Clozapine utilization and outcomes by race in a public mental health system: 1994-2000

OBJECTIVE: This study aimed to assess racial differences in clozapine prescribing, dosing, symptom presentation and response, and hospitalization status. This study extends previous studies of clozapine by examining patient- and treatment-related factors that may help explain or eliminate reasons for differential prescribing. METHOD: Clozapine records for 373 white and African American patients with schizophrenia or schizoaffective disorder treated between March 1, 1994, and December 31, 2000, in inpatient mental health facilities in the state of Maryland were examined. Records for this study were derived from 3 state of Maryland databases: the Clozapine Authorization and Monitoring Program, the State of Maryland Antipsychotic Database, and the Health Maintenance Information System Database. RESULTS: A total of 10.3% of African Americans (150/1458) with schizophrenia received clozapine treatment compared with 15.3% of whites (223/1453) (chi2 = 16.74, df = 1, p < .001) during inpatient treatment in the public mental health system in Maryland. Clozapine doses were lower in African Americans relative to whites (385.3 +/- 200.6 vs. 447.3 +/- 230.3 mg/day) (t = -2.66, df = 366, p = .008). At the time of clozapine initiation, whites had more activating symptoms as measured by the Brief Psychiatric Rating Scale (BPRS) (t = -3.98, df = 301, p < .0001); however, African Americans had significantly greater improvements in BPRS total symptoms (F = 4.80, df = 301, p = .03) and in anxiety/ depressive symptoms during 1 year of treatment with clozapine (F = 10.04, df = 303, p = .002). The estimated rate of hospital discharge was not significantly different for African Americans compared to whites prescribed clozapine (log-rank chi2 = 0.523, df = 1, p = .470); however, African Americans were more likely than whites to discontinue clozapine during hospitalization (log-rank chi2 = 4.19, df = 1, p = .041). CONCLUSION: Our data suggest underutilization of clozapine in African American populations. This racial disparity in clozapine treatment is of special concern because of the favorable outcomes associated with clozapine in treatment-resistant schizophrenia and in the specific benefits observed in African American patients. More research is needed to determine why disparities with clozapine treatment occur and why African Americans may be discontinued from clozapine at a higher rate, despite potential indicators of equal or greater effectiveness among African Americans compared with whites.     

Race, Schizophrenia, and Admission to State Psychiatric Hospitals

The relationships among race, diagnoses of schizophrenia, mood disorder, and admission to state psychiatric hospitals were examined in this study. Two hypotheses and two research questions represented these relationships. Data were analyzed from a sample of 2,311 individuals who had hospital admissions in Indiana during an 8-year period. In comparison with the general population, African Americans were found to be overrepresented among inpatients with diagnoses of schizophrenia. African Americans were four times more likely than White inpatients to receive a diagnosis of schizophrenia. Accountability tools to address issues of differential hospitalization rates and overdiagnosis of schizophrenia are discussed.     

Race, psychiatric diagnosis, and mental health care utilization in older patients.

To evaluate the impact of race on mental health care utilization among older patients within given clinical psychiatric diagnoses, the authors examined a retrospective sample of 23,718 elderly veterans treated in Department of Veterans Affairs inpatient facilities in 1994. Significant racial differences in mental health care utilization found over a subsequent 2-year period were related to outpatient (but not inpatient) care; for instance: 1) African American patients with psychotic disorders had significantly fewer outpatient psychiatric visits; and 2) African American patients with substance abuse disorders had significantly more psychiatric visits than Caucasian patients in their respective groups. Although inpatient utilization appeared to be similar among races, findings related to outpatient utilization may be associated with such factors as compliance, treatment efficacy, access to health care, or possible clinician bias.     

The association of African Americans’ perceptions of neighborhood crime and drugs with mental illness

Background

Many African Americans are socioeconomically disadvantaged and live in neighborhoods containing chronic sources of stress. Although environmental stressors can contribute to the development of mental illness, there is a paucity of national studies examining the association of neighborhood crime and drug problems with psychiatric disorders. This study aims to determine if higher levels of perceived neighborhood problems are associated with greater prevalence of 12-month and lifetime psychiatric disorders among African Americans.

Methods

To do so, we used cross-sectional data from the National Survey of American Life, which interviewed a nationally representative sample of 3,570 African Americans.

Results

Of these African Americans, nearly 20 and 40% reported that crime and drug use are problems in their neighborhoods, respectively. Respondents reporting high levels of perceived neighborhood crime or drug problems are 1.5–2.9 times more likely to have a 12-month psychiatric disorder and 1.4–2.1 times more likely to have a lifetime psychiatric disorder compared to the other respondents. After accounting for sociodemographics and chronic disease, neighborhood crime remains associated with 12-month mood, 12-month substance use, and lifetime substance use disorders, whereas neighborhood drug problems remain significantly associated with 12-month and lifetime anxiety and substance use disorders.

Conclusions

Among African Americans perceived neighborhood problems are widespread and positively associated with psychiatric disorders. Consideration of neighborhood context is important to more comprehensively understand mental illness and its treatment in this population.     

Variables associated with disparities in treatment of patients with schizophrenia and comorbid mood and anxiety disorders

OBJECTIVE: The study compared self-reported comorbid affective and anxiety disorder diagnoses and treatments of African-American and Caucasian subjects in a large sample of patients who had a diagnosis of schizophrenia. METHODS: A total of 685 patients receiving treatment for schizophrenia were interviewed as part of the Schizophrenia Patient Outcomes Research Team study. The associations of race with past and current diagnoses and with current treatment for depression, mania, and anxiety disorders were assessed with multivariate analyses. RESULTS: African Americans were significantly less likely than Caucasians to report having a past or current diagnosis of depression, manic-depression, or anxiety disorder and to be receiving current treatment for these disorders. Gender, education, and marital status were also associated with presence of a comorbid diagnosis and receipt of treatment. CONCLUSIONS: The study suggests the possibility of racial and other disparities in the diagnosis and treatment of patients with schizophrenia and comorbid affective and anxiety disorders. Although various causal explanations are plausible, all point toward the need for enhanced cross-cultural competence at all levels of mental health care, especially in the diagnosis and treatment of comorbid psychiatric illnesses.     

Frequency and Scope of Mental Health Service Delivery to African Americans in Primary Care

This study examines whether African Americans with mental health complaints visit primary care physicians more than psychiatrists, and whether they demonstrate this preference more than do Whites. It addresses also whether when presenting with mental health concerns, African Americans and Whites receive a comparable range of interventions, including psychotropic medications. National estimates using the National Ambulatory Medical Care Surveys conducted in 1995 and 1996 confirmed the first hypothesis: African American did make more mental health-related office visits to primary care physicians than did psychiatrists and they did so more than Whites. Mental health interventions on behalf of African Americans and Whites proved to be similar, except that African Americans were less likely to be provided a psychotropic medication. Because African Americans are especially likely to receive outpatient mental health services from primary care physicians, the lower quality of mental health care occurring in primary care disproportionately affects African Americans. Fewer African American visits resulted in prescribing psychotropic medications, and this corroborated findings by other researchers. More research is needed to understand this disparity.     

Twelve-month prevalence of psychiatric disorders and treatment-seeking among Asian Americans/Pacific Islanders in the United States: results from the National Epidemiological Survey on Alcohol and Related Conditions

To compare the 12-month prevalence of psychiatric disorders in Asian Americans/Pacific Islanders in contrast to non-Hispanic whites; and further compare persistence and treatment-seeking rates for psychiatric disorders among Asian American/Pacific Islanders and non-Hispanic whites, analyses from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions, Wave 1 (n = 43,093) were conducted for the subsample of 1332 Asian Americans/Pacific Islanders (596 men and 736 women) and 24,507 non-Hispanic whites (10,845 men and 13,662 women). The past 12-month prevalence for any psychiatric disorder was significantly lower in Asian American/Pacific Islander males and females than non-Hispanic white males and females. Asian American/Pacific Islander males were less likely than non-Hispanic white males to have any mood, anxiety, substance use, and personality disorders, whereas the prevalence of mood disorders among Asian American/Pacific Islander females did not differ from those of non-Hispanic white females. In some cases, such as drug use disorders, both male and female Asian Americans/Pacific Islanders were more likely to have more persistent disorders than non-Hispanic whites. Compared to non-Hispanic white females, Asian American/Pacific Islander females had lower rates of treatment-seeking for any mood/anxiety disorders. Although less prevalent than among non-Hispanic whites, psychiatric disorders are not uncommon among Asian Americans/Pacific Islanders. The lower treatment-seeking rates for mood/anxiety disorders in Asian American/Pacific Islander females underscore the unmet needs for psychiatric service among this population.     

Perceived criticism in schizophrenia: a comparison of instruments for the assessment of the patient's perspective and its relation to relatives' expressed emotion

Administrative datasets can provide information about mental health treatment in real world settings; however, an important limitation in using these datasets is the uncertainty regarding psychiatric diagnosis. To better understand the psychiatric diagnoses, we investigated the diagnostic variability of schizophrenia and major depression in a large public mental health system. Using schizophrenia and major depression as the two comparison diagnoses, we compared the variability of diagnoses assigned to patients with one recorded diagnosis of schizophrenia or major depression. In addition, for both of these diagnoses, the diagnostic variability was compared across seven types of treatment settings. Statistical analyses were conducted using t tests for continuous data and chi-square tests for categorical data. We found that schizophrenia had greater diagnostic variability than major depression (31% vs. 43%). For both schizophrenia and major depression, variability was significantly higher in jail and the emergency psychiatric unit than in inpatient or outpatient settings. These findings demonstrate that the variability of psychiatric diagnoses recorded in the administrative dataset of a large public mental health system varies by diagnosis and by treatment setting. Further research is needed to clarify the relationship between psychiatric diagnosis, diagnostic variability and treatment setting.     

Concurrent psychiatric diagnoses by age and race among persons with bipolar disorder

The authors characterized concurrent psychiatric diagnoses among patients with a diagnosis of bipolar disorder who were in routine care by using administrative data from a Department of Veterans Affairs facility. Of 813 patients who had a diagnosis of bipolar disorder in 2000, 21 percent were older (>/=60 years) whites, and 2 percent were older African Americans. Older African Americans were the most likely to have a diagnosis of schizophrenia documented in the medical record compared with younger African Americans, older whites, and younger whites (67 percent, 34 percent, 38 percent, and 27 percent, respectively). The results suggest that older African-American patients with bipolar disorder are more likely to receive diagnoses of mutually exclusive conditions, such as schizophrenia, and thus appear to have an elevated risk of their illness being underrecognized or misdiagnosed and receiving inappropriate treatment.     

Ethnicity and prescription patterns for haloperidol, risperidone, and olanzapine

OBJECTIVE: Patients with schizophrenia may respond better to second-generation antipsychotics than to older antipsychotics because of their superior efficacy and safety profiles. However, the reduced likelihood among ethnic minority groups of receiving newer antipsychotics may be associated with reduced medication adherence and health service use, potentially contributing to poor response rates. This study examined whether ethnicity helped predict whether patients with schizophrenia were given a first- or a second-generation antipsychotic, haloperidol versus risperidone or olanzapine, and what type of second-generation antipsychotic was prescribed, risperidone or olanzapine, when other factors were controlled for. METHODS: Texas Medicaid claims were analyzed for persons aged 21 to 65 years with a diagnosis of schizophrenia or schizoaffective disorder who started treatment with olanzapine (N=1875), risperidone (N=982), or haloperidol (N= 726) between January 1, 1997 and August 31, 1998. The association between antipsychotic prescribing patterns among African Americans, Mexican Americans, and whites was assessed by using logistic regression analysis. Covariates included other patient demographic characteristics, region, comorbid mental health conditions, and medication and health care resource use in the 12 months before antipsychotic initiation. RESULTS: The results of the first- versus second-generation antipsychotic analysis indicated that African Americans were significantly less likely than whites to receive risperidone or olanzapine. Although not statistically significant, the odds ratio indicated that Mexican Americans were also less likely to receive risperidone or olanzapine. Ethnicity was not associated with significant differences in the prescribing patterns of risperidone versus olanzapine. CONCLUSIONS: When other factors were controlled for, African Americans were significantly less likely to receive the newer antipsychotics. Among those who received the newer antipsychotics, ethnicity did not affect medication choice.     

Clinical characteristics and service use of persons with mental illness living in an intermediate care facility.

OBJECTIVE: The study examined the characteristics of residents living in a 450-bed intermediate care facility for persons with severe mental illness in Illinois and sought to determine the factors predicting their utilization of mental health services. METHODS: Data on 100 randomly selected residents with a chart diagnosis of schizophrenia were collected using chart review and interviews. Data for 78 residents whose diagnosis of schizophrenia or schizoaffective disorder was confirmed using the Structured Clinical Interview for DSM-IV were included in the analyses. RESULTS: Fifty-three percent of the residents used facility-based specialty mental health services beyond medication management, such as group therapy or a day program. Persons with the least severe psychiatric illnesses and with higher levels of motivation for overall care used the most mental health services. Thirty-five percent of the residents had been discharged to an inpatient psychiatric unit during the previous year. Residents most likely to be discharged to those settings were young men with a history of homelessness who refused facility-based health services. CONCLUSIONS: Despite recent policy-driven efforts to improve care in this intermediate care facility for persons with mental illness, the facility continues to have problems addressing the mental health needs of the residents.     

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.     

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.     

Tri-ethnic variations of co-morbid substance and alcohol use disorders in schizophrenia

OBJECTIVES: This study examined the differential prevalence of substance and alcohol use disorders among European Americans, African Americans, and Latinos with schizophrenia (n = 6424) who received public mental health services in San Diego County during fiscal year 2002-2003. METHODS: Data were obtained from the public mental health database used by the San Diego County Mental Health System. Chi-Square analyses and stepwise logistic regression analyses were used to examine differences regarding the prevalence of substance and alcohol use among clients with schizophrenia and schizoaffective disorder, and to analyze the sociodemographic variables associated with this co-morbidity. RESULTS: Significant differences in the prevalence of diagnosed co-morbidity were found across the ethnic groups. Rates of co-morbid diagnosis among African Americans (25%) were significantly higher than those among European Americans (22%) and Latinos (19%). Logistic regression results revealed ethnicity was a significant predictor of co-morbid substance and alcohol use, as was being homeless and male. Among Latinos, language preference was also a significant predictor. Latinos who denoted English as their primary language were 1.7 times more likely to be diagnosed with co-morbid substance or alcohol use disorders than Latinos who denoted Spanish. CONCLUSIONS: Among people with schizophrenia, there were significant differences in prevalence rates and predictors of diagnosed co-morbid substance and alcohol use disorders. Future research is needed to examine the relationship among language preference, level of acculturation, and subsequent diagnosing barriers for Latinos. Among African Americans, the reasons behind increased co-morbidity rates need to be examined, and homelessness should be carefully addressed among all three ethnic groups.     

Obsessive-compulsive disorder among African Americans and blacks of Caribbean descent: results from the National Survey of American Life

Background: There is limited research regarding the nature and prevalence of obsessive‐compulsive disorder (OCD) among various racial and ethnic subpopulations within the United States, including African Americans and blacks of Caribbean descent. Although heterogeneity within the black population in the United States has largely been ignored, notable differences exist between blacks of Caribbean descent and African Americans with respect to ethnicity, national heritage, and living circumstances. This is the first comprehensive examination of OCD among African Americans and blacks of Caribbean descent. Methods: Data from the National Survey of American Life, a national household probability sample of African Americans and Caribbean blacks in the United States, were used to examine rates of OCD among these groups. Results: Lifetime and 12‐month OCD prevalence estimates were very similar for African Americans and Caribbean blacks. Persistence of OCD and rates of co‐occurring psychiatric disorders were very high and also similar between African American and Caribbean black respondents. Both groups had high levels of overall mental illness severity and functional impairment. Use of services was low for both groups, particularly in specialty mental health settings. Use of anti‐obsessional medications was also rare, especially among the Caribbean black OCD population. Conclusions: OCD among African Americans and Caribbean blacks is very persistent, often accompanied by other psychiatric disorders, and is associated with high overall mental illness severity and functional impairment. It is also likely that very few blacks in the United States with OCD are receiving evidence‐based treatment and thus considerable effort is needed to bring treatment to these groups. Depression and Anxiety, 2008. Published 2008 Wiley‐Liss, Inc.     

Psychiatric disorder,impairment, and service use in rural African American and white youth

BACKGROUND: The Caring for Children in the Community Study examined the prevalence of DSM-IV psychiatric disorders and correlates of mental health service use in rural African American and white youth. METHODS: Four thousand five hundred youth aged 9 to 17 years from 4 North Carolina counties were randomly selected from school databases. Parents completed telephone questionnaires about their children's behavior problems. A second-stage sample of 1302 was identified for recruitment into the interview phase of the study, and 920 (70.7%) of these were successfully interviewed at home using the Child and Adolescent Psychiatric Assessment and related measures of service use. RESULTS: Weighted back to general population estimates, 21.1% of youth had 1 or more DSM-IV psychiatric disorders in the past 3 months. Prevalence was similar in African American (20.5%) and white (21.9%) youth. The only ethnic difference was an excess of depressive disorders in white youth (4.6% vs 1.4%). Thirteen percent of participants (36.0% of those with a diagnosis) received mental health care in the past 3 months. White youth were more likely than African American youth to use specialty mental health services (6.1% vs 3.2%), but services provided by schools showed very little ethnic disparity (8.6% vs 9.2%). The effect of children's symptoms on their parents was the strongest correlate of specialty mental health care. CONCLUSIONS: In this rural sample, African American and white youth were equally likely to have psychiatric disorders, but African Americans were less likely to use specialty mental health services. School services provided care to the largest number of youths of both ethnic groups.     

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.     

Immigration and lifetime prevalence of DSM-IV psychiatric disorders among Mexican Americans and non-Hispanic whites in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions

BACKGROUND: There exist no national prevalence data on specific DSM-IV Axis I psychiatric disorders among foreign-born and US-born Mexican Americans and non-Hispanic whites. OBJECTIVE: To present nationally representative data on the prevalence of DSM-IV lifetime psychiatric disorders among foreign-born and US-born Mexican Americans and non-Hispanic whites. DESIGN: Face-to-face survey conducted in the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions. SETTING: The United States and District of Columbia, including Alaska and Hawaii. PARTICIPANTS: Household and group-quarters residents, aged 18 years and older (n = 43 093). MAIN OUTCOME MEASURES: Prevalence of DSM-IV substance use disorders and mood and anxiety disorders. RESULTS: With few exceptions, foreign-born Mexican Americans and foreign-born non-Hispanic whites were at significantly lower risk (P<.05) of DSM-IV substance use and mood and anxiety disorders compared with their US-born counterparts. Although the risk of specific psychiatric disorders was similar between foreign-born Mexican Americans and foreign-born non-Hispanic whites, US-born Mexican Americans were at significantly lower risk (P<.05) of psychiatric morbidity than US-born non-Hispanic whites. CONCLUSIONS: Data favoring foreign-born Mexican Americans with respect to mental health may extend to foreign-born non-Hispanic whites. Future research among foreign-born and US-born Mexican Americans and the foreign-born and US-born of other origins and descents is needed to understand what appears to be the protective effects of culture and the deleterious effects of acculturation on psychiatric morbidity in the United States.