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1.  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
2.  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
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.  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
5.  Cultural Beliefs and Mental Health Treatment Preferences of Ethnically Diverse Older Adult Consumers in Primary Care 
Background
Beliefs concerning the causes of mental illness may help explain why there are significant disparities in the rates of formal mental health service use among racial/ethnic minority elderly as compared with their Caucasian counterparts. This study applies the Cultural Influences on Mental Health framework to identify the relationship between race/ethnicity and differences in: (1) beliefs on the cause of mental illness; (2) preferences for type of treatment; and (3) provider characteristics.
Method
Analyses were conducted using baseline data collected from participants who completed the Cultural Attitudes toward Healthcare and Mental Illness Questionnaire, 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 1257 non-Latino Whites, 536 African-Americans, 112 Asian-Americans, and 303 Latinos.
Results
African-Americans, Asian-Americans, and Latinos had differing beliefs regarding the causes of mental illness when compared to Non-Latino Whites. Race/ethnicity was also associated with determining who makes healthcare decisions, treatment preferences, and preferred characteristics of healthcare providers.
Conclusions
This study highlights the association between race/ethnicity and health beliefs, treatment preferences, healthcare decisions, and consumers' preferred characteristics of healthcare providers. Accommodating the values and preferences of individuals can be helpful in engaging racial/ethnic minority patients in mental health services.
doi:10.1097/JGP.0b013e318227f876
PMCID: PMC3258470  PMID: 21992942
race/ethnicity; health beliefs; older adults
6.  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
7.  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
8.  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
9.  Using the Patient Health Questionnaire-9 to Measure Depression among Racially and Ethnically Diverse Primary Care Patients 
OBJECTIVE
The Patient Health Questionnaire depression scale (PHQ-9) is a well-validated, Diagnostic and Statistical Manual of Mental Disorders— Fourth Edition (DSM-IV) criterion-based measure for diagnosing depression, assessing severity and monitoring treatment response. The performance of most depression scales including the PHQ-9, however, has not been rigorously evaluated in different racial/ethnic populations. Therefore, we compared the factor structure of the PHQ-9 between different racial/ethnic groups as well as the rates of endorsement and differential item functioning (DIF) of the 9 items of the PHQ-9. The presence of DIF would indicate that responses to an individual item differ significantly between groups, controlling for the level of depression.
MEASUREMENTS
A combined dataset from 2 separate studies of 5,053 primary care patients including non-Hispanic white (n =2,520), African American (n =598), Chinese American (n =941), and Latino (n =974) patients was used for our analysis. Exploratory principal components factor analysis was used to derive the factor structure of the PHQ-9 in each of the 4 racial/ethnic groups. A generalized Mantel-Haenszel statistic was used to test for DIF.
RESULTS
One main factor that included all PHQ-9 items was found in each racial/ethnic group with α coefficients ranging from 0.79 to 0.89. Although endorsement rates of individual items were generally similar among the 4 groups, evidence of DIF was found for some items.
CONCLUSIONS
Our analyses indicate that in African American, Chinese American, Latino, and non-Hispanic white patient groups the PHQ-9 measures a common concept of depression and can be effective for the detection and monitoring of depression in these diverse populations.
doi:10.1111/j.1525-1497.2006.00409.x
PMCID: PMC1924626  PMID: 16808734
depression; diagnosis; screening; ethnicity
10.  Depression Interventions among Racial and Ethnic Minority Older Adults: A Systematic Review across 20 Years 
While there is strong evidence in support of geriatric depression treatments, much less is available with regard to older U.S. racial and ethnic minorities. The objectives of this review are to identify and appraise depression treatment studies tested with samples of U.S. racial and ethnic minority older adults. We include an appraisal of sociocultural adaptations made to the depression treatments in studies meeting our final criteria. Systematic search methods were utilized to identify research published between 1990 and 2010 that describe depression treatment outcomes for older adults by racial/ethnic group, or for samples of older adults that are primarily (i.e., >50%) racial/ethnic minorities. Twenty-three unduplicated articles included older adults and seven met all inclusion criteria. Favorable depression treatment effects were observed for older minorities across five studies based on diverse settings and varying levels of sociocultural adaptations. The effectiveness of depression care remains mixed although collaborative or integrated care shows promise for African Americans and Latinos. The degree to which the findings generalize to non-English-speaking, low acculturated, and low income older persons, and to other older minority groups (i.e., Asian and Pacific Islanders, and American Indian and Alaska Natives) remains unclear. Given the high disease burden among older minorities with depression, it is imperative to provide timely, accessible, and effective depression treatments. Increasing their participation in behavioral health research should be a national priority.
doi:10.1097/JGP.0b013e31825d091a
PMCID: PMC3479358  PMID: 22828202
Depression; Treatment; Minorities; Systematic Review; Sociocultural Adaptations
11.  Differences in the Clinical Recognition of Depression in Diabetes Patients: The Diabetes Study of Northern California (DISTANCE) 
Background
It is unknown to what extent the gap between need and care for depression among patients with diabetes differs across racial/ethnic groups.
Objective
We compared, by race/ethnicity, the likelihood of clinical recognition of depression (diagnosis or treatment) of patients who reported depressive symptoms in a well-characterized community-based population with diabetes.
Design
We used a survey follow-up study of 20,188 patients with diabetes from Kaiser Permanente Northern California. Analyses were limited to 910 patients who scored 10 or higher on the Patient Health Questionnaire (PHQ-8) which was included in the survey and who had no clinical recognition of depression in the12 months prior to survey. Clinical recognition of depression was defined by a depression diagnosis, referral to mental health services, or antidepressant medication prescription.
Key Results
Among the 910 patients reporting moderate to severe depressive symptoms on the survey and who had no clinical recognition in the prior year, 12%, 8%, 8%, 14%, and 15% of African American, Asian, Filipino, Latino and white patients were clinically recognized for depression in the subsequent 12 months. After adjusting for sociodemographics, limited English proficiency, and depressive symptom severity, racial/ethnic minorities were less likely to be clinically recognized for depression compared to whites (relative risk: Filipino: 0.30, African American: 0.62).
Conclusions
More work is needed to understand the modifiable patient and provider factors that influence clinical recognition of depression among diabetes patients from different racial/ethnic groups, and the potential impact of low rates of clinical recognition on quality of care.
PMCID: PMC3703822  PMID: 23781889
12.  Disparities in detection and treatment history among mothers with major depression in Los Angeles 
Objective
This study's goal was to determine disparities in detection and treatment histories among a group of racial and ethnically diverse mothers with major depression.
Methods
Our sample included 276 racially and ethnically diverse mothers who participated in the Los Angeles Family and Neighborhood Survey (L.A.FANS) and who were classified with major depression based on the Comprehensive International Diagnostic Interview -Short Form (CIDI-SF). We used logistic regression to assess the association between demographic factors and previous detection with major depression, mental health specialty use, and the use of a primary care physician among these women. The demographic factors examined included race and ethnicity, immigration status, marital status, education, income, body mass index (BMI), maternal age, number of children, children's ages, history of emotional problems, and history of diabetes.
Results
Results indicated that 69 percent of mothers had not been previously detected with major depression nor had they sought mental health treatment in the 12 months prior to the interview. The odds of having been previously detected with major depression were significantly higher among white and single mothers, as well as among mothers with higher BMIs and those with a history of emotional problems. Non-immigrant mothers without emotional problems had higher odds of having seen a mental health specialist in the 12 months prior to the interview compared to immigrant mothers without emotional problems; no differences in mental health treatment were found between non-immigrant and immigrant mothers with emotional problems. Finally, African-American mothers and those with a history of diabetes had significantly higher odds of seeing a primary care physician compared to Hispanic mothers and those with no history of diabetes, respectively.
Conclusion
Our analyses of a population of depressed mothers living in Los Angeles highlight the need for detection and treatment of racial minority and immigrant mothers.
doi:10.1016/j.whi.2009.03.007
PMCID: PMC2766662  PMID: 19589472
13.  Impact of Motivational Pharmacotherapy on Treatment Retention among Depressed Latinos 
Psychiatry  2013;76(3):210-222.
Compared to non-Latino Whites, US racial/ethnic minority groups show higher non-adherence with outpatient antidepressant therapy, including lower retention, despite adjusting for sociodemographic and insurance covariates. Culturally salient concerns about antidepressants leading to ambivalence about treatment engagement may contribute to this discrepancy. To improve treatment adherence among depressed Latinos, we developed Motivational Pharmacotherapy, a novel approach that combines Motivational Interviewing, standard pharmacotherapy, and attention to Latino cultural concerns about antidepressants. This 12-week, open-trial, pre-post pilot study assessed the impact of Motivational Pharmacotherapy on antidepressant therapy retention, response (symptoms, functioning, and quality of life), and visit duration among N=50 first-generation Latino outpatients with Major Depressive Disorder. At study endpoint, 20% of patients discontinued treatment, with a mean therapy duration of 74.2 out of 84 days. Patients’ symptoms, psychosocial functioning, and quality of life improved significantly. Mean visit length was 36.7 minutes for visit 1 and 24.3 minutes for subsequent visits, compatible with use in community clinics. Responder and remitter rates were 82% and 68%. Compared to published Latino proportions of non-retention (32-53%) and previous studies at our clinic with similar samples and medications (36-46%), Motivational Pharmacotherapy appears to improve Latino retention in antidepressant therapy, and should be investigated further in controlled designs.
doi:10.1521/psyc.2013.76.3.210
PMCID: PMC4331057  PMID: 23965261
14.  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
15.  Improving Care for Minorities: Can Quality Improvement Interventions Improve Care and Outcomes For Depressed Minorities? Results of a Randomized, Controlled Trial 
Health Services Research  2003;38(2):613-630.
Objective
Ethnic minority patients often receive poorer quality care and have worse outcomes than white patients, yet practice-based approaches to reduce such disparities have not been identified. We determined whether practice-initiated quality improvement (QI) interventions for depressed primary care patients improve care across ethnic groups and reduce outcome disparities.
Study Setting
The sample consists of 46 primary care practices in 6 U.S. managed care organizations; 181 clinicians; 398 Latinos, 93 African Americans, and 778 white patients with probable depressive disorder.
Study Design
Matched practices were randomized to usual care or one of two QI programs that trained local experts to educate clinicians; nurses to educate, assess, and follow-up with patients; and psychotherapists to conduct Cognitive Behavioral Therapy. Patients and physicians selected treatments. Interventions featured modest accommodations for minority patients (e.g., translations, cultural training for clinicians).
Data Extraction Methods
Multilevel logistic regression analyses assessed intervention effects within and among ethnic groups.
Principal Findings
At baseline, all ethnic groups (Latino, African American, white) had low to moderate rates of appropriate care and the interventions significantly improved appropriate care at six months (by 8–20 percentage points) within each ethnic group, with no significant difference in response by ethnic group. The interventions significantly decreased the likelihood that Latinos and African Americans would report probable depression at months 6 and 12; the white intervention sample did not differ from controls in reported probable depression at either follow-up. While the intervention significantly improved the rate of employment for whites and not for minorities, precision was low for comparing intervention response on this outcome. It is important to note that minorities remained less likely to have appropriate care and more likely to be depressed than white patients.
Conclusions
Implementation of quality improvement interventions that have modest accommodations for minority patients can improve quality of care for whites and underserved minorities alike, while minorities may be especially likely to benefit clinically. Further research needs to clarify whether employment benefits are limited to whites and if so, whether this represents a difference in opportunities. Quality improvement programs appear to improve quality of care without increasing disparities, and may offer an approach to reduce health disparities.
doi:10.1111/1475-6773.00136
PMCID: PMC1360906  PMID: 12785564
Mental health; quality improvement; ethnic minorities; depression; managed health care
16.  Differences in Mental Health Outcomes among Whites, African Americans, and Hispanics Following a Community Disaster 
Psychiatry  2005;68(3):250-265.
A number of studies have assessed the association between race and ethnicity and psychological health status following exposure to a stressful event. However, some of these studies indicate racial and ethnic minorities have poorer mental health relative to Whites, while others show no differences or that minorities may actually have better psychological health. One year after the terrorist attacks on the World Trade Center, we collected data on a random sample of city residents (N = 2368). The dependent variables were posttraumatic stress disorder (PTSD), PTSD symptom severity, major depression, panic attack, and general physical and mental well–being. We categorized our respondents as Non–Hispanic White, Non–Hispanic African American, Dominican, Puerto Rican, and Other Hispanics. Bivariate results indicated racial/ethnic differences for PTSD symptom severity, depression, general physical and mental health, and panic attack. Using logistic regression and controlling for possible confounding factors, most of these associations were rendered non–significant. That is, we found no post-disaster racial/ethnic differences for PTSD, PTSD symptom severity, or physical health. African Americans and Other Hispanics were less likely to meet criteria for major depression or to be classified as unhealthy on the self–report SF–12 mental health scale compared to Whites. Only for panic attack were African Americans and Puerto Ricans more likely to meet criteria for this outcome. Thus, our study found little support for the hypothesis that Latinos or African Americans consistently suffered from poorer psychological and physical well–being in the aftermath of traumatic events, relative to Whites.
doi:10.1521/psyc.2005.68.3.250
PMCID: PMC2699395  PMID: 16253112
17.  Disparities in Care for Depression Among Primary Care Patients 
CONTEXT
Ethnic minorities traditionally receive less care for depression than do white populations; we examine ethnic minority care for depression in a large cross-national primary care sample.
DESIGN
This is a cross-sectional study of identification and treatment of depression among diverse primary care patients, using self-report of symptoms and care.
SUBJECTS
One thousand four hundred and ninety-eight depressed primary care patients participating in four large studies of quality improvement for depression care are examined at baseline.
RESULTS
Primary care providers recommend depression treatments for Latino and African-American patients as frequently as they do for white patients. However, Latino and African-American patients are less likely to take antidepressant medications (adjusted odds ratio [OR], 0.30; 95% confidence interval [CI], 0.21 to 0.42 and adjusted OR, 0.56; 95% CI, 0.36 to 0.87, respectively) and Latinos are less likely to obtain specialty mental health care (adjusted OR, 0.50; 95% CI, 0.36 to 0.75).
CONCLUSIONS
Primary care providers are now able to recognize depression and recommend treatment for Latino and African-American patients, with this care recommended at equal rates to that of white patients. However, Latino and African-American patients remain less likely to obtain appropriate care, such as antidepressant medications or specialty care. New approaches to improving access to appropriate care for Latino and African-American primary care patients are needed.
doi:10.1111/j.1525-1497.2004.30272.x
PMCID: PMC1492138  PMID: 15009791
disparities; depression; primary care; African Americans; Latinos; ethnic minorities
18.  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
19.  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
20.  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
21.  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
22.  Racial/Ethnic Disparities in ART Adherence in the United States: Findings From the MACH14 Study 
Background
Minority race/ethnicity is generally associated with antiretroviral therapy nonadherence in US-based studies. Limitations of the existing literature include small samples, subjective adherence measures, and inadequate control for potential confounders such as mental health and substance use, which have been consistently associated with poorer adherence.
Methods
Individual-level data were pooled from 13 US-based studies employing electronic drug monitoring to assess adherence. Adherence was operationalized as percent of prescribed doses taken from the first 12 (monthly) waves of data in each study. Depression symptoms were aggregated from several widely used assessments, and substance use was operationalized as any use of cocaine/stimulants, heroin/opiates, ecstasy, hallucinogens, or sedatives in the 30–365 days preceding baseline.
Results
The final analytic sample of 1809 participants ranged in age from 18 to 72 years and was 67% male. Participants were 53% African American, 14% Latino, and 34% White. In a logistic regression adjusting for age, gender, income, education, and site, race/ethnicity was significantly associated with adherence (P < 0.001) and persisted in a model that also controlled for depression and substance use (P < 0.001), with African Americans having significantly lower adherence than Latinos [odds ratio (OR) = 0.72, P = 0.04] and whites (OR = 0.60, P < 0.001). Adherence did not differ between whites and Latinos (OR = 0.84, P = 0.27).
Conclusions
Racial/ethnic differences in demographics, depression, and substance abuse do not explain the lower level of antiretroviral therapy adherence in African Americans observed in our sample. Further research is needed to explain the persistent disparity and might examine factors such as mistrust of providers, health literacy, and inequities in the health care system.
doi:10.1097/QAI.0b013e31825db0bd
PMCID: PMC3607367  PMID: 22595873
HIV/AIDS; race/ethnicity; antiretroviral treatment; medication adherence
23.  The role of provider supply and organization in reducing racial/ethnic disparities in mental health care in the U.S 
Racial and ethnic disparities in mental health care access in the United States are well documented. Prior studies highlight the importance of individual and community factors such as health insurance coverage, language and cultural barriers, and socioeconomic differences, though these factors fail to explain the extent of measured disparities. A critical factor in mental health care access is a local area’s organization and supply of mental health care providers. However, it is unclear how geographic differences in provider organization and supply impact racial/ethnic disparities. The present study is the first analysis of a nationally representative U.S. sample to identify contextual factors (county-level provider organization and supply, as well as socioeconomic characteristics) associated with use of mental health care services and how these factors differ across racial/ethnic groups. Hierarchical logistic models were used to examine racial/ethnic differences in the association of county-level provider organization (health maintenance organization (HMO) penetration) and supply (density of specialty mental health providers and existence of a community mental health center) with any use of mental health services and specialty mental health services. Models controlled for individual- and county-level socio-demographic and mental health characteristics. Increased county-level supply of mental health care providers was significantly associated with greater use of any mental health services and any specialty care, and these positive associations were greater for Latinos and African-Americans compared to non-Latino Whites. Expanding the mental health care workforce holds promise for reducing racial/ethnic disparities in mental health care access. Policymakers should consider that increasing the management of mental health care may not only decrease expenditures, but also provide a potential lever for reducing mental health care disparities between social groups.
doi:10.1016/j.socscimed.2013.02.006
PMCID: PMC3659418  PMID: 23466259
Racial/ethnic disparities in mental health; care in the United States; Social and contextual factors; Availability of mental health care providers; HMO penetration
24.  Retention and Attrition Among African Americans in the STAR*D Study: What Causes Research Volunteers to Stay or Stray? 
Depression and anxiety  2013;30(11):10.1002/da.22134.
Background
High attrition rates among African-Americans (AA) volunteers are a persistent problem that makes clinical trials less representative and complicates estimation of treatment outcomes. Many studies contrast AA with other ethnic/racial groups, but few compare the AA volunteers who remain in treatment with those who leave. Here, in addition to comparing patterns of attrition between African Americans and whites, we identify predictors of overall and early attrition among African Americans.
Method
Sample comprised non-Hispanic African-American (n=673) and white (n=2,549) participants in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study. Chi-square tests were used to examine racial group differences in reasons for exit. Multivariate logistic regression was used to examine predictors of overall attrition, early attrition (by Level 2) and top reasons cited for attrition among African Americans.
Results
For both African-American and white dropouts, non-compliance reasons for attrition were most commonly cited during the earlier phases of the study while reasons related to efficacy and medication side effects were cited later in the study. Satisfaction with treatment strongly predicted overall attrition among African Americans independent of socioeconomic, clinical, medical or psychosocial factors. Early attrition among African American dropouts was associated with less psychiatric comorbidity, and higher perceived physical functioning but greater severity of clinician-rated depression.
Conclusions
The decision to drop out is a dynamic process that changes over the course of a clinical trial. Strategies aimed at retaining African Americans in such trials should emphasize engagement with treatment and patient satisfaction immediately following enrollment and after treatment initiation.
doi:10.1002/da.22134
PMCID: PMC3818393  PMID: 23723044
Research Volunteers; Ethnic Groups; Blacks; Depression; Disparities; Treatment
25.  Correlates of depressive symptoms among Latino and Non-Latino White adolescents: Findings from the 2003 California Health Interview Survey 
BMC Public Health  2007;7:21.
Background
The prevalence of depression is increasing not only among adults, but also among adolescents. Several risk factors for depression in youth have been identified, including female gender, increasing age, lower socio-economic status, and Latino ethnic background. The literature is divided regarding the role of acculturation as risk factor among Latino youth. We analyzed the correlates of depressive symptoms among Latino and Non-Latino White adolescents residing in California with a special focus on acculturation.
Methods
We performed an analysis of the adolescent sample of the 2003 California Health Interview Survey, which included 3,196 telephone-interviews with Latino and Non-Latino White adolescents between the ages of 12 and 17. Depressive symptomatology was measured with a reduced version of the Center for Epidemiologic Studies Depression Scale. Acculturation was measured by a score based on language in which the interview was conducted, language(s) spoken at home, place of birth, number of years lived in the United States, and citizenship status of the adolescent and both of his/her parents, using canonical principal component analysis. Other variables used in the analysis were: support provided by adults at school and at home, age of the adolescent, gender, socio-economic status, and household type (two parent or one parent household).
Results
Unadjusted analysis suggested that the risk of depressive symptoms was twice as high among Latinos as compared to Non-Latino Whites (10.5% versus 5.5 %, p < 0.001). The risk was slightly higher in the low acculturation group than in the high acculturation group (13.1% versus 9.7%, p = 0.12). Similarly, low acculturation was associated with an increased risk of depressive symptoms in multivariate analysis within the Latino subsample (OR 1.54, CI 0.97–2.44, p = 0.07). Latino ethnicity emerged as risk factor for depressive symptoms among the strata with higher income and high support at home and at school. In the disadvantaged subgroups (higher poverty, low support at home and at school) Non-Latino Whites and Latinos had a similar risk of depressive symptoms.
Conclusion
Our findings suggest that the differences in depressive symptoms between Non-Latino Whites and Latino adolescents disappear at least in some strata after adjusting for socio-demographic and social support variables.
doi:10.1186/1471-2458-7-21
PMCID: PMC1805430  PMID: 17313675

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