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.     

Racial and Ethnic Disparities in Serious Psychological Distress Among Those With Alzheimer's Disease and Related Dementias

BackgroundAlzheimer's disease and related dementias (ADRD) is a growing public health challenge. Prior research suggests that non-Hispanic whites (whites), non-Hispanic African Americans (African Americans), and Hispanics have differing risks for ADRD.ObjectiveTo examine the existence of serious psychological distress (SPD) among whites, African Americans, and Hispanics; to calculate the predicted probability of ADRD in whites, African Americans, and Hispanics, and to decompose the differences among ADRD populations, quantifying the burden of higher SPD among African Americans and Hispanics, compared to whites.Data and MethodThe authors use nationally representative data from the Medical Expenditure Panel Survey (2007–2015) to estimate the association between ADRD and race, ethnicity, and SPD. Using Blinder-Oaxaca decomposition analysis, the authors estimate to what extent higher SPD among Hispanics and African Americans was associated with higher ADRD rates compared to whites.ResultsAfter controlling for individuals’ demographic and socioeconomic characteristics and co-existing medical conditions, the presence of SPD was still significantly associated with a higher likelihood of having ADRD. The model predicted significantly higher likelihood of having ADRD among African Americans (7.1%) and Hispanics (5.7%) compared to whites (4.5%). Higher rates of having SPD among African Americans explained 15% of white-black difference and 40% of the white-Hispanic difference in ADRD rates, respectively.Discussion and ConclusionOur findings suggest a significant relationship between SPD and ADRD and that the burden of SPD was greater among African Americans and Hispanics with ADRD. Efficient screening using self-reported SPD, compared to simply using diagnoses codes of mental illness, may be more helpful to reduce racial and ethnic disparities in ADRD.     

Race-ethnicity and the prevalence and co-occurrence of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, alcohol and drug use disorders and Axis I and II disorders: United States, 2001 to 2002

The objective of this study was to compare the current prevalence and co-occurrence of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, alcohol and drug use disorders and mood, anxiety, and personality disorders among whites, blacks, Native Americans, Asians, and Hispanics in a large representative sample of the US population. Striking mental health disparities were observed in the prevalences of psychiatric disorders, especially among Native Americans. Disparities in psychiatric comorbidity differed from those associated with prevalence. Most significantly, the association between alcohol disorders and personality disorders was significantly greater among Asians relative to whites, blacks, and Native Americans, despite lower prevalences of these disorders among Asians. Taken together, the results of this study highlight the need of future studies that help unravel the risk factors underlying the disparities in both prevalence and comorbidity of psychiatric disorders observed among race-ethnic groups in the United States.     

Use of psychotropic medications among HIV-infected patients in the United States

OBJECTIVE: This study describes the prevalence and pattern of use of psychotropic medications by HIV-positive patients receiving medical care in the United States and the search for possible predictors of use. METHOD: The HIV Cost and Services Utilization Study database was analyzed. From the estimated 231,400 HIV-positive patients in medical care in the contiguous United States, a probability sample of 2,864 adults who had paid at least one visit to their medical provider in early 1996 was selected. A representative group of 1,561 received the long form of the Composite International Diagnostic Interview and a questionnaire on psychotropic medications used during the previous 6 months; 1,489 patients (95.4%) completed the assessments. RESULTS: An estimated 27.2% of HIV-positive patients took psychotropic medications in 1996. Antidepressants were the most commonly prescribed drug class (20.9% of patients), followed by anxiolytics (16.7%), antipsychotics (4.7%), and psychostimulants (3.0%). Among patients with major depression or dysthymia, 43.2% reported receiving antidepressants, and 34.3% reported receiving anxiolytics. Psychiatric comorbidity was associated with greater use of psychotropics. Use of psychotropics in general, and antidepressants in particular, was significantly lower among African Americans than whites or Hispanics. Among patients with mood disorders, 61.0% of whites, 51.4% of African Americans, and 66.7% of Hispanics reported use of antidepressant medications or some type of psychosocial intervention. CONCLUSIONS: Psychotropics were commonly used by HIV-positive patients in medical care. About half of the patients suffering from depressive disorders did not receive antidepressants. Psychotropic drug use was lower among African Americans than other ethnic groups.     

Racial and ethnic disparities in stroke subtypes: a multiethnic sample of patients with stroke

Stroke subtypes have been reported to differ by race and ethnic subgroups and have not been adequately explained. We aim to evaluate if the prevalence of vascular risk factors accounts for differences observed in stroke subtypes by race/ethnicity. Patients with acute stroke were prospectively enrolled in the Miami Stroke Registry. Patients’ demographic, clinical and radiological characteristics were systematically collected. Stroke subtypes were ascertained using TOAST criteria. The sample was divided into Non-Hispanic Whites (NHW), Hispanics, African Americans (AA), and Non-Hispanic Black Caribbean (NHBC). Univariable and multivariable logistic regression analyses were performed to assess differences among groups. Among 473 stroke patients (mean age 64 ± 14 years; 63.7 % were men) of which 52.9 % were Hispanic, 22.6 % were AA, 13.5 % NHBC and 11.0 % were NHW. Large artery atherosclerosis was more prevalent in NHBC (OR 1.74, 95 % CI 1.02–2.97) than in the other groups. Adjusting for covariates rendered the association not significant (OR 1.71, 95 % CI 0.93–3.16). Cardioembolism was more frequent in Hispanics (OR 1.94, 95 % CI 1.28–2.96) and NHW (OR 2.66, 95 % CI 1.42–4.96) as compared to NHBC and AA combined. Adjusting for covariates, the association was no longer significant for Hispanics but was further strengthened for NHW (OR 3.02, 95 % CI 1.42–6.42). Our results suggest that the vascular risk factors prevalence among different racial and ethnic groups partially explains disparities found in the prevalence of some stroke subtypes. Addressing health disparities remains an important public health aspect of stroke prevention.     

Racial and ethnic differences in diabetes mellitus among people with and without psychiatric disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions

Objective

This study examined racial/ethnic differences in the prevalence of diabetes mellitus in a nationally representative sample of adults with and without common psychiatric disorders.

Method

Data were drawn from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (N=34,653). Logistic regression models adjusting for sociodemographic variables and diabetes risk factors were used to examine racial/ethnic differences in 12-month prevalence rates of diabetes by psychiatric status.

Results

Among people without psychiatric disorders, African Americans, Hispanics and American Indians/Alaska Natives, but not Asians/Pacific Islanders, had significantly higher rates of diabetes than non-Hispanic whites even after adjusting for sociodemographic variables and diabetes risk factors. In the presence of psychiatric disorders, these health disparities persisted for African Americans and Hispanics, but not for American Indians/Alaska Natives. No significant interactions between race/ethnicity and psychiatric disorders in the odds of diabetes were found across any group.

Conclusion

Policies and services that support culturally appropriate prevention and treatment strategies are needed to reduce racial/ethnic disparities in diabetes among people with and without psychiatric disabilities.     

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.     

Ethnic differences in substance abuse treatment retention, compliance, and outcome from two clinical trials

OBJECTIVE: This study examined the results of two previous studies that evaluated African Americans and whites who were undergoing treatment for cocaine dependence to determine whether the groups differed in pretreatment characteristics, treatment retention, compliance, and cocaine use outcome. METHODS: Data were taken from two trials (N=111 in each), in which patients were randomly assigned to groups that used different behavioral treatments (cognitive-behavioral treatment and 12-step facilitation) and pharmacotherapies (desipramine and disulfiram). RESULTS: Few differences between African Americans and whites were found in terms of demographic characteristics, reasons for seeking treatment, or expectations of treatment. In both studies African Americans and whites did not differ significantly with respect to cocaine use outcomes, but African-American participants completed significantly fewer days of treatment than white participants. In study 2, which was not placebo controlled, African Americans who received disulfiram remained in treatment significantly longer than African Americans who did not receive disulfiram. However, in study 1, in which patients took either desipramine or a placebo, no interactions of ethnicity by medication were found. Among patients who expected improvement to take a month or longer in study 1, African Americans remained in treatment for fewer days than whites. CONCLUSIONS: The behavioral therapies evaluated did not significantly differ in effectiveness for African Americans and whites, suggesting that they are broadly applicable across these ethnic groups. Findings also suggest possible strategies for improving retention of African Americans in treatment. Such strategies might include offering treatment with a medication component and better addressing participants' treatment expectations.     

Anxiety disorders among Mexican Americans and non-Hispanic whites in Los Angeles

This report from the Los Angeles site of the NIMH Epidemiologic Catchment Area study reveals significant ethnic and national origin differences in lifetime prevalence rates for three out of six specific, DSM-III-defined anxiety disorders. In the case of simple phobia, United States-born Mexican Americans report higher rates than native non-Hispanic whites or immigrant Mexican Americans, the latter two groups having similar rates. Mexican Americans born in the United States had higher rates of agoraphobia than immigrant Mexican Americans, and non-Hispanic whites reported higher lifetime rates of generalized anxiety disorder compared with both immigrant and native Mexican Americans. Neither ethnic nor national origin differences in lifetime prevalence rates were found for panic disorder, social phobia, and obsessive-compulsive disorder. Selective migration is postulated as a potential factor influencing prevalence differences between native and immigrant Mexican Americans.     

Eliminating institutional child abuse: a road too well traveled

OBJECTIVE: To determine the relative risk (RR) of intracerebral hemorrhage (ICH) among African Americans compared with that among whites. METHODS: Data from the First National Health and Nutrition Examination Survey Epidemiologic Follow-up Study were used to determine the incidence of ICH (n = 78) in 10,851 whites and 1,802 African Americans during a 20-year follow-up period. Cox proportional hazards analyses were used to determine the RR of ICH among African Americans compared with that among whites. RESULTS: The estimated annual incidence of ICH was 50 per 100,000 among African Americans and 28 per 100,000 among whites. The age- and sex-adjusted RR for ICH among African Americans was 1.9 (95% confidence interval [CI], 1.1 to 3.2). With the addition of systolic blood pressure and educational attainment to the Cox proportional hazards model, the RR decreased to 1.6 (95% CI, 0.9 to 2.7). The adjustment for additional cerebrovascular disease risk factors did not change this risk estimate appreciably. CONCLUSIONS: Compared with whites, African Americans have a twofold increased risk for ICH. Most of this risk may be explained by differences in educational attainment and systolic blood pressure. Unless additional efforts are undertaken to reduce racial differences in the prevalence of stroke risk factors, mainly systolic blood pressure and socioeconomic status, the African American-white disparities in the risk for ICH will likely continue.     

Diversity and disparity in dementia: the impact of ethnoracial differences in Alzheimer disease

Debate exists regarding differences in the prevalence of Alzheimer disease (AD) in African Americans and Hispanics in the United States, with some evidence suggesting that the prevalence of AD may be considerably higher in these groups than in non-Hispanic whites. Despite this possible disparity, patients of minority ethnoracial groups often receive delayed diagnosis or inadequate treatment for dementia. This review investigates these disparities by conceptualizing the dementia disease process as a product of both biological and cultural factors. Ethnoracial differences in biological risk factors, such as genetics and cardiovascular disease, may help to explain disparities in the incidence and prevalence of AD, whereas race-specific cultural factors may impact diagnosis and treatment. Cultural factors include differences in perceptions about what is normal aging and what is not, lack of adequate access to medical care, and issues of trust between minority groups and the medical establishment. The diagnosis of AD in diverse populations may also be complicated by racial biases inherent in cognitive screening tools widely used by clinicians, but controlling for literacy level or using savings scores in psychometric analyses has the potential to mitigate these biases. We also suggest that emerging biomarker-based diagnostic tools may be useful in further characterizing diverse populations with AD. Recognizing the gap in communication that exists between minority communities and the medical research community, we propose that education and outreach are a critical next step in the effort to understand AD as it relates to diverse populations.     

Sleep paralysis in African Americans with panic disorder

Studies have reported a wide range in lifetime prevalence of sleep paralysis (SP). This variation may stem from cultural factors, stressful life events and genetic differences in studied populations. We found that recurrent SP was more common among African-American participants, especially those with panic disorder. Recurrent SP was reported by 59% of African Americans with panic disorder, 7% of whites with panic disorder, 23% of African-American community volunteers and 6% of white community volunteers. Significantly more early life stressors were reported by African Americans than whites. Higher levels of psychosocial stressors, including poverty, racism and acculturation, may contribute to the higher rates of SP experienced by African Americans.     

Racial Disparities in Diagnosis and Treatment of Depression: A Literature Review

The purpose of this study was to systematically review the literature to determine whether racial disparities exist in the diagnosis and treatment of depression in the United States. A literature search using PubMed of potentially relevant articles in English that include data from population-based studies examining the diagnosis and/or treatment of depression; or data from prospective studies stratifying the rates of diagnosis and/or treatment of depression by race/ethnicity and ethnic comparisons between Caucasians, African Americans and/or Hispanics. Initial searches identified 2,396 articles. On the basis of our criteria, 14 articles were eligible for inclusion in this review. Four included data on the diagnosis of depression in different ethnic groups; their results were not consistent. Twelve included data on treatment variability in the treatment of depression; overall these suggested lower rates of treatment for African Americans and Hispanics than for Caucasians. More research is needed focusing on ethnic variation in the diagnosis of depression. Racial disparities exist in the treatment of depression. Sources of Support: This material is based upon work supported in part by the Houston Center for Quality of Care & Utilization Studies, Health Services Research and Development Service, Office of Research and Development.     

Interethnic differences in dementia epidemiology: global and Asia-Pacific perspectives

The burden of dementia will continue to rise globally, particularly in developing countries, many of which lie in the Asia-Pacific region. It was initially thought that both prevalence and incidence of dementia showed little geographic variation. More recent work has suggested differences: migrant populations attain rates between their homelands and adopted countries, and higher rates have been found in African Americans and Hispanics compared to Caucasian Whites, and also among native Australians. The only interethnic studies in the Asia-Pacific region were performed in Singapore, which showed lower standardized prevalence among ethnic Chinese compared to ethnic Malays and Indians, independent of vascular risk factors. There was conflicting information about the relative frequencies of Alzheimer's disease and vascular dementia between ethnic groups in Singapore. More research, with careful attention to potential cultural confounders, is needed to further explore and better understand interethnic differences in dementia epidemiology.     

Ethnicity and preferences for depression treatment

OBJECTIVE: The objective of this work was to describe ethnic differences in attitudes toward depression, depression treatment, stigma and preferences for depression treatment (counseling vs. medication). METHOD: This study used a cross-sectional Internet survey measuring treatment preference, stigma and attitudes toward depression. Depressive symptoms were measured with the Center for Epidemiological Studies Depression (CES-D) scale. Multivariable regression models adjusting for treatment attitudes and demographics estimated the independent effect of ethnicity on treatment preference. RESULTS: A total of 78,753 persons with significant depressive symptoms (CES-D>22), including 3596 African Americans, 2794 Asians/Pacific Islanders and 3203 Hispanics, participated. Compared to whites, African Americans, Asians/Pacific Islanders and Hispanics were more likely to prefer counseling to medications [odds ratio (OR)=2.6, 95% confidence interval (95% CI)=2.4-2.8; OR=2.5, 95% CI=2.2-2.7; and OR=1.8, 95% CI=1.7-2.0, respectively]. Ethnic minorities were less likely to believe that medications were effective and that depression was biologically based, but were more likely to believe that antidepressants were addictive and that counseling and prayer were effective in treating depression. Attitudes and beliefs somewhat attenuated the association between ethnicity and treatment preference in adjusted analyses. CONCLUSION: Racial and ethnic minorities prefer counseling for depression treatment more than whites. Beliefs about the effects of antidepressants, prayer and counseling partially mediate preferences for depression treatment.     

Ethnicity and four personality disorders

The current study examined the relationship between ethnicity and DSM-IV personality disorders. The distribution of four personality disorders--borderline (BPD), schizotypal (STPD), avoidant (AVPD), and obsessive-compulsive (OCPD)--along with their criteria sets, were compared across three ethnic groups (Caucasians, African Americans, and Hispanics) using both a clinician-administered diagnostic interview and a self-report instrument. Participants were 554 patients drawn from the Collaborative Longitudinal Personality Disorders Study (CLPS) who comprised these three ethnic groups and met personality disorder criteria based on reliably administered semistructured interviews. Chi-square analyses revealed disproportionately higher rates of BPD in Hispanic than in Caucasian and African American participants and higher rates of STPD among African Americans when compared to Caucasians. Self-report data reflected similar patterns. The findings suggest that in treatment-seeking samples, Caucasians, Hispanics, and African Americans may present with different patterns of personality pathology. The factors contributing to these differences warrant further investigation.     

Ethnic differences in worry in a nonclinical population

The present study examined ethnic differences in worry in a college student population. No differences were found between Caucasians, African Americans, and Asian Americans in pathological worry as measured by the Penn State Worry Questionnaire (PSWQ) or in the frequency with which they met self-report criteria for generalized anxiety disorder on the Generalized Anxiety Disorder Questionnaire for DSM-IV (GAD-Q-IV). Groups differed in Worry Domains Questionnaire (WDQ) total scores and on all WDQ domain subscales except for the Financial domain. Within ethnic groups, Caucasians and African Americans experienced variations in intensity of worry across the specific domains, but Asian Americans did not. These results suggest that ethnic groups may differ from each other in the degree to which they worry and in the breadth of their concerns. Further examination of ethnic differences and worry (and anxiety more generally) is suggested.     

Does Medicare managed care provide equal treatment for mental illness across races?

BACKGROUND: While disparities in access to care are well documented, little is known about the quality of mental health care received by racial and ethnic minorities. We examined the quality of mental health care received by elderly enrollees in Medicare + Choice plans. METHODS: An observational study was performed using individual-level Health Plan Employer Data and Information Set data. From 4182 to 5,016,028 individuals 65 years or older and enrolled in Medicare + Choice plans in 1999 were involved in different measures. Rates of mental health inpatient discharges, average length of stay, percentage of members receiving mental health services, rates of follow-up after hospitalization for mental illness, optimal practitioner contacts for antidepressant medication management, and effective acute- and continuation-phase treatment were assessed. RESULTS: Compared with whites, minorities received substantially less follow-up after hospitalization for mental illness. The 30-day follow-up rates for whites, African Americans, Asians, and Hispanics were 60.2%, 42.4%, 54.1%, and 52.6%, respectively. Minorities also had lower rates of antidepressant medication management for newly diagnosed episodes of depression. The rates of optimal practitioner contacts for whites, African Americans, Asians, and Hispanics were 12.5%, 12.0%, 11.1%, and 10.6%; the rates of effective acute-phase treatment were 60.1%, 48.5%, 40.7%, and 57.6%; and the rates of effective continuation-phase treatment were 46.7%, 32.7%, 31.9%, and 39.6%, respectively. The statistically significant disparities persisted after adjusting for effects of age, sex, income, plan model, profit status, and region of the country. CONCLUSIONS: The overall quality of mental health care for people enrolled in Medicare + Choice managed care plans is far from optimal. There are large and persistent racial differences that merit further attention to better understand their underlying causes and solutions.     

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.