Research Article: Antidepressant use among Asians in the United States

Objectives: We examined the prevalence and predictors of past‐year antidepressant use in a nationally representative sample of Asian Americans and non‐Latino Whites. Methods: Analyses of 12‐month antidepressant medication use were based on data from the Collaborative Psychiatric Epidemiology Surveys that surveyed Asian (Chinese, Filipino, Vietnamese, and others; N=2,284) and non‐Latino White (N=6,696) household residents ages 18 years and older in the 48 contiguous United States and Hawaii. Results: Prevalence rates for 12‐month antidepressant use for Asians with major depression ranged from 8.7% among Vietnamese to 17% among Chinese respondents. Compared to non‐Latino Whites (32.4%), all Asians (10.9%) meeting criteria for 12‐month depressive and anxiety disorders, but especially Filipinos (8.8%) were less likely to report past‐year antidepressant use. Conclusions: We found disparities in past‐year antidepressant use among all the examined major Asian groups meeting criteria for 12‐month depressive and anxiety disorders. These disparities were not explained by mental health need or socioeconomic factors that enable access to care. Depression and Anxiety, 2010. © 2009 Wiley‐Liss, Inc.     

From placement to prison revisited: Do mental health services disrupt the delinquency pipeline among Latino,African American and Caucasian youth in the child welfare system?

Racial and ethnic disparities in delinquency among child welfare-involved youth are well documented. However, less is known about the mechanisms through which these disparities occur. This study explores the extent to which sets of variables predict the occurrence of juvenile delinquency and whether race/ethnicity moderates the strength of the relationships between (1) social, emotional, and behavioral (SEB) problems and delinquency and (2) mental health service use and delinquency. We used a nationally representative sample of 727 African American, Caucasian, and Latino youth between the ages of 12–17 who were referred to the child welfare system. Controlling for age, gender, placement instability, maltreatment history, poverty, and urbanicity, linear regression analyses revealed that African American and Latino youth engaged in more delinquent acts than Caucasian youth did. However, service use decreased the likelihood of engaging in more delinquent acts for African Americans. Additional efforts are needed to illuminate and address the contextual and organizational barriers to delivering effective mental health services as a strategy to reduce racial disparities in delinquent behavior.     

Ethnic disparities in unmet need for alcoholism, drug abuse, and mental health care.

OBJECTIVE: Recent policy has focused on documenting and reducing ethnic disparities in availability and quality of health care. The authors examined differences by ethnic status in unmet need for alcoholism, drug abuse, and mental health treatment. METHOD: Data were from a follow-up survey of adult respondents to a 1996-1997 national survey. Non-Hispanic whites, African Americans, and Hispanics were compared in access to alcoholism and drug abuse treatment and mental health care (primary or specialty), unmet need for care, satisfaction with care, and use of active treatment for alcoholism, drug abuse, and mental health problems in the prior 12 months. RESULTS: A total of 31.9% of whites, 28.1% of African Americans, and 30.1% of Hispanics had some alcoholism, drug abuse, and mental health care, mostly in primary care. Among those with perceived need, compared to whites, African Americans were more likely to have no access to alcoholism, drug abuse, or mental health care (25.4% versus 12.5%), and Hispanics were more likely to have less care than needed or delayed care (22.7% versus 10.7%). Among those with need, whites were more likely than Hispanics or African Americans to be receiving active alcoholism, drug abuse, or mental health treatment (37.6% versus 22.4%-25.0%). CONCLUSIONS: The authors document greater unmet need for alcoholism and drug abuse treatment and mental health care among African American and Hispanics relative to whites. New policies are needed to improve access to and quality of alcoholism, drug abuse, and mental health treatment across diverse populations.     

Retention in depression treatment among ethnic and racial minority groups in the United States

Background: Premature discontinuation of psychiatric treatment among ethnic–racial minorities is a persistent concern. Previous 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 United States as compared to non‐Latino whites. Second, we aim to identify the factors that are related to treatment retention. Methods: We use data from the Collaborative Psychiatric Epidemiology Surveys 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 during 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. Depression and Anxiety, 2010.© 2010 Wiley‐Liss, Inc.     

Limited English proficiency as a barrier to mental health service use: A study of Latino and Asian immigrants with psychiatric disorders

Language barriers pose problems in mental health care for foreign-born individuals in the United States. Immigrants with psychiatric disorders may be at particular risk but are currently understudied. The purpose of this study was to examine the effect of limited English proficiency (LEP) on mental health service use among immigrant adults with psychiatric disorders. Drawn from the National Latino and Asian American Study (NLAAS), Latino and Asian immigrant adults aged 18-86 with any instrument-determined mood, anxiety, and substance use disorder (n = 372) were included in the present analysis. Results from hierarchical logistic regression analyses showed that having health insurance, poor self-rated mental health, and more psychiatric disorders were independently associated with higher probability of mental health service use in the Latino group. After controlling for all background characteristics and mental health need factors, LEP significantly decreased odds of mental health service use among Latino immigrants. None of the factors including LEP predicted mental health service use among Asian immigrants, who were also the least likely to access such services. LEP was a barrier to mental health service use among Latino immigrants with psychiatric disorders. This study suggests that future approaches to interventions might be well advised to include not only enhancing the availability of bilingual service providers and interpretation services but also increasing awareness of such options for at least Latino immigrants. In addition, further investigation is needed to identify factors that can enhance access to mental health care services among Asians.     

English proficiency and peer interethnic relations as predictors of math achievement among Latino and Asian immigrant students

Studies show math achievement to be the best predictor of entering post-secondary education. However, less is known about the predictors of math achievement, particularly among immigrant youth. This study examined English proficiency and peer interethnic relations as predictors of mathematics achievement among Latino and Asian high school students, postulating an interaction between the predictors and mediation by academic motivation. A multilevel moderated-mediation model was used to analyze data from a national sample of 2113 non-native English speaking Latino and Asian students attending high school in the U.S. We found that higher academic motivation mediated the relationship between English proficiency during their sophomore year and gains in senior math achievement scores for both Asian and Latino students. For Latino students however, this indirect path was only significant for students whose perceptions of positive peer interethnic relations at school were average or above average.     

Racial/Ethnic Disparities in Admissions to Public and Private Psychiatric Inpatient Settings: The Effect of Managed Care

This study investigates the effect of managed care on access patterns among people of color who are severely and persistently mentally ill. The distribution of admissions to public and private psychiatric hospitals was compared for African-American, Asian, Latino, and white case managed clients of the Massachusetts Department of Mental Health before and after implementation of Medicaid managed mental health care in October 1997. Managed care appears to have increased access to private services across all racial and ethnic groups, although admissions of non-white patients were still more likely to take place in publicly operated settings. These data suggest that equalizing access to putatively better inpatient treatment settings may be an externality of managed care.     

Access to specialty mental health services among women in California

OBJECTIVE: The Anderson behavioral model was used to investigate racial and ethnic disparities in access to specialty mental health services among women in California as well as factors that might account for such disparities. METHODS: The study was a cross-sectional examination of a probability sample of 3,750 California women. The main indicators of access to services were perceived need, service seeking, and service use. Multivariate models were constructed that accounted for need and enabling and demographic variables. RESULTS: Significant racial and ethnic variations in access to specialty mental health services were observed. African-American, Hispanic, and Asian women were significantly less likely to use specialty mental health services than white women. Multivariate analyses showed that Hispanic and Asian women were less likely than white women to report perceived need, even after frequent mental distress had been taken into account. Among women with perceived need, African-American and Asian women were less likely than white women to seek mental health services after differences in insurance status had been taken into account. Among women who sought services, Hispanic women were less likely than white women to obtain services after adjustment for the effects of poverty. Need and enabling factors did not entirely account for the observed disparities in access to services. CONCLUSIONS: Additional research is needed to identify gender- and culture-specific models for access to mental health services in order to decrease disparities in access. Factors such as perceived need and decisions to seek services are important factors that should be emphasized in future studies.     

Inequalities in use of specialty mental health services among Latinos,African Americans,and non-Latino whites

OBJECTIVE: The authors investigated whether there are disparities in the rates of specialty mental health care for Latinos and African Americans compared with non-Latino whites in the United States. METHODS: Data were analyzed from the 1990-1992 National Comorbidity Survey, which surveyed a probability sample of 8,098 English-speaking respondents aged 15 to 54 years. Respondents self-identified their race or ethnicity, yielding a sample of 695 Latinos, 987 African Americans, and 6,026 non-Latino whites. Data on demographic characteristics, insurance status, psychiatric morbidity, whether the respondent lived in an urban or a rural area, geographic location, income, and use of mental health services were determined for each ethnic or racial group. Logistic regression analyses were used to examine the associations between ethnic or racial group and use of specialty services, with relevant covariates adjusted for. RESULTS: Significant differences between ethnic groups were found in demographic characteristics, geographic location, zone of residence, insurance status, income, wealth, and use of mental health services. The results indicated that poor Latinos (family income of less than $15,000) have lower access to specialty care than poor non-Latino whites. African Americans who were not classified as poor were less likely to receive specialty care than their white counterparts, even after adjustment for demographic characteristics, insurance status, and psychiatric morbidity. CONCLUSIONS: To understand ethnic or racial disparities in specialty care, the effects of ethnicity or race should be analyzed in combination with variables related to poverty status and environmental context. Further research needs to address the complex construct of social position in order to bridge the gap in unmet need in specialty care.     

National trends in school victimization among Asian American adolescents

The “model minority” perception of Asian American students often ignores the academic and social challenges that many face in schools. One area that has received less attention is the school victimization experiences of Asian American adolescents. While some qualitative researchers have explored factors contributing to school victimization in recent years, missing in the literature is the scope of these incidents among Asian Americans. This paper contributes to this literature by (1) examining national trends in the victimization of Asian American adolescents in schools over the last decade and (2) investigating how victimization varies according to their gender, socioeconomic status, and achievement levels. The results show that although Asian American adolescents are consistently less likely to be bullied relative to other students, they are more likely to report experiences of racial discrimination. Victimization incidents for Asian Americans also differ by gender and academic achievement levels.     

The effect on treatment outcomes of assigning patients to ethnically focused inpatient psychiatric units

OBJECTIVE: The authors examined whether assigning patients from three ethnic groups-blacks, Latinos, and Asians-to three ethnically focused psychiatric inpatient units would affect treatment outcome. METHODS: Retrospective administrative data for 5,983 inpatients at a large urban community hospital with several ethnically focused units were examined. The data represented 10,645 admissions between 1989 and 1996. Cox proportional-hazards models, logistic and multinomial regressions, and chi square analyses were used to assess the relationship between matching patients to ethnically focused units and time to rehospitalization, referral destination on discharge, and length of stay for Asian, black, and Latino patients. RESULTS: Ethnic matching status was strongly associated with referral destination for Asian and Latino patients but not for black patients. Asian and Latino patients who had been treated on the appropriate ethnically focused units were more frequently sent to outpatient or residential treatment (71 to 73 percent of discharges) than unmatched patients, black patients, and white patients (44 to 49 percent of discharges), who more frequently refused follow-up or were sent to locked facilities. No association was found between matching status and time to rehospitalization or length of stay for any ethnic group. CONCLUSIONS: Matching inpatients to ethnically focused psychiatric units was related to referral destination at discharge. Matched patients were more likely than unmatched patients to accept referral to postdischarge treatment, which has been shown previously to reduce readmission rates. Among persons with serious mental illness, matching patients to ethnically focused units may be important for enhancing communication and trust as a means of improving participation in ongoing treatment programs.     

Factors Associated with Mental Health Service Use Among Latino and Asian Americans

Literature concur that there is a disparity between epidemiological prevalence and mental health services (MHS) utilization rates for Latino and Asian Americans. This study adapted the behavioral model of health service use to examine factors associated with MHS use among Latino and Asian Americans. The model consists of predisposing, enabling, and need factors. This study used the National Latino and Asian American Study data, including six ethnic groups. The outcome measure for this study was the use of MHS in the past 12 months. Age, sex, and education predicted higher odds of MHS use among Latinos, none of which were significant among Asians. Needs factors were strongly associated with higher odds of MHS use among Latinos and Asians.     

Who Gets Care? Mental Health Service Use Following a School-Based Suicide Prevention Program

OBJECTIVE: To examine symptomatology and mental health service use following students' contact with a large urban school district's suicide prevention program. METHOD: In 2001 school district staff conducted telephone interviews with 95 randomly selected parents approximately 5 months following their child's contact with the district's suicide prevention program, a School Gatekeeper Training model. Parents provided information regarding service use, their child's depressive symptoms (using the Diagnostic Interview Schedule for Children Predictive Scale, Depression module), and their perceptions of their child's need for services. Information about the crisis intervention was abstracted from a standardized assessment form. RESULTS: More than two thirds of students received school or community mental health services following contact with the suicide prevention program. Depressive symptoms, but not past year suicide attempt, predicted community mental health service use. Latino students had lower rates of community mental health service use than non-Latinos. School-based service use did not differ by student characteristics including race/ethnicity. CONCLUSIONS: Most students identified by a school-based suicide prevention program received follow-up care, although Latinos were less likely to access services outside the school. School-based mental health services may be an important way in which underserved populations at risk of suicide can receive care.     

Differential referral patterns to ethnic-specific and mainstream mental health programs for four Asian American groups

This study examined the referral patterns of Chinese, Japanese, Filipino, and Korean Americans at ethnic-specific versus mainstream programs in a public mental health system. As predicted, social/ community-based services and family/friends to a lesser degree referred each Asian American group to ethnic-specific programs more than other referral sources (e.g., criminal justice and health services). Referrals by social/community-based programs to ethnic-specific versus mainstream programs were the most significant for Chinese Americans, followed by Japanese and Filipino Americans, and the least significant for Korean Americans. These findings suggest Asian American clients themselves and their social networks may view ethnic-specific programs as more culturally responsive than mainstream programs.     

Identifying adolescents at risk through voluntary school-based mental health screening

This study compares referrals for mental health services among high school students randomized to two means of referral to mental health services: referral via systematic identification through a brief mental health screening procedure (n = 365) or referral via the usual process of identification by school personnel, parents, or students themselves (n = 291). Screened students were significantly more likely than control students (AOR: 21.64 95%CI 6.66-70.36) to receive a referral for mental health services, whether it be to school-based services (AOR: 11.68 95%CI 3.52-8.73) or community-based services (AOR: 20.02 95%CI 2.66-150.41). Post-study, for those screened, 95.5% of school-based mental health services referrals, and 39.3% of community-based referrals were accessed. School based mental health screening identified a significantly greater proportion of youth to be in clinical need of mental health services than would have likely been identified without screening, and increased rates of referral resulted in greater access to mental health services.     

Outcome of referral to social services departments for people with cognitive impairment

The objective of this study was to determine how the entry into long term care of people assessed by their local social services department (SSD) under the National Health Service and Community Care Act 1990 is predicted by the severity of their cognitive impairment, care provided by family members, and the receipt of community care services. The design involved a cohort study of people over one and a half years following referral (min-max: 1-2 years) from three SSDs (county council, metropolitan and inner London boroughs). Consecutive recruitment of 141 people with cognitive impairment aged 65 and over took place over a 4 month period. The main outcome measure was survival analysis of time taken from referral to entering long term care at follow-up. The receipt and intensity of community care services increased the probability of remaining at home. People with mild or moderate cognitive impairment were more likely to remain at home if they had a spouse or daughter carer. Analysis of the interaction between three main effects predicting entry to long term care (severity of cognitive impairment, access to a carer, and the receipt of home care or day care) suggests that while carers are central in determining whether older people with cognitive impairment are able to remain living in the community, there are limits to the care they can provide.     

Considering context, place and culture: the National Latino and Asian American Study

This paper provides a rationale for, and overview of, procedures used to develop the National Latino and Asian American Study (NLAAS). The NLAAS is nationally representative community household survey that estimates the prevalence of mental disorders and rates of mental health service utilization by Latinos and Asian Americans in the US. The central aims of the NLAAS are to: 1) describe the lifetime and 12-month prevalence of psychiatric disorders and the rates of mental health services use for Latino and Asian American populations using nationwide representative samples of Latinos and Asian Americans, 2) assess the associations among social position, environmental context, and psychosocial factors with the prevalence of psychiatric disorders and utilization rates of mental health services, and 3) compare the lifetime and 12-month prevalence of psychiatric disorders, and utilization of mental health services of Latinos and Asian Americans with national representative samples of non-Latino whites (from the National Comorbidity Study-Replication) (NCS-R) and African Americans (from the National Survey of American Life) (NSAL). This paper presents new concepts and methods utilized in the development of the NLAAS to capture and investigate ethnic, cultural and environmental considerations that are often ignored in mental health research.     

Racial/Ethnic Differences in Contemporaneous Use of Mental Health and Substance Use Treatment Among Individuals Experiencing Both Mental Illness and Substance Use Disorders

This study examined whether the well-established racial/ethnic differences in mental health service utilization among individuals with mental illness are reflected in the treatment utilization patterns of individuals experiencing both mental illness and substance use disorders, particularly in regards to the use of contemporaneous mental health and substance abuse treatment. Using pooled data from the National Survey on Drug Use and Health (2009–2013), the patterns of mental health and substance use treatment utilization of 8748 White, Black, or Latino individuals experiencing both mental illness and substance use disorders were analyzed. Multinomial logistic regression was conducted to test the relationships among racial/ethnic groups and the receipt of contemporaneous treatment, mental health treatment alone, and substance use treatment alone as compared with no treatment utilization. Results indicated that Black and Latino respondents were less likely to receive contemporaneous treatment than Whites respondents. Also, significantly associated with outcomes were several interactions between race/ethnicity and predisposing, need and enabling factors known to be associated with service utilization. The findings suggest that an underlying mechanism of racial/ethnic differences among individuals with co-occurring mental illness and substance use disorders in the treatment utilization may differ by the specific types of treatment and between Blacks and Latinos. Therefore, efforts to reduce these disparities should consider specialty in each treatment settings and heterogeneity within diverse racial/ethnic groups.     

Relationship between race and ethnicity and forensic clinical triage dispositions

OBJECTIVE: Racial and ethnic disparities in the criminal justice system have been widely reported, as have racial and ethnic disparities in diagnoses and certain aspects of clinical management. This study examined the association between race and ethnicity and dispositions for pretrial defendants who were referred for forensic mental health evaluations. METHODS: Available data were reviewed for all defendants in Massachusetts who were referred to a Massachusetts court clinic from 1994 to 2001 for a screening evaluation of their competence to stand trial, their criminal responsibility, or both. Logistic regression models were developed to assess the relationship between defendants' race and ethnicity and the likelihood that they would be referred for inpatient evaluation and the likelihood that they would be evaluated within a strict-security facility. Race or ethnicity of the pretrial defendants was identified by clinicians. RESULTS: Blacks, but not Hispanics, were significantly more likely than whites to be referred for an inpatient evaluation after an outpatient forensic screening evaluation. Among male defendants, both Hispanics and blacks were more likely than whites to be referred for an inpatient evaluation in a strict-security facility, regardless of diagnoses and the level of severity of the criminal charges. CONCLUSIONS: Racial and ethnic disparities in disposition decisions exist within the forensic mental health system. These disparities, however, likely reflect numerous clinician and nonclinician variables.     

Racial/Ethnic Differences in Parental Endorsement of Barriers to Mental Health Services for Youth

The present study investigated parental endorsement of barriers to care in a racially/ethnically diverse, at-risk sample of youth with mental health needs by testing the following hypotheses: (1) African American, Asian/Pacific Islander American, and Latino youth would have higher levels of unmet need compared to Non-Hispanic Whites (NHWs); (2) Parents of ethnic minority youth would report a greater number of barriers to mental health services for their children than would parents of NHWs; (3) The pattern of greater barrier endorsement by parents of ethnic minorities compared to parents of NHWs would persist across different barrier types; (4) Barrier endorsement would be related to unmet need for mental health services. As hypothesized, ethnic minority youth had higher levels of unmet need as compared to NHWs. However, despite this finding, parents of ethnic minority youth reported fewer barriers than did parents of NHWs, and this pattern generally persisted across barrier types. Furthermore, barrier endorsement was unrelated to unmet need. Post hoc analyses suggest the influence of cultural factors upon barrier endorsement, indicating the importance of taking such influences into account in future research on barriers to care.