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.
Pooled data from the nationally representative NIMH Collaborative Psychiatric Epidemiological Studies (2001–2003).
We employ a novel reweighting method to estimate service disparities in the presence and absence of insurance coverage.
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.
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.
Expansion of insurance coverage might have different effects for racial/ethnic groups, requiring additional interventions to reduce disparities for all groups.
Disparities; minorities; expanding insurance; behavioral health; mechanisms
This study evaluated the effect of race-ethnicity and geography on the adoption of a pharmacological innovation (long-acting injectable risperidone, LAIR) among Medicaid beneficiaries with schizophrenia, and also evaluated the contribution of geographic location to observed racial-ethnic disparities.
Data source was a claims dataset from the Florida Medicaid program for the 2.5 year period that followed the launch of LAIR in the US market. Study participants were beneficiaries with schizophrenia who had filled at least 1 antipsychotic prescription during the study period. Outcome variable was any use of LAIR; model variables were need indicators and random effects for 11 Medicaid areas, multi-county units used by the Medicaid program to administer benefits. Adjusted probability of use of LAIR for blacks and Latinos versus whites was estimated with logistic regression models.
The study cohort included 13,992 Medicaid beneficiaries: 25% blacks, 37% Latinos, and 38% whites. Unadjusted probability of LAIR use was lower for Latinos than whites and it varied across the state’s geographic areas. Adjustment for need confirmed the unadjusted finding of a Latino-white disparity (OR = .58, 95% CI = .49–.70). While the inclusion of geographic location in the model eliminated the Latino-white disparity, doing so confirmed the unadjusted finding of geographic variation in adoption.
Within a state Medicaid program, the initial finding of a Latino-white adoption disparity was driven by geographic disparities in adoption rates and the geographic concentration of Latinos in a low-adoption area. Possible contributors and implications of these results are discussed.
We examine differential validity of DSM-IV diagnoses assessed by the fully-structured Composite International Diagnostic Interview Version 3.0 (CIDI) among Latino, Non-Latino Black, and Non-Latino White adolescents in comparison to gold standard diagnoses derived from the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS). Results are based on the National Comorbidity Survey Replication Adolescent Supplement, a national US survey of adolescent mental health. Clinicians re-interviewed 347 adolescent/parent dyads with the K-SADS. Sensitivity and/or specificity of CIDI diagnoses varied significantly by ethnicity/race for four of ten disorders. Modifications to algorithms sometimes reduced bias in prevalence estimates, but at the cost of reducing individual-level concordance. These findings document the importance of assessing fully-structured diagnostic instruments for differential accuracy in ethnic/racial subgroups.
National Comorbidity Survey Replication Adolescent Supplement; Validity; Disparities
Effectiveness trials have confirmed the superiority of clozapine in the treatment of schizophrenia, but little is known about whether the drug’s superiority holds across racial-ethnic groups. This study examined the effect of race-ethnicity on the effectiveness of clozapine relative to other antipsychotics among patients in maintenance antipsychotic treatment.
Black, Latino, and white Florida Medicaid beneficiaries with schizophrenia receiving maintenance treatment with clozapine or other antipsychotic medications during 7/1/00-6/30/05 were identified. Cox proportional hazard regression models were used to estimate associations of clozapine, race-ethnicity, and their interaction, with time to discontinuation for any cause, our primary measure of effectiveness.
The study cohort included 20,122 episodes of treatment with clozapine (3.7%) and other antipsychotics (96.3%), with 23% black and 36% Latino. Unadjusted analyses suggested that Latinos continue on clozapine longer than whites, while they and blacks discontinue other antipsychotics sooner than whites. Adjusted analyses using 749 propensity score matched sets of clozapine and other antipsychotic users indicated that risk of discontinuation was lower for clozapine users (RR = .45, 95% CI = .39 – .52), an effect that was not moderated by race-ethnicity. Times to discontinuation were longer for clozapine users. Overall risk of antipsychotic discontinuation was higher for blacks (RR =1.56, CI = 1.27 – 1.91), and Latinos (RR = 1.23, CI = 1.02 – 1.48).
This study confirmed clozapine’s superior effectiveness and did not find evidence that race-ethnicity modifies this effect. These findings heighten the need for efforts to increase clozapine use, particularly among minority groups.
To examine the population prevalence, patterns of onset, and important demographic covariates for dual (co-occurring) diagnoses of substance and non-substance mental disorders.
A nationally representative sample of U.S. Latino adults was interviewed face-to-face.
Estimates were made using data from the National Latino and Asian Services Survey (NLAAS) using the World Health Organization CIDI, DSM-IV criteria, for case ascertainment.
U.S. born Latinos are much more likely to report a dual diagnoses than are foreign born Latinos in both sexes; 16.88% vs. 5.02% for males (p<0.000), and 7.48% vs. 0.58% for women (p<.000). Total dual diagnoses prevalence was 6.79%, with non-substance mental disorder occurring first 70% of the time, with an earlier age of onset for U.S. Latinos. Immigrants were less likely to be positive for dual diagnoses (OR= 0.234, p=<0.0001), or any substance disorder diagnosis (OR=0.261, p=<.0001), if they reported lifetime substance use when compared to U.S. born Latinos.
Latino adults residing in the U.S. have one-fourth the risk of dual diagnoses compared to the U.S. population. Most of this difference is accounted for by lower rates of substance and non-substance disorders and a lower propensity for progression from substance use to substance use disorders, combined with a later age of onset for mental disorders among immigrants. Immigrant women rarely reported dual diagnoses. We recommend bio-behavioral models and transnational studies to identify life course factors contributing dual diagnoses among U.S. born Latinos.
epidemiology; minority groups; comorbidity; immigration
The role of individual versus community level social connections in promoting health is an important factor to consider when addressing Latino health. This analysis examines the relationships between social support, social cohesion, and health in a sample of Latinos in the United States. Using data from the National Latino and Asian American Study, the analysis uses ordered logistic regression to explore the relationships of family support, friend support, family cultural conflict, and neighborhood social cohesion with self-rated physical and mental health, taking into account language proficiency and use, nativity, and sociodemographic variables. Family support, friend support, and neighborhood social cohesion were positively related to self-rated physical and mental health, and family cultural conflict was negatively related when controlled only for sex and age. After controlling for education, income, and other demographic measures, only family support was found to have a weak association with self-rated physical health; however, the relationship seemed to be mediated by language. In contrast, family support and family cultural conflict were strongly associated with self-rated mental health, after controlling for language, education, income, and other demographic measures. The study did not find neighborhood social cohesion to be significantly related to either self-rated physical or mental health, after accounting for the effects of the other social connection variables. Language of interview did not explain the highly significant effects of language proficiency and use. Social connections are important for health and mental health, but language and other sociodemographic factors seem to be related to how Latinos establish these social linkages. Further investigation into the role of language in the development and maintenance of social connections may help unravel the mechanisms by which they promote or decrease health.
USA; social cohesion; social support; Latino; self-rated health; self-rated mental health
To describe the mental health service use of Haitian, African American, and non-Latino White youth in a community mental health setting. Groups are compared on adherence to treatment guidelines for attention-deficit/hyperactivity disorder (ADHD) and depressive disorders.
Retrospective review of outpatient mental health charts (n=252) from five community sites in an urban area of the Northeastern United States. We recorded total number and treatment type of sessions during the first six months of treatment. Guideline-adherent treatments were compared and predicted after controlling for clinical need.
Most Haitian and African American youth stopped treatment by six months, with the majority attending less than eight sessions. One third of Haitian and African American patients attended just one session. Haitians patients who presented with less severe symptoms and dysfunction were more likely to have single-session treatments. Guideline-adherent treatment for ADHD and depression was less likely for Haitians. Older patients were more likely to receive adequate depression treatment. Haitian youth were relatively underinsured, had more family separations documented, and received Adjustment Disorder diagnoses more often.
Haitian youth use outpatient mental health services in similar proportion to African American youth, and at lower rates than White youth. Guideline-adherent treatment for ADHD and depression is limited by low retention in care for Black youth. Low insurance coverage is likely an important contributor to reduced use of services, especially for Haitians. These findings are discussed in the context of providing culturally sensitive mental health care to diverse communities.
mental health services; Haitian; cross-cultural; treatment guidelines; youth
To review the literature on racial and ethnic disparities in behavioral health services and present recent data, focusing on services for substance use disorders (SUD) and comorbid mental health disorders for children and adolescents.
A literature review was conducted of behavioral health services for minority youth. Papers were included if specific comparisons in receipt of SUD services for youth were made by race or ethnicity. The review was organized following the Sociocultural Framework.
Compared to non-Latino Whites with SUD, Black adolescents with SUD report receiving less specialty and informal care, while Latinos with SUD report less informal services. Potential mechanisms of racial and ethnic disparities were identified in: federal and economic health care policies and regulations; the operation of the health care system and provider organization; provider level factors; the environmental context; the operation of the community system; and patient level factors. Significant disparities reductions could be achieved by adoption of certain state policies and regulations that increase eligibility in public insurance. There is also a need to study how the organization of treatment services might lead to service disparities, particularly problems in treatment completion. Institutional and family characteristics linked to better quality of care should be explored. Since treatments appear to work well independent of race/ethnicity, translational research to bring evidence based care in diverse communities can bolster their effectiveness.
Our review suggests promising venues to reduce ethnic and racial disparities in behavioral health services for ethnic and racial minority youth.
disparities; behavioral health services; youth; race; ethnicity
The development of measures of self-reported racial/ethnic discrimination is an active area of research, but few measures have been validated across multiple racial/ethnic and language groups. Our goal is to develop and evaluate a discrimination measure that is appropriate for use in surveys of racially and ethnically diverse populations.
To develop our measure, we employ a mixed-methods approach for survey research, drawing from both qualitative and quantitative traditions, including literature review, cognitive testing, psychometric analyses, behavior coding as well as two rounds of field testing using a split-sample design. We tested our new measure using two different approaches to elicit self-reported experiences of racial/ethnic discrimination.
Our new measure captures four dimensions of racial/ethnic discrimination: 1) frequency of encounters with discrimination across several domains (e.g., medical care, school, work, street and other public places); 2) timing of exposure (e.g., recent, lifetime); 3) appraisal of discrimination as stressful; and 4) responses to discrimination.
Because of the growing interest in measurement of racial/ethnic discrimination in health surveys, we think this report on the methods informing the development and testing of the discrimination module that will be used on the California Health Interview Survey would be useful to other researchers. The application of mixed methods to rigorously test the validity and reliability of our instrument proves to be a good roadmap for measuring racial/ethnic discrimination in multicultural and multilingual populations.
Cross-Cultural Comparison; Discrimination; Survey Methods
It is advantageous for a clinician to understand how patients feel about their initial encounters, but it can be difficult to discern what is and what is not working. This qualitative, exploratory study is guided by the question, “What happens during an initial mental health encounter between a Black patient and a non-Black provider that leads the patient to describe it as a good or poor experience?” The findings are based on face to face, postintake interviews with 14 Black patients seen by 11 non-Black providers as part of the Patient-Provider Encounter Study (PPES). The objective is to explore the initial interpersonal interactions between Black patients and their non-Black mental health providers and to better understand how patients come to describe the encounter as good (favorable) or poor (unfavorable). A framework inclusive of 5 specific elements is introduced that maps the patient’s conceptualization process about how judgments are made about the encounter. Due to the naturalistic and exploratory nature of the study, a research hypothesis was not established. Instead, we observed how patients scanned the interaction with the provider, made assessments about their provider, and determined whether their experience was positive or negative. The implications of these findings will help to improve the interactions in mental health settings between minority patients and their providers.
African American mental health; race concordance; healthy cultural paranoia; scanning; Patient-Provider Encounter Study
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.
Pooled data from the NIMH Collaborative Psychiatric Epidemiological Studies (CPES; ) were used.
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.
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.
Anorexia Nervosa; Bulimia Nervosa; Binge-eating disorder; Ethnicity
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.
DROPOUT; TRAUMA; MENTAL HEALTH; MINORITY YOUTH; IMMIGRATION
This study examined the occurrence, correlates, and psychiatric co-morbidities of lifetime and 12-month intermittent explosive disorder (IED) and whether impairment due to IED differed across Latino groups. We used data on 2,554 Latino adults (75.5% response rate) from the National Latino and Asian American Study (NLAAS). Lifetime and 12-month prevalence of IED among Latinos were 5.8% and 4.1%, respectively. Unemployment was a common risk factor for both lifetime and 12-month IED. Protective factors for both lifetime and 12-month IED were having poor/fair English proficiency and being born outside the U.S. mainland. Cubans, Mexicans and other Latinos had lower odds of both lifetime and 12-month IED relative to Puerto Ricans, while Puerto Ricans with IED did not demonstrate worse impairment compared with the other groups with IED. Lifetime and 12-month IED were associated with several depressive, anxiety, and substance use disorders. Given its significant association with a wide-range of mental disorders, future research should consider the validity of IED as a unique disorder or whether it is merely a constellation of symptoms that accompanies a variety of mental diseases.
Hispanic Americans; impulse control disorders; mental health; comorbidity; epidemiology
To assess health care disparities among black and Latino adults with schizophrenia receiving services during the period July 1994–June 2006, and to evaluate trends in observed disparities.
Administrative claims data from the Florida Medicaid program. Data sources included membership files (demographic information), medical claims (diagnostic, service, and expenditure information), and pharmacy claims (prescriptions used and expenditures).
We identified adults with at least two schizophrenia claims during a fiscal year. We used generalized estimating equation models to estimate disparities in spending on psychotropic drugs, psychiatric inpatient services, all mental health services, and all health services.
Spending on psychotropic drugs, mental health, and all health was 0.9–70 percent lower for blacks and Latinos than for whites. With the exception of blacks with substance use disorder comorbidity, minorities were less likely than whites to use psychiatric inpatient services. Psychiatric inpatient spending among users did not differ by race/ethnicity. With the exception of psychiatric inpatient utilization/spending, trend analyses showed no change or modest reductions in disparities.
Black and Latino Medicaid recipients diagnosed with schizophrenia experience health care disparities. Some but not all disparities narrowed modestly over the study period.
Racial/ethnic disparities; schizophrenia; quality of care; trends; Medicaid
Disparities remain in mental health status and care for racial and ethnic minority youth, despite national attention to disparity reduction. This paper offers a comprehensive picture of the status of pediatric disparities, by addressing the major areas affecting minority youth mental health, including: prevention of problems, need for services, access to care, mental health treatment types and treatment outcomes. It addresses relevant factors in the family, community and socioeconomic context, and describes various local and national programs that aim to tackle the obstacles and fill the gaps in high quality care for racial/ethnic minority youth. It concludes by offering recommendations for improvement which acknowledge the importance of understanding preferences and attitudes towards treatment, ensuring that screening and diagnosis is appropriate to minority youth, and ensuring that evidence-based programs are available at multiple levels to best service children and succeed in addressing their needs.
ethnic; racial; disparities; youth; mental health; minorities; healthcare
This article presents the first epidemiological portrait of ataques de nervios among Latinos in the mainland United States. Much of the previous literature has focused on Puerto Ricans in Puerto Rico and New York City.
This study examines the social and psychiatric correlates of ataque de nervios in a nationally representative sample of Latinos in the United States.
This study employs data from the Latino sample [N=2554] of the National Latino and Asian American Study. Analyses examined the associations between ataques de nervios and a range of social and migration variables, as well as psychiatric diagnoses and measures of mental health need.
Ataques de nervios were reported by 7 to 15% of the different Latino groups, with Puerto Ricans reporting the highest frequency. Ataques de nervios were more frequent in women, those with disrupted marital status, and those more acculturated the U.S. The frequency of those who met criteria for affective, anxiety and substance abuse disorders was higher among those reporting an ataque de nervios.
Ataque de nervios can serve as an important indicator of social and psychiatric vulnerability in future epidemiological and clinical studies with Latino populations.
ataques de nervios; cultural syndromes; Latinos; NLAAS; social and psychiatric vulnerability
Individuals with early onset of psychiatric disorder have worse social outcomes than individuals with adult onset. It is unknown whether this association varies by racial/ethnic group. Identifying groups at risk for poor social outcomes is important for improving clinical and policy interventions. We compared unemployment, high school dropout, arrest, and welfare participation by race/ethnicity and time of onset using a nationally representative sample of Whites, Blacks, Asians, and Latinos with lifetime psychiatric disorder. Early onset was associated with worse social outcomes than adult onset. Significant Black-White and Latino-White differences in social outcomes were identified. The association between early onset and negative social outcomes was similar across Whites, Latinos, and Blacks. For Asians, the association between unemployment and early onset was opposite that of Whites. Increasing early detection and treatment of psychiatric illness should be prioritized. Further study will clarify the association between onset and social outcomes among sub-ethnic populations.
Social determinants; mental health; racial/ethnic disparities; children’s mental health
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.
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.
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.
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.
Depression; Retention in Care; Ethnic-Racial Minorities
Evidence suggests that the current mental health system is failing in the provision of quality mental health care for diverse children and families. This paper discusses one critical domain missing to improve care: serious attention given to diversity, culture, and context. It discusses what we mean by understanding culture and context at the individual, family, organizational, and societal level. Focusing on key predictors of children’s adjustment in natural contexts would increase attention to building community and family capacities that strengthen children’s mental health. To conclude, we suggest changes in organizational culture to build natural supports to enhance children's mental health.
culture; context; diversity; disparities; public health model
We examined potential pathways by which time in the U.S. may relate to differences in the predicted probability of last year psychiatric disorder among Latino immigrants as compared to U.S.-born Latinos.
We estimated predicted probabilities of psychiatric disorder for U.S.-born and immigrant groups with varying time in the U.S. adjusting for different combinations of covariates. We examined six “pathways” by which time in the U.S. could be associated with psychiatric disorder.
Increased time in the U.S. is associated with higher risk of psychiatric disorders among Latino immigrants. After adjustment for covariates, differences in psychiatric disorder rates disappear between U.S.-born and immigrant Latinos. Discrimination and family cultural conflict appear to have a significant role in the association between time in the U.S. and the likelihood of developing psychiatric disorders.
Increased perceived discrimination and family cultural conflict are pathways by which acculturation might relate to deterioration of mental health for immigrants. Future studies assessing how these implicit pathways evolve with increased contact with U.S. culture may help to identify strategies for ensuring maintenance of mental health for Latino immigrants.
acculturation; measures; immigrants
This study examined whether there were associations between individual measures of socioeconomic status (SES) and the 12-month prevalence of major depressive disorder (MDD) in representative samples of Blacks, Latinos, Asians, and Whites in the United States.
The data used were from the Collaborative Psychiatric Epidemiology Studies.
There was an association between household income and MDD among Whites. However, the association was not statistically significant. Statistically significant associations were present between educational attainment and MDD among Whites. Among both Whites and Latinos, being out of the labor force was significantly associated with MDD. In analyses by nativity, being out of the labor force was significantly associated with MDD among US-born and foreign-born Latinos.
Significant associations between various measures of SES and MDD were consistently observed among White and in some cases, among Latino populations. Future studies should continue to examine sociopsychological factors related to SES that increase the risk of MDD among people from racial-ethnic communities.
Major depression; racial-ethnic status; socio-economic status
Given recent adaptations of the World Health Organization Composite International Diagnostic Interview (WMH-CIDI), new methodological studies are needed to evaluate the concordance of CIDI diagnoses with clinical diagnostic interviews. This paper summarizes lessons learned from a clinical reappraisal study done with U. S. Latinos. We compare CIDI diagnoses with independent clinical diagnosis using the World Mental Health Structured Clinical Interview for DSM-IV (WMH SCID 2000). Three sub-samples stratified by diagnostic status (CIDI positive, CIDI negative, or CIDI subthreshold for a disorder) based on nine disorders were randomly selected for a telephone re-interview using the SCID. We calculated sensitivity, specificity, and weight-adjusted Cohen's kappa. Weighted 12 month prevalence estimates of the SCID are slightly higher than those of the CIDI for generalized anxiety disorder, alcohol abuse/dependence, and drug abuse/dependence. For Latinos, CIDI-SCID concordance at the aggregate disorder level is comparable, albeit lower, to other published reports. The CIDI does very well identifying negative cases and classifying disorders at the aggregate level. Good concordance was also found for major depressive episode and panic disorder. Yet, our data suggests that the CIDI presents problems for assessing PTSD and GAD. Recommendations on how to improve future versions of the CIDI for Latinos are offered.
concordance; reliability; validity; diagnosis; CIDI; SCID; Latinos