Ethnicity and diagnostic patterns in veterans with psychoses

Post-Traumatic Stress Across Color Lines: A History of Anti-Black Exclusion & PTSD

Black Americans with Posttraumatic Stress Disorder have less access to mental healthcare compared to White Americans. Many factors contribute to this inequity, including broader disparities within the healthcare system driven by systemic racism, and an underutilization of mental health services by Black Americans due to provider bias and stigma around mental health care. These disparities are rooted in a racist historical context of exclusion and abuse of the Black community by the White psychiatric establishment, and a perpetration of further trauma on Black clients, a context that is largely missing from traditional mental health education and literature on Black mental health today. This article aims to provide a necessary historical context of how the U.S. mental health care system has excluded Black Americans from trauma treatment. We use a contemporary trauma lens to demonstrate the ways in which Black trauma has existed throughout U.S. history, but how White psychiatry has cast trauma symptoms as evidence of racial inferiority, has excluded Black individuals from treatment, and has abused Black patients, thereby increasing Black trauma. The purpose of this review is to inform and educate mental health providers about our collective history, to counter a narrative of amnesia which identifies Black underutilization of services but forgets the exclusion from and abuse of Black people within the mental health system. We conclude with recommendations that providers can utilize to engage in antiracist practice and create an affirmative space for Black Americans to utilize trauma treatment and mental health care freely.

Ethnoracial Risk Variation Across the Psychosis Continuum in the US: A Systematic Review and Meta-Analysis

Importance

Studies suggest a higher risk of schizophrenia diagnoses in Black vs White Americans, yet a systematic investigation of disparities that include other ethnoracial groups and multiple outcomes on the psychosis continuum is lacking.

Objective

To identify ethnoracial risk variation in the US across 3 psychosis continuum outcomes (ie, schizophrenia and other psychotic disorders, clinical high risk for psychosis [CHR-P], and psychotic symptoms [PSs] and psychotic experiences [PEs]).

Data Sources

PubMed, PsycINFO and Embase were searched up to December 2022.

Study Selection

Observational studies on ethnoracial differences in risk of 3 psychosis outcomes.

Data Extraction and Synthesis

Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. Using a random-effects model, estimates for ethnoracial differences in schizophrenia and PSs/PEs were pooled and moderation by sampling and setting was determined, along with the assessment of heterogeneity and risk of bias.

Main Outcomes and Measures

Risk of schizophrenia and other psychotic disorder, CHR-P, and conversion to psychosis among CHR-P and PSs/PEs.

Results

Of 64 studies in the systematic review, 47 were included in the meta-analysis comprising 54 929 people with schizophrenia and 223 097 with data on PSs/PEs. Compared with White individuals, Black individuals had increased risk of schizophrenia (pooled odds ratio [OR], 2.07; 95% CI, 1.64-2.61) and PSs/PEs (pooled standardized mean difference [SMD], 0.10; 95% CI, 0.03-0.16), Latinx individuals had higher risk of PSs/PEs (pooled SMD, 0.15; 95% CI, 0.08-0.22), and individuals classified as other ethnoracial group were at significantly higher risk of schizophrenia than White individuals (pooled OR, 1.81; 95% CI, 1.31-2.50). The results regarding CHR-P studies were mixed and inconsistent. Sensitivity analyses showed elevated odds of schizophrenia in Asian individuals in inpatient settings (pooled OR, 1.84; 95% CI, 1.19-2.84) and increased risk of PEs among Asian compared with White individuals, specifically in college samples (pooled SMD, 0.16; 95% CI, 0.02-0.29). Heterogeneity across studies was high, and there was substantial risk of bias in most studies.

Conclusions and Relevance

Findings of this systematic review and meta-analysis revealed widespread ethnoracial risk variation across multiple psychosis outcomes. In addition to diagnostic, measurement, and hospital bias, systemic influences such as structural racism should be considered as drivers of ethnoracial disparities in outcomes across the psychosis continuum in the US.

Ethnoracialized group differences in attitudes and knowledge about schizophrenia and willingness to engage in biomarker research: The UBIGR Study

Although there is renewed optimism in biomarker research in schizophrenia, there is also need for greater inclusion of historically underrepresented groups in the research. In the present study, we surveyed 599 African American, 352 American Indian/Alaska Native, and 725 NonHispanic White participants about their attitudes toward research, knowledge and attitudes about schizophrenia, and willingness to engage in biomarker testing. Attitudes toward research were examined using the standardized 7-item Research Attitudes Questionnaire (RAQ) measure. Using structural equation modeling (SEM), we tested our predictive model of the likelihood of willingness to engage in biomarker testing for schizophrenia risk. Members of historically underrepresented groups were less willing to engage in biomarker testing. Overall, attitudes toward research, particularly trust, influenced biomarker testing willingness. These findings suggest that factors influencing willingness to engage in schizophrenia biomarker testing may be modifiable by outreach engagement and education.

Racial differences in the major clinical symptom domains of bipolar disorder

BACKGROUND

Across clinical settings, black individuals are disproportionately less likely to be diagnosed with bipolar disorder compared to schizophrenia, a traditionally more severe and chronic disorder with lower expectations for remission. The causes of this disparity are likely multifactorial, ranging from the effects of implicit bias, to developmental and lifelong effects of structural racism, to differing cultural manifestations of psychiatric symptoms and distress. While prior studies examining differences have found a greater preponderance of specific psychotic symptoms (such as persecutory delusions and hallucinations) and a more dysphoric/mixed mania presentation in Black individuals, these studies have been limited by a lack of systematic phenotypic assessment and small sample sizes. In the current report, we have combined data from two large multi-ethnic studies of bipolar disorder with comparable semi-structured interviews to investigate differences in symptoms presentation across the major clinical symptom domains of bipolar disorder.

RESULTS

In the combined meta-analysis, there were 4423 patients diagnosed with bipolar disorder type I, including 775 of self-reported as Black race. When symptom presentations were compared in Black versus White individuals, differences were found across all the major clinical symptom domains of bipolar disorder. Psychotic symptoms, particularly persecutory hallucinations and both persecutory and mood-incongruent delusions, were more prevalent in Black individuals with bipolar disorder type I (ORs = 1.26 to 2.45). In contrast, Black individuals endorsed fewer prototypical manic symptoms, with a notably decreased likelihood of endorsing abnormally elevated mood (OR = 0.44). Within depression associated symptoms, we found similar rates of mood or cognitive related mood symptoms but higher rates of decreased appetite (OR = 1.32) and weight loss (OR = 1.40), as well as increased endorsement of initial, middle, and early-morning insomnia (ORs = 1.73 to 1.82). Concurrently, we found that black individuals with BP-1 were much less likely to be treated with mood stabilizers, such as lithium (OR = 0.45), carbamazepine (OR = 0.37) and lamotrigine (OR = 0.34), and moderately more likely to be on antipsychotic medications (OR = 1.25).

CONCLUSIONS

In two large studies spanning over a decade, we found highly consistent and enduring differences in symptoms across the major clinical symptom domains of bipolar disorder. These differences were marked by a greater burden of mood-incongruent psychotic symptoms, insomnia and irritability, and fewer prototypical symptoms of mania. While such symptoms warrant better recognition to reduce diagnostic disparities, they may also represent potential targets of treatment that can be addressed to mitigate persistent disparities in outcome.

Comparison of Black and white individuals who report diagnoses of schizophrenia in a national sample of US adults: Discrimination and service use

BACKGROUND

While there is increasing recognition of disparities in healthcare for Black Americans, there have been no comparisons in a nationally representative U.S. sample of Black and White adults with clinical diagnoses of schizophrenia.

METHODS

Using nationally representative survey data from the National Epidemiologic Survey on Alcohol and Related Conditions-III, we compared Black (n = 240, 36.2%) and White (n = 423, 63.8%) adults who report having been told by a physician that they have schizophrenia. Due to the large sample size, effect sizes (risk ratios and Cohen's d), rather than p-values, were used to identify the magnitude of differences in sociodemographic and clinical characteristics, including experiences of discrimination and service use. Multivariate analyses were used to identify independent factors.

RESULTS

Black individuals with diagnoses of schizophrenia reported multiple sociodemographic disadvantages, including lower rates of employment, educational attainment, income, marriage, and social support, with little difference in incarceration, violent behavior, and quality of life. They reported much higher scores on a general lifetime discrimination scale (Cohen's d = 0.75) and subscales representing job discrimination (d = 0.85), health system discrimination (d = 0.70), and public race-based abuse (d = 0.55) along with higher rates of past year alcohol and drug use disorders, but lower rates of co-morbid psychiatric disorders. Multivariable-adjusted regression analyses highlighted the independent association of Black race with measures of discrimination and religious service attendance; less likelihood of receiving psychiatric treatment (p = 0.02) but no difference in substance use treatment.

CONCLUSION

Black adults with schizophrenia report numerous social disadvantages, especially discrimination, but religious service attendance may be an important social asset.

Psychotic Misdiagnosis of Racially Minoritized Patients: A Case-Based Ethics, Equity, and Educational Exploration

The overdiagnosis and misdiagnosis of racially minoritized groups as having a primary psychotic disorder is one of psychiatry's longest-standing inequities born of real-time clinician racial bias. Evidence suggests that providers assign a diagnosis of schizophrenia and/or schizoaffective disorder according to race more than any other demographic variable, and this inequity persists even in the absence of differences in clinician symptom ratings. This case report describes the journey of one young Black woman through her racialized misdiagnosis of schizophrenia and the process by which interdisciplinary, health equity-minded providers across the spectrum of medical education and practice joined together to provide a culturally informed, systematic rediagnosis of major depressive disorder and post-traumatic stress disorder. Expert discussion is provided by three Black academic psychiatrists with expertise in social justice and health equity. We provide an evidence-based exploration of mechanisms of clinician racial bias and detail how the psychosis misdiagnosis of racially minoritized groups fails medical ethics and perpetuates iatrogenic harm to patients who truly need help with primary mood, trauma, and substance use disorders.

The Impact of Mental Health Intensive Case Management on Functioning and Clinical Outcomes of Older Black and White Veterans With Serious Mental Illness

OBJECTIVES

To examine differences in service delivery, functioning, and clinical outcomes between older Black and White veterans participating in a national Veterans Health Administration (VHA) program of intensive case management.

DESIGN

Secondary analysis of national program evaluation data.

SETTING

VHA Intensive Community Mental Health Recovery (ICMHR) program.

PARTICIPANTS

Black (n = 1327) and White (n = 4402) veterans age 55 and older who enrolled in ICMHR between 2000-2013.

MEASUREMENTS

Measures evaluated sociodemographic factors, service delivery, functioning, and clinical outcomes. ANOVA and chi-squares were used to evaluate differences in enrollment characteristics and service delivery between Black and White veterans. Regression analyses were used to examine changes in outcomes over 6 months controlling for confounding baseline differences and service delivery. Cohen's d of .20 was used as a threshold for a clinically meaningful effect.

RESULTS

Black veterans were more likely to be diagnosed with schizophrenia, alcohol use disorder, and drug use disorder. Although case managers spent significantly less time with Black veterans, there was no difference in the frequency of contacts. Medication management and substance use treatment were more often provided to Black veterans. Black veterans experienced substantially greater improvement in anxiety/depression than White veterans with a small effect size (Cohen's d =-0.25). Changes in all other outcome measures did not meet criteria for clinically meaningful differences.

CONCLUSIONS

Black veterans experienced meaningfully greater improvements than White veterans on anxiety/depression but not on other measures. Provision of high-intensity services in an equal-access setting may reduce health disparities between Black and White older adults with serious mental illness.

From Womb to Neighborhood: A Racial Analysis of Social Determinants of Psychosis in the United States

The authors examine U.S.-based evidence that connects characteristics of the social environment with outcomes across the psychosis continuum, from psychotic experiences to schizophrenia. The notion that inequitable social and economic systems of society significantly influence psychosis risk through proxies, such as racial minority and immigrant statuses, has been studied more extensively in European countries. While there are existing international reviews of social determinants of psychosis, none to the authors' knowledge focus on factors in the U.S. context specifically-an omission that leaves domestic treatment development and prevention efforts incomplete and underinformed. In this review, the authors first describe how a legacy of structural racism in the United States has shaped the social gradient, highlighting consequential racial inequities in environmental conditions. The authors offer a hypothesized model linking structural racism with psychosis risk through interwoven intermediary factors based on existing theoretical models and a review of the literature. Neighborhood factors, cumulative trauma and stress, and prenatal and perinatal complications were three key areas selected for review because they reflect social and environmental conditions that may affect psychosis risk through a common pathway shaped by structural racism. The authors describe evidence showing that Black and Latino people in the United States suffer disproportionately from risk factors within these three key areas, in large part as a result of racial discrimination and social disadvantage. This broad focus on individual and community factors is intended to provide a consolidated space to review this growing body of research and to guide continued inquiries into social determinants of psychosis in U.S. contexts.

Clinicians' Racial Bias Contributing to Disparities in Electroconvulsive Therapy for Patients From Racial-Ethnic Minority Groups

Patients from racial-ethnic minority groups undergo disparate electroconvulsive therapy (ECT) treatment compared with Caucasian peers. One leading hypothesis is that clinicians may unknowingly display racial bias when considering ECT for patients of color. Studies have consistently shown that patients of color face numerous racially driven, provider-level interpersonal and perceptual biases that contribute to clinicians incorrectly overdiagnosing them as having a psychotic-spectrum illness rather than correctly diagnosing a severe affective disorder. A patient's diagnosis marks the entry to evidence-based service delivery, and ECT is best indicated for severe affective disorders rather than for psychotic disorders. As a consequence of racially influenced clinician misdiagnosis, patients from racial-ethnic minority groups are underrepresented among those given severe affective diagnoses, which are most indicated for ECT referral. Evidence also suggests that clinicians may use racially biased treatment rationales when considering ECT after they have given a diagnosis of a severe affective or psychotic disorder, thereby producing secondary inequities in ECT referral. Increasing the use of gold-standard treatment algorithms when considering ECT for patients of color is contingent on clinicians transcending the limitations posed by aversive racism to develop culturally unbiased, clinically indicated diagnostic and treatment rationales.

Schizophrenia hospitalization in the US 2005-2014: Examination of trends in demographics, length of stay, and cost

Primarily we aimed to examine the crude and standardized schizophrenia hospitalization trend from 2005 to 2014. We hypothesized that there will be a statistically significant linear trend in hospitalization rates for schizophrenia from 2005 to 2014. Secondarily we also examined trends in hospitalization by race/ethnicity, age, gender, as well as trends in hospitalization Length of Stay (LOS) and inflation adjusted cost.In this observational study, we used Nationwide Inpatient Sample data and International Classification of Diseases, Eleventh Revisions codes for Schizophrenia, which revealed 6,122,284 cases for this study. Outcomes included crude and standardized hospitalization rates, race/ethnicity, age, cost, and LOS. The analysis included descriptive statistics, indirect standardization, Rao-Scott Chi-Square test, t-test, and adjusted linear regression trend.Hospitalizations were most prevalent for individuals ages 45-64 (38.8%), African Americans were overrepresented (25.8% of hospitalizations), and the gender distribution was nearly equivalent. Mean LOS was 9.08 days (95% confidence interval 8.71-9.45). Medicare was the primary payer for most hospitalizations (55.4%), with most of the costs ranging from $10,000-$49,999 (57.1%). The crude hospitalization rates ranged from 790-1142/100,000 admissions, while the US 2010 census standardized rates were 380-552/100,000 from 2005-2014. Linear regression trend analysis showed no significant difference in trend for race/ethnicity, age, nor gender (P > .001). The hospitalizations' overall rates increased while LOS significantly decreased, while hospitalization costs and Charlson's co-morbidity index increased (P < .001).From 2005-2014, the overall US hospitalization rates significantly increased. Over this period, observed disparities in hospitalizations for middle-aged and African Americans were unchanged, and LOS has gone down while costs have gone up. Further studies addressing the important disparities in race/ethnicity and age and reducing costs of acute hospitalization are needed.

Considerations for working with youth with socially complex needs

TOPIC

The presence of adverse childhood experiences offers a glimpse into the social complexity in the lives of youth. Thus far, youth have been categorized as "at-risk" or "vulnerable,"-identifiers which highlight a deficits-based framework and continue to stigmatize youth. To combat this systemic marginalization, we propose using the term youth with socially complex needs. These youth, often minority ethnic/racial and/or sexual/gender minorities, experience repeated adversity and discrimination.

PURPOSE

The purpose of this paper is to conceptualize the unique considerations of working with youth with socially complex needs-who have an increased vulnerability for social marginalization.

SOURCES USED

Given the adversity experienced and challenges inherent in working with youth with socially complex needs, ethical principles, and relevant care delivery models were explored.

CONCLUSIONS

Delivering mental health care and/or conducting research in collaboration with youth with socially complex needs requires thoughtful consideration of ethical principles and models of care. In conclusion, we propose a strengths-based, individualized approach to working with youth with socially complex needs that requires a dynamic, fluid, multisystemic approach to care and research.

Association of Income With the Incidence Rates of First Psychiatric Hospital Admissions in Finland, 1996-2014

IMPORTANCE

The association between income and mental health has long been a question of interest. Nationwide register data provide means to examine trends and patterns of these associations.

OBJECTIVES

To compare income-specific trends in the incidence rates of first psychiatric hospital admissions and to evaluate whether an income gradient exists in the incidence rates at all levels of household income.

DESIGN, SETTING, AND PARTICIPANTS

This population-based open cohort study used linked registry data from nationwide Finnish Hospital Discharge and Statistics Finland population registers to determine annual incidence rates of first psychiatric hospital admissions. All Finnish citizens (N = 6 258 033) living in the country at any time from January 1, 1996, through December 31, 2014, contributed to 96 184 614 person-years at risk of first inpatient treatment for mental disorders. The analyses were conducted from August 1, 2018, through September 30, 2019.

EXPOSURES

Equivalized disposable income, sex, age group, reduction in income decile in the previous 3 years, urbanicity, educational level, and living alone status.

MAIN OUTCOMES AND MEASURES

Annual percentage changes in the age-standardized incidence rates and incidence rate ratios (IRRs).

RESULTS

Altogether, 186 082 first psychiatric inpatient treatment episodes occurred (93 431 [50.2%] men), with overall age-standardized incidence rates per 1000 person-years varying from 1.59 (95% CI, 1.56-1.63) in 2014 to 2.11 (95% CI, 2.07-2.15) in 2008. In the highest income deciles, a continuous mean decrease per year of 3.71% (95% CI, 2.82%-4.59%) in men and 0.91% (95% CI, 0.01%-1.80%) in women occurred throughout the study period, in contrast to the lowest deciles, where the trends first increased (1.31% [95% CI, 0.62%-2.01%] increase in men from 1996 to 2007 and 5.61% [95% CI, 2.36%-8.96%] increase in women from 1996 to 2001). In the adult population, an income gradient was observed at all levels of household income: the lower the income decile, the higher the adjusted IRRs compared with the highest decile. The IRRs in the lowest decile varied from 2.94 (95% CI, 2.78-3.11) to 4.46 (95% CI, 4.17-4.76). In other age groups, the gradient did not persist at the highest income deciles. Diagnosis-specific income gradient was steepest in schizophrenia and related psychotic disorders, with estimated IRRs of the lowest income decile of 5.89 (95% CI, 5.77-6.02).

CONCLUSIONS AND RELEVANCE

In this cohort study, clear negative income gradient in the incidence rates of first hospital-treated mental disorders was observed in the adult population of Finland. These findings suggest that reduction in the use of inpatient care has not taken place equally between different income groups.

Decreased core symptoms of mania and utilization of lithium/mood stabilizing anticonvulsants in U.S. bipolar I patients of African vs European ancestry

OBJECTIVE

Misdiagnosis is common in bipolar disorder and disproportionally affects racial and ethnic minorities. There is interest in better understanding the contribution of differential symptomatic illness presentation to misdiagnosis.

METHODS

Utilizing the Genetic Association Information Network (GAIN) public database, this study compared clinical phenomenology between bipolar patients of African vs European ancestry (AA = 415 vs EA = 480). The Diagnostic Interview for Genetic Studies (DIGS) was utilized to evaluate symptom endorsement contributing to diagnostic confirmation of bipolar I disorder (BPI) and lifetime medication use.

RESULTS

Elevated/euphoric mood was less endorsed in AA vs EA participants (p = 0.03). During the most severe episode of mania, AA participants, in comparison to EA participants, had a lower sum of manic symptoms (p = 0.006) and a higher rate of hallucinations (p = 0.01). During lifetime psychosis, AA participants, in comparison to EA participants, had a higher lifetime sum of delusions (p = 0.01) and hallucinations (p < 0.0001). AA participants reported lower use of lithium (p < 0.0001) and mood stabilizing anticonvulsants (p = 0.0003).

CONCLUSIONS

The differential rate of manic and psychotic symptom endorsement from a semi-structured diagnostic interview may represent differential illness presentation based on biological differences or racial or study biases (e.g. ascertainment). Increased minority recruitment in bipolar research is therefore a necessary future direction.

LIMITATIONS

Recall and interviewer bias may affect study results, but are likely diminished by the alignment of symptom endorsement and medication use.

Mental Health Disparities, Treatment Engagement, and Attrition Among Racial/Ethnic Minorities with Severe Mental Illness: A Review

Mounting evidence indicates that there are mental health disparities in the United States that disadvantage racial/ethnic minorities in medical and mental health settings. Less is known, however, about how these findings apply to a particularly vulnerable population, individuals with severe mental illness (SMI). The aim of this paper is to (1) provide a critical review of the literature on racial/ethnic disparities in mental health care among individuals with SMI; (2) identify factors which may contribute to the observed disparities; and (3) generate recommendations on how best to address these disparities. Specifically, this article provides an in-depth review of sociocultural factors that may contribute to differences in treatment engagement and rates of attrition from treatment among racial/ethnic minorities with SMI who present at medical and mental health facilities. This review is followed by a discussion of specific strategies that may promote engagement in mental health services and therefore reduce racial/ethnic disparities in SMI.

Ethnic differences in the diagnosis of schizophrenia and mood disorders during admission to an academic safety-net psychiatric hospital

U.S. Hispanics, now the single largest minority group in the country, face unique mental health disparities. The current study utilizes Andersen's Behavioral Model of Health Service Use to examine ethnic disparities in receiving a schizophrenia or mood disorder diagnosis at psychiatric hospital admission. Our retrospective cohort study examined electronic health record data at an academic safety-net psychiatric hospital for adult patients (n = 5571) admitted between 2010 and 2013. Logistic regression with block-wise entry of predisposing, enabling and need variables was used to examine ethnic disparities in receiving a schizophrenia diagnosis at admission. The block of need factors was the strongest predictor of receiving a schizophrenia diagnosis compared to predisposing and enabling factors. Compared to non-Hispanic whites, Hispanics and African Americans had a greater likelihood of receiving a schizophrenia diagnosis at admission. Additionally, patients diagnosed with schizophrenia had elevated positive and negative symptoms and were more likely to be male, single/unmarried, homeless, high inpatient service utilizers, involuntarily hospitalized, and to exhibit functional impairment at psychiatric hospital admission. To address elevated positive and negative symptoms of schizophrenia, functional impairment, social withdrawal, and high inpatient service utilization, promising psychosocial interventions should be adapted for racial and ethnic minority populations and utilized as an adjuvant to antipsychotic medication.

Racial disparities in bipolar disorder treatment and research: a call to action

OBJECTIVES

Health disparities between individuals of African and European ancestry are well documented. The disparities in bipolar disorder may be driven by racial bias superimposed on established factors contributing to misdiagnosis, including: evolving empirically based diagnostic criteria (International Classification of Diseases [ICD], Research Diagnostic Criteria [RDC] and Diagnostic and Statistical Manual [DSM]), multiple symptom domains (i.e. mania, depression and psychosis), and multimodal medical and additional psychiatric comorbidity.

METHODS

For this paper, we reviewed the phenomenological differences between bipolar individuals of African and European ancestry in the context of diagnostic criteria and clinical factors that may contribute to a potential racial bias.

RESULTS

Published data show that bipolar persons of African ancestry, compared with bipolar persons of non-African ancestry, are more often misdiagnosed with a disease other than bipolar disorder (i.e. schizophrenia). Additionally, studies show that there are disparities in recruiting patients of African ancestry to participate in important genomic studies. This gap in biological research in this underrepresented minority may represent a missed opportunity to address potential racial differences in the risk and course of bipolar illness.

CONCLUSION

A concerted effort by the research community to increase inclusion of diverse persons in studies of bipolar disorder through community engagement may facilitate fully addressing these diagnostic and treatment disparities in bipolar individuals of African ancestry.

A Bayesian Approach to Modeling Risk of Hospital Admissions Associated With Schizophrenia Accounting for Underdiagnosis of the Disorder in Administrative Records

Schizophrenia is a debilitating serious mental illness characterized by a complex array of symptoms with varying severity and duration. Patients may seek treatment only intermittently, contributing to challenges diagnosing the disorder. A misdiagnosis may potentially bias and reduce study validity. Thus we developed a statistical model to assess the risk of 1-year hospitalization for patients diagnosed with schizophrenia, accounting for when schizophrenia is underreported in administrative databases. A retrospective study design identified patients seeking care during 2010 within an integrated health care system from the Health Maintenance Organization Research Network located in the southwestern United States. Bayesian analysis addressed the problem of underdiagnosed schizophrenia with a statistical measurement error model assuming varying rates of underreporting. Results were then compared to classical multivariable logistic regression. Assuming no underreporting, there was an 87% greater relative odds of hospitalization associated with schizophrenia, OR = 1.87, CI [1.08, 3.23]. Effect sizes and interval estimates representing the association between hospitalization and schizophrenia were reduced with the Bayesian approach accounting for underdiagnosis, suggesting that less severe patients may be underrepresented in studies of schizophrenia. The analytical approach has useful applications in other contexts where the identification of patients with a given condition may be underreported in administrative records.

Counseling Psychology Model Training Program

The counseling psychology Model Training Program (MTP) was written to reflect new developments in counseling psychology, the American Psychological Association, and the world. The updated MTP is aspirational, intended to guide the development and maintenance of counseling psychology programs. The MTP conforms to the American Psychological Association’s and the Society of Counseling Psychology’s standards and guidelines. A strategic task group appointed by 2015 Society president James W. Lichtenberg sought feedback from the field to assist in its formulation, and the executive boards of the Society and the Council of Counseling Psychology Training Programs approved the final version. The 2017 MTP consists of four core values (i.e., growth toward full potential, holistic and contextual, diversity and social justice, communitarian perspective) as well as 20 principles grouped into six clusters: counseling psychology identity; multiculturalism, diversity, and social justice; health service psychology; developmental, prevention, and strengths orientation; science–practice integration; and relationships within and between professional communities.

The musculoskeletal diagnosis cohort: examining pain and pain care among veterans

Musculoskeletal disorders (MSDs) are highly prevalent, painful, and costly disorders. The MSD Cohort was created to characterize variation in pain, comorbidities, treatment, and outcomes among patients with MSD receiving Veterans Health Administration care across demographic groups, geographic regions, and facilities. We searched electronic health records to identify patients treated in Veterans Health Administration who had ICD-9-CM codes for diagnoses including, but not limited to, joint, back, and neck disorders, and osteoarthritis. Cohort inclusion criteria were 2 or more outpatient visits occurring within 18 months of one another or one inpatient visit with an MSD diagnosis between 2000 and 2011. The first diagnosis is the index date. Pain intensity numeric rating scale (NRS) scores, comorbid medical and mental health diagnoses, pain-related treatments, and other characteristics were collected retrospectively and prospectively. The cohort included 5,237,763 patients; their mean age was 59, 6% were women, 15% identified as black, and 18% reported severe pain (NRS ≥ 7) on the index date. Nontraumatic joint disorder (27%), back disorder (25%), and osteoarthritis (21%) were the most common MSD diagnoses. Patients entering the cohort in recent years had more concurrent MSD diagnoses and higher NRS scores. The MSD Cohort is a rich resource for collaborative pain-relevant health service research.

Persistent Serious Mental Illness Among Former Applicants for VA PTSD Disability Benefits and Long-Term Outcomes: Symptoms, Functioning, and Employment

Millions of U.S. veterans have returned from military service with posttraumatic stress disorder (PTSD), for which a substantial number receive U.S. Department of Veterans Affairs (VA) disability benefits. Although PTSD is treatable, comorbid serious mental illness (defined here as schizophrenia, schizoaffective disorder, and bipolar spectrum disorders) could complicate these veterans' recovery. Using VA administrative data, we examined the burden of persistent serious mental illness in a nationally representative cohort of 1,067 men and 1,513 women who applied for VA PTSD disability benefits between 1994 and 1998 and served during or after the Vietnam conflict. Self-reported outcomes were restricted to the 713 men and 1,015 women who returned surveys at each of 3 collection points. More than 10.0% of men and 20.0% of women had persistent serious mental illness; of these, more than 80.0% also had persistent PTSD. On repeated measures modeling, those with persistent serious mental illness consistently reported more severe PTSD symptoms and poorer functioning in comparison to other participants (ps < .001); their employment rate did not exceed 21.0%. Interactions between persistent serious mental illness and PTSD were significant only for employment (p = .002). Persistent serious mental illness in this population was almost 2 to 19 times higher than in the general U.S.

POPULATION

The implications of these findings are discussed.

Improving Physical Health in Patients With Chronic Mental Disorders: Twelve-Month Results From a Randomized Controlled Collaborative Care Trial

OBJECTIVE

Persons with chronic mental disorders are disproportionately burdened with physical health conditions. We determined whether Life Goals Collaborative Care compared to usual care improves physical health in patients with mental disorders within 12 months.

METHODS

This single-blind randomized controlled effectiveness study of a collaborative care model was conducted at a midwestern Veterans Affairs urban outpatient mental health clinic. Patients (N = 293 out of 474 eligible approached) with an ICD-9-CM diagnosis of schizophrenia, bipolar disorder, or major depressive disorder and at least 1 cardiovascular disease risk factor provided informed consent and were randomized (February 24, 2010, to April 29, 2015) to Life Goals (n = 146) or usual care (n = 147). A total of 287 completed baseline assessments, and 245 completed 12-month follow-up assessments. Life Goals included 5 weekly sessions that provided semistructured guidance on managing physical and mental health symptoms through healthy behavior changes, augmented by ongoing care coordination. The primary outcome was change in physical health-related quality of life score (Veterans RAND 12-item Short Form Health Survey [VR-12] physical health component score). Secondary outcomes included control of cardiovascular risk factors from baseline to 12 months (blood pressure, lipids, weight), mental health-related quality of life, and mental health symptoms.

RESULTS

Among patients completing baseline and 12-month outcomes assessments (N = 245), the mean age was 55.3 years (SD = 10.8; range, 25-78 years), and 15.4% were female. Intent-to-treat analysis revealed that compared to those in usual care, patients randomized to Life Goals had slightly increased VR-12 physical health scores (coefficient = 3.21; P = .01).

CONCLUSIONS

Patients with chronic mental disorders and cardiovascular disease risk who received Life Goals had improved physical health-related quality of life.

TRIAL REGISTRATION

ClinicalTrials.gov identifiers: NCT01487668 and NCT01244854.

Incidence of Mental Health Diagnoses in Veterans of Operations Iraqi Freedom, Enduring Freedom, and New Dawn, 2001-2014

OBJECTIVES

To evaluate gender, age, and race/ethnicity as predictors of incident mental health diagnoses among Operations Iraqi Freedom, Enduring Freedom, and New Dawn veterans.

METHODS

We used US Veterans Health Administration (VHA) electronic health records from 2001 to 2014 to examine incidence rates and sociodemographic risk factors for mental health diagnoses among 888 142 veterans.

RESULTS

Posttraumatic stress disorder (PTSD) was the most frequently diagnosed mental health condition across gender and age groups. Incidence rates for all mental health diagnoses were highest at ages 18 to 29 years and declined thereafter, with the exceptions of major depressive disorder (MDD) in both genders, and PTSD among women. Risk of incident bipolar disorder and MDD diagnoses were greater among women; risk of incident schizophrenia, and alcohol- and drug-use disorders diagnoses were greater in men. Compared with Whites, risk incident PTSD, MDD, and alcohol-use disorder diagnoses were lower at ages 18 to 29 years and higher at ages 45 to 64 years for both Hispanics and African Americans.

CONCLUSIONS

Differentiating high-risk demographic and gender groups can lead to improved diagnosis and treatment of mental health diagnoses among veterans and other high-risk groups.

Racial/Ethnic Differences in Primary Care Experiences in Patient-Centered Medical Homes among Veterans with Mental Health and Substance Use Disorders

BACKGROUND

Patient-Centered Medical Homes (PCMH) may be effective in managing care for racial/ethnic minorities with mental health and/or substance use disorders (MHSUDs). How such patients experience care in PCMH settings is relatively unknown.

OBJECTIVE

We aimed to examine racial/ethnic differences in experiences with primary care in PCMH settings among Veterans with MHSUDs.

DESIGN

We used multinomial regression methods to estimate racial/ethnic differences in PCMH experiences reported on a 2013 national survey of Veterans Affairs patients.

PARTICPANTS

Veterans with past-year MHSUD diagnoses (n = 65,930; 67 % White, 20 % Black, 11 % Hispanic, 1 % American Indian/Alaska Native[AI/AN], and 1 % Asian/Pacific Island[A/PI]).

MAIN MEASURES

Positive and negative experiences from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) PCMH Survey.

RESULTS

Veterans with MHSUDs reported the lowest frequency of positive experiences with access (22 %) and the highest frequency of negative experiences with self-management support (30 %) and comprehensiveness (16 %). Racial/ethnic differences (as compared to Whites) were observed in all seven healthcare domains (p values < 0.05). With access, Blacks and Hispanics reported more negative (Risk Differences [RDs] = 2 .0;3.6) and fewer positive (RDs = -2 .3;-2.3) experiences, while AI/ANs reported more negative experiences (RD = 5.7). In communication, Blacks reported fewer negative experiences (RD = -1.3); AI/ANs reported more negative (RD = 3.6) experiences; and AI/ANs and APIs reported fewer positive (RD = -6.5, -6.7) experiences. With office staff, Hispanics reported fewer positive experiences (RDs = -3.0); AI/ANs and A/PIs reported more negative experiences (RDs =  3.4; 3.7). For comprehensiveness, Blacks reported more positive experiences (RD = 3.6), and Hispanics reported more negative experiences (RD = 2.7). Both Blacks and Hispanics reported more positive (RDs = 2.3; 4.2) and fewer negative (RDs = -1.8; -1.9) provider ratings, and more positive experiences with decision making (RDs = 2.4; 3.0). Blacks reported more positive (RD = 3.9) and fewer negative (RD = -5.1) experiences with self-management support.

CONCLUSIONS

In a national sample of Veterans with MHSUDs, potential deficiencies were observed in access, self-management support, and comprehensiveness. Racial/ethnic minorities reported worse experiences than Whites with access, comprehensiveness, communication, and office staff helpfulness/courtesy.

Racial-Ethnic Differences in Psychiatric Diagnoses and Treatment Across 11 Health Care Systems in the Mental Health Research Network

OBJECTIVE

The objective of this study was to characterize racial-ethnic variation in diagnoses and treatment of mental disorders in large not-for-profit health care systems.

METHODS

Participating systems were 11 private, not-for-profit health care organizations constituting the Mental Health Research Network, with a combined 7,523,956 patients age 18 or older who received care during 2011. Rates of diagnoses, prescription of psychotropic medications, and total formal psychotherapy sessions received were obtained from insurance claims and electronic medical record databases across all health care settings.

RESULTS

Of the 7.5 million patients in the study, 1.2 million (15.6%) received a psychiatric diagnosis in 2011. This varied significantly by race-ethnicity, with Native American/Alaskan Native patients having the highest rates of any diagnosis (20.6%) and Asians having the lowest rates (7.5%). Among patients with a psychiatric diagnosis, 73% (N=850,585) received a psychotropic medication. Non-Hispanic white patients were significantly more likely (77.8%) than other racial-ethnic groups (odds ratio [OR] range .48-.81) to receive medication. In contrast, only 34% of patients with a psychiatric diagnosis (N=548,837) received formal psychotherapy. Racial-ethnic differences were most pronounced for depression and schizophrenia; compared with whites, non-Hispanic blacks were more likely to receive formal psychotherapy for their depression (OR=1.20) or for their schizophrenia (OR=2.64).

CONCLUSIONS

There were significant racial-ethnic differences in diagnosis and treatment of psychiatric conditions across 11 U.S. health care systems. Further study is needed to understand underlying causes of these observed differences and whether processes and outcomes of care are equitable across these diverse patient populations.

"Sorry, I'm Not Accepting New Patients": An Audit Study of Access to Mental Health Care

Through a phone-based field experiment, I investigated the effect of mental help seekers' race, class, and gender on the accessibility of psychotherapists. Three hundred and twenty psychotherapists each received voicemail messages from one black middle-class and one white middle-class help seeker, or from one black working-class and one white working-class help seeker, requesting an appointment. The results revealed an otherwise invisible form of discrimination. Middle-class help seekers had appointment offer rates almost three times higher than their working-class counterparts. Race differences emerged only among middle-class help-seekers, with blacks considerably less likely than whites to be offered an appointment. Average appointment offer rates were equivalent across gender, but women were favored over men for appointment offers in their preferred time range.

Posttransplantation Outcomes in Veterans With Serious Mental Illness

BACKGROUND

Anticipating poor recovery due to impaired self-management and appointment-keeping, clinicians may consider serious mental illness (SMI) a significant concern in organ transplantation. However, little empirical evidence exists regarding posttransplantation outcomes for patients with SMI.

METHODS

This study analyzed health services data to evaluate posttransplantation 3-year survival by SMI status in a nationwide cohort of patients in the Veterans Health Administration (VHA).

RESULTS

A total of 960 recipients of solid organ or bone marrow transplants were identified from Veterans Health Administration administrative data extracts for fiscal years 2006 to 2009. Of these, 164 (17%) had an SMI diagnosis before transplantation (schizophrenia, posttraumatic stress, major depressive, and bipolar disorders); 301 (31%) had some other mental illness diagnosis (such as anxiety, adjustment reactions, or substance abuse); and 495 (52%) had no mental health diagnosis. Twenty-two patients (2%) required retransplantation and 208 patients (22%) died during follow-up. Data on whether these were primary or repeat transplantations were unavailable. Rates of attendance at postoperative outpatient visits and number of months for which immunosuppressive drugs fills were recorded were similar among mental illness groups, as were rates of diagnosed immunological rejection. Three-year mortality was equivalent among mental health groups: no mental health (19%) versus other mental illness (23%) versus SMI (27%; χ(2) = 5.11; df = 2; P = .08). In adjusted survival models, no effect of mental health status was observed.

CONCLUSIONS

Serious mental illness diagnosis does not appear to be associated with adverse transplantation outcomes over the first 3 years; however, a potentially diverging survival curve may portend higher mortality at 5 years.

Race/ethnicity and gender differences in mental health diagnoses among Iraq and Afghanistan veterans

Veterans who served in Operation Enduring Freedom (OEF; predominantly in Afghanistan) and Operations Iraqi Freedom and New Dawn (OIF and OND; predominantly in Iraq) and are enrolled in the VA are comprised of a growing cohort of women and higher proportions of racial/ethnic minorities than civilians. To compare rates of mental health disorders by race/ethnicity and gender for this diverse cohort, we conducted a retrospective analysis of existing records from OEF/OIF/OND veterans who were seen at the VA 10/7/01-8/1/2013 (N=792,663). We found that race/ethnicity was related to diagnoses of mental health disorders. Asian/Pacific Islanders (A/PIs) were diagnosed with all disorders at lower rates than whites, and American Indian/Alaska Native (AI/AN) males were diagnosed with most disorders at higher rates than white males. Research is needed to identify contributing factors to differential rates of diagnoses based on race/ethnicity and gender. A/PIs and AI/ANs have unique patterns of mental health diagnoses indicating they should be considered separately to present a comprehensive picture of veteran mental health.

Persistence of racial disparities in prescription of first-generation antipsychotics in the USA

PURPOSE

The aim of this study was to estimate the prevalence of first-generation antipsychotics (FGA) prescribed for treatment of psychiatric and neurological conditions and use of benztropine to reduce extrapyramidal side effects (EPS) by patient race/ethnicity in a nationally representative sample of adult outpatient visits.

METHODS

The study sample included all outpatient visits (N = 8154) among patients aged 18-69 years where a prescription for one or more antipsychotics was recorded across 6 years of the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey (2005-2010). Use of FGA was compared by race/ethnicity using multiple logistic regression models accounting for patient and clinical characteristics stratified by neighborhood poverty rate. Frequency of EPS was determined by use of benztropine to reduce or prevent EPS.

RESULTS

Black patients were significantly more likely than White patients to use FGA (odds ratio = 1.48, p = 0.040) accounting for psychiatric and neurological diagnoses, treatment setting, metabolic factors, neighborhood poverty, and payer source. Black patients were more than twice as likely as White patients to receive higher-potency FGA (haloperidol or fluphenazine), particularly in higher-poverty areas (odds ratio = 2.50, p < 0.001). Use of FGA, higher among Black than White patients, was positively associated with use of benztropine to reduce EPS.

CONCLUSIONS

Racial disparities in the pharmacological treatment of severe mental disorders persist 30 years after the introduction of second-generation antipsychotics. The relatively high frequency of FGA of use among Black patients compared with White patients despite more Food and Drug Administration-approved indications and lower EPS risk for second-generation antipsychotics requires additional research.

Racial/Ethnic disparities in monitoring metabolic parameters for patients with schizophrenia receiving antipsychotic medications

OBJECTIVE

Patients with schizophrenia experience risks for metabolic dysregulation from medications and lifestyle behaviors. Although most patients with schizophrenia in the Veterans Health Administration (VA) receive antipsychotics, variation in monitoring metabolic dysregulation by race/ethnicity has not been assessed. This study analyzed differential monitoring of metabolic parameters by minority status.

METHODS

This retrospective study approximated the five components of metabolic syndrome (fasting glucose, high-density-lipoprotein cholesterol, triglycerides, blood pressure, and large waistline) using archival data, substituting body mass index for waistline. VA patients with schizophrenia age 50 or older were followed from October 1, 2001 through September 2009 (N = 30,258). Covariates included age, gender, race (white, black), Hispanic ethnicity, region, marital status, VA priority status, comorbidity, and antipsychotic type. Repeated-measures analysis assessed the association of race/ethnicity with metabolic monitoring.

RESULTS

Average patients age was 59 years (standard deviation: 9; range: 50-101), 97% were men, 70% white, 30% black, and 8% Hispanic. At baseline, 6% were monitored on all five metabolic components; this increased to 29% by 2005. In adjusted models, blacks were less likely to be monitored on all parameters, whereas Hispanics were less likely to have glucose and high-density-lipoprotein cholesterol monitored but more likely to have triglycerides tested. By 2009, lab assays were similar across race and ethnicity.

CONCLUSION

Guideline-concordant monitoring metabolic parameters appear to be equitable but low and somewhat at odds with racial/ethnic risk among older patients with schizophrenia. Physicians should discuss lipids, weight, and glucose with patients at risk for developing heart disease, diabetes, and other sequelae of the metabolic syndrome.

Racial Differences in Chronic Conditions and Sociodemographic Characteristics Among High-Utilizing Veterans

PURPOSE

African-Americans are disproportionally represented among high-risk, high-utilizing patients. To inform program development for this vulnerable population, the current study describes racial variation in chronic conditions and sociodemographic characteristics among high-utilizing patients in the Veterans Affairs Healthcare System (VA).

METHODS

We identified the 5 % most costly Veterans who used inpatient or outpatient care at the VA during fiscal year 2010 (N = 237,691) based on costs of inpatient and outpatient care, pharmacy services, and VA-sponsored contract care. Patient costs and characteristics were abstracted from VA outpatient and inpatient data files. Racial differences in sociodemographic characteristics (age, sex, marital support, homelessness, and health insurance status) were assessed with chi-square tests. Racial differences in 32 chronic condition diagnoses were calculated as relative risk ratios.

RESULTS

African-Americans represented 21 % of high-utilizing Veterans. African-Americans had higher rates of homelessness (26 vs. 10 %, p < 0.001) and lower rates of supplemental health insurance (44 vs. 58 %, p < 0.001). The mean number of chronic conditions was similar across race. However, there were racial differences in the prevalence of specific chronic conditions, including a higher prevalence of HIV/AIDS (95 % confidence interval (CI) 4.86, 5.50) and schizophrenia (95 % CI 1.94, 2.07) and a lower prevalence of ischemic heart disease (95 % CI 0.57, 0.59) and bipolar disorder (95 % CI 0.78, 0.85) among African-American high-utilizing Veterans.

CONCLUSION

Racial disparities among high-utilizing Veterans may differ from those found in the general population. Interventions should devote attention to social, environmental, and mental health issues in order to reduce racial disparities in this vulnerable population.

Variation in Utilization of Health Care Services for Rural VA Enrollees With Mental Health-Related Diagnoses

PURPOSE

Rural-dwelling Department of Veterans Affairs (VA) enrollees are at high risk for a wide variety of mental health-related disorders. The objective of this study is to examine the variation in the types of mental and nonmental health services received by rural VA enrollees who have a mental health-related diagnosis.

METHODS

The Andersen and Aday behavioral model of health services use and the Agency for Healthcare Research and Quality Medical Expenditure Panel Survey (MEPS) data were used to examine how VA enrollees with mental health-related diagnoses accessed places of care from 1999 to 2009. Population survey weights were applied to the MEPS data, and logit regression was conducted to model how predisposing, enabling, and need factors influence rural veteran health services use (measured by visits to different places of care). Analyses were performed on the subpopulations: rural VA, rural non-VA, urban VA, and urban non-VA enrollees.

FINDINGS

For all types of care, both rural and urban VA enrollees received care from inpatient, outpatient, office-based, and emergency room settings at higher odds than urban non-VA enrollees. Rural VA enrollees also received all types of care from inpatient, office-based, and emergency room settings at higher odds than urban VA enrollees. Rural VA enrollees had higher odds of a mental health visit of any kind compared to urban VA and non-VA enrollees.

CONCLUSIONS

Based on these variations, the VA may want to develop strategies to increase screening efforts in inpatient settings and emergency rooms to further capture rural VA enrollees who have undiagnosed mental health conditions.

Racial disparities in psychotic disorder diagnosis: A review of empirical literature

Psychotic disorder diagnoses are common in the United States and internationally. However, racial disparities in rates of psychotic disorder diagnoses have been reported across time and mental health professions. This literature review provides an updated and comprehensive summary of empirical research on race and diagnosis of psychotic disorders spanning a 24-year period. Findings reveal a clear and pervasive pattern wherein African American/Black consumers show a rate of on average three to four higher than Euro-American/White consumers. Latino American/Hispanic consumers were also disproportionately diagnosed with psychotic disorders on average approximately three times higher compared to Euro-American/White consumers. In addition, a trend among international studies suggests that immigrant racial minority consumers receiving mental health services may be assigned a psychotic disorder diagnosis more frequently than native consumers sharing a majority racial background. Potential explanations for this phenomenon are discussed, including possible clinical bias and sociological causes such as differential access to healthcare and willingness to participate in mental health services. Directions for future research should include the exploration of disproportionate diagnoses according to race through qualitative interviewing as well as empirical investigation.

Prevalence of suicidality among Hispanic and African American veterans following surgery

OBJECTIVES

We evaluated factors associated with suicidal behavior and ideation (SBI) during 3 years of follow-up among 89,995 Veterans Health Administration (VHA) patients who underwent major surgery from October 2005 to September 2006.

METHODS

We analyzed administrative data using Cox proportional hazards models. SBI was ascertained by International Classification of Disease, 9th Revision codes.

RESULTS

African Americans (18% of sample; 16,252) were at an increased risk for SBI (hazard ratio [HR] = 1.21; 95% confidence interval [CI]  = 1.10, 1.32), whereas Hispanics were not (HR = 1.10; 95% CI = 0.95, 1.28). Other risk factors included schizophrenia, bipolar disorder, depression, posttraumatic stress disorder, pain disorders, postoperative new-onset depression, and postoperative complications; female gender and married status were protective against SBI.

CONCLUSIONS

The postoperative period might be a time of heightened risk for SBI among minority patients in the VHA. Tailored monitoring and postoperative management by minority status might be required to achieve care equity.

Glucose control and medication adherence among veterans with diabetes and serious mental illness: does collocation of primary care and mental health care matter?

OBJECTIVE

Persons with serious mental illness (SMI) may benefit from collocation of medical and mental health healthcare professionals and services in attending to their chronic comorbid medical conditions. We evaluated and compared glucose control and diabetes medication adherence among patients with SMI who received collocated care to those not receiving collocated care (which we call usual care).

RESEARCH DESIGN AND METHODS

We performed a cross-sectional, observational cohort study of 363 veteran patients with type 2 diabetes and SMI who received care from one of three Veterans Affairs medical facilities: two sites that provided both collocated and usual care and one site that provided only usual care. Through a survey, laboratory tests, and medical records, we assessed patient characteristics, glucose control as measured by a current HbA1c, and adherence to diabetes medication as measured by the medication possession ration (MPR) and self-report.

RESULTS

In the sample, the mean HbA1c was 7.4% (57 mmol/mol), the mean MPR was 80%, and 51% reported perfect adherence to their diabetes medications. In both unadjusted and adjusted analyses, there were no differences in glucose control and medication adherence by collocation of care. Patients seen in collocated care tended to have better HbA1c levels (β = -0.149; P = 0.393) and MPR values (β = 0.34; P = 0.132) and worse self-reported adherence (odds ratio 0.71; P = 0.143), but these were not statistically significant.

CONCLUSIONS

In a population of veterans with comorbid diabetes and SMI, patients on average had good glucose control and medication adherence regardless of where they received primary care.

Changing psychiatric perception of African-Americans with affective disorders

This article explored the origins and implications of the underdiagnosis of affective disorders in African-Americans. MEDLINE and old collections were searched using relevant key words. Reference lists from the articles that were gathered from this procedure were reviewed. The historical record indicated that the psychiatric perception of African-Americans with affective disorders changed significantly during the last 200 years. In the antebellum period, the mental disorders of slaves mostly went unnoticed. By the early 20th century, African-Americans were reported to have high rates of manic-depressive disorder compared with whites. By the mid-century, rates of manic-depressive disorder in African-Americans plummeted, whereas depression remained virtually nonexistent. In recent decades, diagnosed depression and bipolar disorder, whether in clinical or research settings, were inexplicably low in African-Americans compared with whites. Given these findings, American psychiatry needs to appraise the deep-seated effects of historical stereotypes on the diagnosis and treatment of African-Americans.

A comparative study of Arab and Jewish patients admitted for psychiatric hospitalization in Jerusalem: the demographic, psychopathologic aspects, and the drug abuse comorbidity

BACKGROUND

The influence of ethnicity on different aspects of psychiatric hospitalization is far from clear.

THE AIM OF THE STUDY

The main aim of the study was to compare the Arab and the Jewish inpatients, at the time of admission, for the demographic factors, severity of psychotic, and affective psychopathology and comorbid drug abuse rate. POPULATION, METHOD, AND TOOLS: Among 250 consecutively admitted patients in the Jerusalem Mental Health Center-Kfar Shaul Hospital, 202 Jews and 42 Arabs (aged 18-65 years) were examined within 48 hours after admission. The psychiatric diagnoses were made according to the criteria of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. For the differential measurement of psychopathologic severity, the following rating scales were used: 21-item Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Positive and Negative Syndrome Scale (PANSS), and Young Mania Rating Scale. Urine tests for Δ9-tetrahydrocannabinol (THC), cocaine, opiates, amphetamines, and methamphetamine were performed using the Sure Step TM kits (Applied Biotech, Inc, San Diego, CA, USA). The Structured Clinical Interview Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for drug abuse were applied based on self-report and results of urine analysis.

RESULTS

The comparison of the 2 population showed that among the Arab inpatients, there were more males (81% vs 67.4%; P < .005). No significant difference in psychiatric diagnosis was observed. The overall severity of positive symptoms (PANSS positive) in Arab group was higher, but only slightly so (P = .05). No significant difference was observed for total rates of PANSS negative subscale. The rates of PANSS-general were also similar. The Arab patients were significantly less depressive according to 21-item Hamilton Depression Rating Scale (P = .032), and the total score of Hamilton Anxiety Rating Scale for the Jewish group was significantly higher (P = .001). No significant difference in general severity of manic symptoms for 2 groups was detected according to Young Mania Rating Scale. The rate of comorbid drug abuse for Jewish inpatients was borderline higher (P = .068).

CONCLUSIONS

The issue of referral to psychiatric hospitalization could be culturally influenced; it may be the result of disparities in demographic, psychopathologic, and drug abuse comorbid presenting symptoms, which are demonstrated upon admission by patients of different ethnic origins.

Disparities in diagnosis of bipolar disorder in individuals of African and European descent: a review

BACKGROUND

Over the past 3 decades, a wide range of studies in the United States and the United Kingdom has reported that white individuals are more likely to be diagnosed with bipolar and affective disorders, whereas black individuals appear to be at higher risk for schizophrenia spectrum diagnoses. Despite the pressing need for strategies aimed at eliminating racial and cultural disparities in diagnosis and treatment of bipolar disorder, no systematic review of the existing literature in this area has been done. This study draws together the disparate strands of information in a comprehensive overview of the research base in this area.

METHODS

An electronic literature search of the Medline and PsychINFO databases was conducted in October 2009, supplemented by a review of references in the identified articles, for a total of 51 articles included in this qualitative review.

RESULTS

Black patients have consistently been found to be more likely than white patients to be diagnosed with schizophrenia rather than bipolar disorder. Four factors were identified as potential contributors to racial disparities in diagnostic rates: clinical presentation and expression of symptoms, access to care, help-seeking behaviors, and clinician judgment.

CONCLUSION

Despite efforts to curtail the phenomenon, racial disparities in diagnosis of bipolar disorder persist. Racial and cultural elements may affect how patients manifest behaviors and symptoms and how these are interpreted and attributed by clinicians in the diagnostic process. As an appropriate diagnosis determines treatment options and is central to quality of care, incorrect diagnosis can potentially have a negative impact on treatment effectiveness and accuracy of prognosis.

Medication adherence, ethnicity, and the influence of multiple psychosocial and financial barriers

Medication adherence is critical for patients with bipolar disorder to avoid symptom exacerbation and diminished quality of life. Most analyses consider adherence barriers individually rather than conjointly, while neglecting potential ethnic differences. 435 patients in the Continuous Improvement for Veterans in Care--Mood Disorders study reported multiple financial and psychosocial factors influencing adherence. Logistic regression modeled adherence as a function of perceived barriers, including cost burden, access, binge drinking, poor therapeutic alliance, and medication beliefs. Nearly half the cohort experienced adherence difficulty, averaging 2.8 barriers, with minority veterans reporting lower adherence than white patients, particularly financial burden and treatment access. Total barriers were significantly associated with worse adherence (OR = 1.24 per barrier), notably poor medication beliefs, binge drinking, and difficulty accessing psychiatric specialists (ORs of 2.41, 1.95 and 1.73, respectively). Veterans with bipolar disorder experience numerous adherence barriers, with certain obstacles proving especially pernicious. Fortunately tailored clinical interventions can improve adherence, particularly by addressing modifiable risk factors.

Reliability and validity of diabetes specific Health Beliefs Model scales in patients with diabetes and serious mental illness

AIMS

In this study we evaluate the reliability and validity of existing Health Beliefs Model (HBM) scales developed to assess HBM domains in a population of patients with both diabetes and serious mental illness (SMI). While diabetes medication adherence has frequently been evaluated through the lens of the HBM, it is unclear if developed scales are reliable and valid in patients with SMI.

METHODS

We surveyed 152 veterans with diabetes and SMI. Domains of the HBM assessed included perceived benefits, side effects and barriers to diabetes medication taking, perceived susceptibility to and severity of diabetes, diabetes self-efficacy, diabetes locus of control, and perceived diabetes control.

RESULTS

HBM scales showed good internal reliability within a SMI population, with Cronbach alphas ranging between 0.73 and 0.86 for all scales assessed except one. HBM scales also showed associations with self reported diabetes medication adherences in six of the ten domains.

CONCLUSION

Scales assessing diabetes specific domains of the HBM exhibit both reliability and validity in patients with both diabetes and SMI.

High rates of psychosis for black inpatients in Padua and Montreal: different contexts, similar findings

OBJECTIVE

This study tested the hypothesis that despite differences in setting, specifically in Padua or Montreal, black psychiatric inpatients will have higher rates of assigned diagnosis of psychosis than their non-black counterparts.

METHODS

Data on psychotic patients admitted to the psychiatry ward were extracted from records of general hospitals in Padua and Montreal. Logistic regression analyses were conducted separately for each site to determine the relation between being black and receiving a diagnosis of psychosis, while controlling for sex and age.

RESULTS

Most black patients at both sites received a diagnosis of psychosis (76% in Padua and 81% in Montreal). Being black was independently and positively associated with being diagnosed with psychosis compared to patients from other groups.

CONCLUSIONS

Black patients admitted to psychiatry, whether in Padua or Montreal, were more likely to be assigned a diagnosis of psychosis than were other patients.

Ethnic origin and increased risk for schizophrenia in immigrants to countries of recent and longstanding immigration

OBJECTIVES

Compare the risk for schizophrenia in immigrants to countries of recent and longstanding immigration. Compare prevalence and incidence rates in black subjects under different conditions.

METHOD

An electronic literature search was complemented by review articles and cross-references. Studies reporting standard diagnosis and incidence or prevalence rates were included.

RESULTS

Immigrants had an increased risk for schizophrenia in countries of longstanding immigration, but with lower risk ratios than in those of recent immigration. The risk was higher in black immigrants and the black population living in the United States. But incidence and prevalence rates in Africa and the Caribbean were similar to those of international studies.

CONCLUSION

Comparing the most recent generation of immigrants with descendants of previous ones may account for the lower risk ratios observed in countries of longstanding vs. recent immigration. Two neurobiological hypotheses are proposed to explain the epidemiological findings in black populations and in immigrants.

Differences in prevalence and treatment of bipolar disorder among immigrants: results from an epidemiologic survey

OBJECTIVE

To add to the limited data on the prevalence, clinical characteristics, and treatment of bipolar disorder (BD) among immigrants.

METHOD

Data were obtained from a large epidemiologic survey, the Canadian Community Health Survey-Mental Health and Well-Being (CCHS 1.2). Lifetime prevalence rates of BD were compared between immigrant and nonimmigrant respondents. Among BD subjects (n = 831), sociodemographic, clinical, and mental health treatment use variables were compared based on immigrant status. Logistic regression was used to determine the correlates of lifetime contact with a mental health professional and 12-month psychotropic medication use.

RESULTS

Lifetime prevalence rate of CCHS 1.2-defined BD was significantly lower among immigrant, compared with nonimmigrant, participants (1.50% and 2.27%, P = 0.01). There were few sociodemographic or clinical differences, yet immigrants with BD were significantly less likely to report any lifetime contact with mental health professionals (OR = 0.25, 95% CI 0.13 to 0.50, P < 0.001). Past-year psychotropic medication use was numerically lower among immigrants with BD (24.5% and 41.0%); however, this did not reach statistical significance when controlling for other factors (OR = 0.49, 95% CI 0.24 to 1.01, P = 0.05).

CONCLUSIONS

Based on the results of this study, there are in the range of 56 000 to 104 000 immigrants with BD in Canada. Further efforts are needed to better understand and address the barriers to mental health treatment use among immigrants who have BD.

Longitudinal patterns of health system retention among veterans with schizophrenia or bipolar disorder

Inconsistent service use for schizophrenia and bipolar disorder is associated with poorer outcomes of care. We analyzed VHA National Psychosis Registry data for 164,150 veterans with these disorders to identify characteristics associated with 5-year patterns of survival and with retention in VHA care. Most cohort members (63%) survived the period with no break in VHA healthcare lasting over 12 months. Inconsistent utilization was associated with younger age, no service-connected disability, and less physical comorbidity, regardless of diagnosis. The influence of gender and ethnicity on attrition varied by diagnosis and gap-duration. Variation in attrition by gender and ethnicity warrants additional attention.

Quality of care for cardiovascular disease-related conditions in patients with and without mental disorders

OBJECTIVE

We compared the quality of care for cardiovascular disease (CVD)-related risk factors for patients diagnosed with and without mental disorders.

METHODS

We identified all patients included in the fiscal year 2005 (FY05) VA External Peer Review Program's (EPRP) national random sample of chart reviews for assessing quality of care for CVD-related conditions. Using the VA's National Psychosis Registry and the National Registry for Depression, we assessed whether patients had received diagnoses of serious mental illness (schizophrenia, bipolar disorder, or other psychoses) or depression during FY05. Using multivariable logistic regression and generalized estimating equation analyses, we assessed patient and facility factors associated with receipt of guideline concordant care for hypertension (total N = 24,016), hyperlipidemia (N = 46,430), and diabetes (N = 10,943).

RESULTS

Overall, 70% had good blood pressure control, 90% received a cholesterol (hyperlipidemia) screen, 77% received a retinal exam for diabetes, and 63% received recommended renal tests for diabetes. After adjustment, compared to patients without SMI or depression, patients with SMI were less likely to be assessed for CVD risk factors, notably hyperlipidemia (OR = 0.58; p < 0.001), and less likely to receive recommended follow-up assessments for diabetes: foot exam (OR = 0.68; p < 0.001), retinal exam (OR = 0.65; p < 0.001), or renal testing (OR = 0.64; p < 0.001). Patients with depression were also significantly less likely to receive adequate quality of care compared to non-psychiatric patients, although effects were smaller than those observed for patients with SMI.

CONCLUSIONS

Quality of care for major chronic conditions associated with premature CVD-related mortality is suboptimal for VA patients with SMI, especially for procedures requiring care by a specialist.