 50th, 75th, and 95th quantiles for positive users. In the full population, we tested interaction coefficients between race/ethnicity and income, insurance, and education levels to determine whether racial/ethnic disparities in the upper quantiles differed by income, insurance and education.
Results
Significant Black-white and Latino-white disparities were identified in any mental health care expenditures. In the full population, moving up the quantiles of mental health care expenditures, Black-White and Latino-White disparities were reduced but remained statistically significant. No statistically significant disparities were found in analyses of positive users only. The magnitude of black-white disparities was smaller among those enrolled in public insurance programs compared to the privately insured and uninsured in the 97.5th and 99th quantiles. Disparities persist in the upper quantiles among those in higher income categories and after excluding psychiatric inpatient and emergency department (ED) visits.
Discussion
Disparities exist in any mental health care and among those that use the most mental health care resources, but much of disparities seem to be driven by lack of access. The data do not allow us to disentangle whether disparities were related to white respondent’s overuse or underuse as compared to minority groups. The cross-sectional data allow us to make only associational claims about the role of insurance, income, and education in disparities. With these limitations in mind, we identified a persistence of disparities in overall expenditures even among those in the highest income categories, after controlling for mental health status and observable sociodemographic characteristics.
Implications for Health Care Provision and Use
Interventions are needed to equalize resource allocation to racial/ethnic minority patients regardless of their income, with emphasis on outreach interventions to address the disparities in access that are responsible for the no/low expenditures for even Latinos at higher levels of illness severity.
Implications for Health Policies
Increased policy efforts are needed to reduce the gap in health insurance for Latinos and improve outreach programs to enroll those in need into mental health care services.
Implications for Further Research
Future studies that conclusively disentangle overuse and appropriate use in these populations are warranted.
PMCID: PMC3662479  PMID: 23676411
23.  Stigmatizing Attitudes towards Mental Illness among Racial/Ethnic Older Adults in Primary Care 
Objective
The current study applies the perceived stigma framework to identify differences in attitudes toward mental health and mental health treatment among various racial/ethnic minority older adults with common mental health problems including depression, anxiety disorders, or at-risk alcohol use. Specifically, this study examines to what extent race/ethnicity is associated with differences in: (1) perceived stigma of mental illness; and (2) perceived stigma for different mental health treatment options.
Methods
Analyses were conducted using baseline data collected from participants who completed the SAMHSA Mental Health and Alcohol Abuse Stigma Assessment, developed for the PRISM-E (Primary Care Research in Substance Abuse and Mental Health for the Elderly) study, a multi-site randomized trial for older adults (65+) with depression, anxiety, or at-risk alcohol consumption. The final sample consisted of 1247 non-Latino Whites, 536 African-Americans, 112 Asian-Americans, and 303 Latinos.
Results
African-Americans and Latinos expressed greater comfort in speaking to primary care physicians or mental health professionals concerning mental illness compared to non-Latino Whites. Asian-Americans and Latinos expressed greater shame and embarrassment about having a mental illness than non-Latino Whites. Asian-Americans expressed greater difficulty in seeking or engaging in mental health treatment.
Conclusions
Racial/ethnic differences exist among older adults with mental illness with respect to stigmatizing attitudes towards mental illness and mental health treatment. Results of this study could help researchers and clinicians educate racial/ethnic minority older adults about mental illness and engage them in much needed mental health services.
doi:10.1002/gps.3928
PMCID: PMC3672370  PMID: 23361866
race/ethnicity; stigma; older adults
24.  Using colorectal trends in the U.S. to identify unmet primary care needs of vulnerable populations 
Preventive medicine  2012;55(2):131-136.
Background
Colorectal cancer screening (CRC) disparities have worsened in recent years.
Objective
To examine progress toward Healthy People 2010 goals for CRC screening among ethnic/racial groups, including disaggregated Latino groups.
Methods
Multivariate logistic regressions examined associations between ethnicity/race and primary outcomes of self-reported guideline-concordant CRC screenings considering time trends for 65,947 respondents of the Medical Expenditure Panel Survey from 2000–2007 age 50-years and older from six groups (non-Latino White, non-Latino Black, Puerto Rican, Cuban, Mexican, and Other Latino). We also tested for modification effects by education, income, and health insurance.
Results
Most groups approached Healthy People 2010 CRC screening rate goals, including non-Latino Whites (47%), non-Latino Blacks (42%) and Puerto Ricans (40%), while Mexicans remained disparately lower (28%). Higher education, income and insurance coverage, partially attenuated this lower likelihood, but Mexican rates remained significantly lower than non-Latino Whites for receiving endoscopy in the past 5 years {OR(95% CI) =0.68(0.59–0.77)} and having received any CRC screening {0.70(0.62–0.79)}.
Conclusions
Among ethnic/racial groups examined, only Mexicans met healthcare disparity criteria in CRC screening. Findings suggest that healthcare equity goals can be attained if resources affecting continuity of care or ability to pay for preventive services are available, and targeted populations are adequately identified.
doi:10.1016/j.ypmed.2012.05.016
PMCID: PMC3786063  PMID: 22659226
25.  Estimates of Outcomes Up to Ten Years after Stroke: Analysis from the Prospective South London Stroke Register 
PLoS Medicine  2011;8(5):e1001033.
Charles Wolfe and colleagues collected data from the South London Stroke Register on 3,373 first strokes registered between 1995 and 2006 and showed that between 20% and 30% of survivors have poor outcomes up to 10 years after stroke.
Background
Although stroke is acknowledged as a long-term condition, population estimates of outcomes longer term are lacking. Such estimates would be useful for planning health services and developing research that might ultimately improve outcomes. This burden of disease study provides population-based estimates of outcomes with a focus on disability, cognition, and psychological outcomes up to 10 y after initial stroke event in a multi-ethnic European population.
Methods and Findings
Data were collected from the population-based South London Stroke Register, a prospective population-based register documenting all first in a lifetime strokes since 1 January 1995 in a multi-ethnic inner city population. The outcomes assessed are reported as estimates of need and included disability (Barthel Index <15), inactivity (Frenchay Activities Index <15), cognitive impairment (Abbreviated Mental Test < 8 or Mini-Mental State Exam <24), anxiety and depression (Hospital Anxiety and Depression Scale >10), and mental and physical domain scores of the Medical Outcomes Study 12-item short form (SF-12) health survey. Estimates were stratified by age, gender, and ethnicity, and age-adjusted using the standard European population. Plots of outcome estimates over time were constructed to examine temporal trends and sociodemographic differences. Between 1995 and 2006, 3,373 first-ever strokes were registered: 20%–30% of survivors had a poor outcome over 10 y of follow-up. The highest rate of disability was observed 7 d after stroke and remained at around 110 per 1,000 stroke survivors from 3 mo to 10 y. Rates of inactivity and cognitive impairment both declined up to 1 y (280/1,000 and 180/1,000 survivors, respectively); thereafter rates of inactivity remained stable till year eight, then increased, whereas rates of cognitive impairment fluctuated till year eight, then increased. Anxiety and depression showed some fluctuation over time, with a rate of 350 and 310 per 1,000 stroke survivors, respectively. SF-12 scores showed little variation from 3 mo to 10 y after stroke. Inactivity was higher in males at all time points, and in white compared to black stroke survivors, although black survivors reported better outcomes in the SF-12 physical domain. No other major differences were observed by gender or ethnicity. Increased age was associated with higher rates of disability, inactivity, and cognitive impairment.
Conclusions
Between 20% and 30% of stroke survivors have a poor range of outcomes up to 10 y after stroke. Such epidemiological data demonstrate the sociodemographic groups that are most affected longer term and should be used to develop longer term management strategies that reduce the significant poor outcomes of this group, for whom effective interventions are currently elusive.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Every year, 15 million people have a stroke. About 5 million of these people die within a few days, and another 5 million are left disabled. Stroke occurs when the brain's blood supply is suddenly interrupted by a blood clot blocking a blood vessel in the brain (ischemic stroke, the commonest type of stroke) or by a blood vessel in the brain bursting (hemorrhagic stroke). Deprived of the oxygen normally carried to them by the blood, the brain cells near the blockage die. The symptoms of stroke depend on which part of the brain is damaged but include sudden weakness or paralysis along one side of the body, vision loss in one or both eyes, and confusion or trouble speaking or understanding speech. Anyone experiencing these symptoms should seek immediate medical attention because prompt treatment can limit the damage to the brain. Risk factors for stroke include age (three-quarters of strokes occur in people over 65 years old), high blood pressure, and heart disease.
Why Was This Study Done?
Post-stroke rehabilitation can help individuals overcome the physical disabilities caused by stroke, and drugs and behavioral counseling can reduce the risk of a second stroke. However, people can also have problems with cognition (thinking, awareness, attention, learning, judgment, and memory) after a stroke, and they can become depressed or anxious. These “outcomes” can persist for many years, but although stroke is acknowledged as a long-term condition, most existing data on stroke outcomes are limited to a year after the stroke and often focus on disability alone. Longer term, more extensive information is needed to help plan services and to help develop research to improve outcomes. In this burden of disease analysis, the researchers use follow-up data collected by the prospective South London Stroke Register (SLSR) to provide long-term population-based estimates of disability, cognition, and psychological outcomes after a first stroke. The SLSR has recorded and followed all patients of all ages in an inner area of South London after their first-ever stroke since 1995.
What Did the Researchers Do and Find?
Between 1995 and 2006, the SLSR recorded 3,373 first-ever strokes. Patients were examined within 48 hours of referral to SLSR, their stroke diagnosis was verified, and their sociodemographic characteristics (including age, gender, and ethnic origin) were recorded. Study nurses and fieldworkers then assessed the patients at three months and annually after the stroke for disability (using the Barthel Index, which measures the ability to, for example, eat unaided), inactivity (using the Frenchay Activities Index, which measures participation in social activities), and cognitive impairment (using the Abbreviated Mental Test or the Mini-Mental State Exam). Anxiety and depression and the patients' perceptions of their mental and physical capabilities were also assessed. Using preset cut-offs for each outcome, 20%–30% of stroke survivors had a poor outcome over ten years of follow-up. So, for example, 110 individuals per 1,000 population were judged disabled from three months to ten years, rates of inactivity remained constant from year one to year eight, at 280 affected individuals per 1,000 survivors, and rates of anxiety and depression fluctuated over time but affected about a third of the population. Notably, levels of inactivity were higher among men than women at all time points and were higher in white than in black stroke survivors. Finally, increased age was associated with higher rates of disability, inactivity, and cognitive impairment.
What Do These Findings Mean?
Although the accuracy of these findings may be affected by the loss of some patients to follow-up, these population-based estimates of outcome measures for survivors of a first-ever stroke for up to ten years after the event provide concrete evidence that stroke is a lifelong condition with ongoing poor outcomes. They also identify the sociodemographic groups of patients that are most affected in the longer term. Importantly, most of the measured outcomes remain relatively constant (and worse than outcomes in an age-matched non-stroke-affected population) after 3–12 months, a result that needs to be considered when planning services for stroke survivors. In other words, these findings highlight the need for health and social services to provide long-term, ongoing assessment and rehabilitation for patients for many years after a stroke.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001033.
The US National Institute of Neurological Disorders and Stroke provides information about all aspects of stroke (in English and Spanish); the US National Institute of Health SeniorHealth Web site has additional information about stroke
The Internet Stroke Center provides detailed information about stroke for patients, families, and health professionals (in English and Spanish)
The UK National Health Service Choices Web site also provides information about stroke for patients and their families
MedlinePlus has links to additional resources about stroke (in English and Spanish)
More information about the South London Stroke Register is available
doi:10.1371/journal.pmed.1001033
PMCID: PMC3096613  PMID: 21610863

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