1
|
Foster AA, Hoffmann JA, Douglas MD, Monuteaux MC, Douglas KE, Benevides TW, Hudgins JD, Stewart AM. Comprehensiveness of State Insurance Laws and Perceived Access to Pediatric Mental Health Care. JAMA Netw Open 2024; 7:e2426402. [PMID: 39133489 PMCID: PMC11320173 DOI: 10.1001/jamanetworkopen.2024.26402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 06/10/2024] [Indexed: 08/13/2024] Open
Abstract
Importance Many US children and adolescents with mental and behavioral health (MBH) conditions do not access MBH services. One contributing factor is limited insurance coverage, which is influenced by state MBH insurance parity legislation. Objective To investigate the association of patient-level factors and the comprehensiveness of state MBH insurance legislation with perceived poor access to MBH care and perceived inadequate MBH insurance coverage for US children and adolescents. Design, Setting, and Participants This retrospective cross-sectional study was conducted using responses by caregivers of children and adolescents aged 6 to 17 years with MBH conditions in the National Survey of Children's Health and State Mental Health Insurance Laws Dataset from 2016 to 2019. Data analyses were conducted from May 2022 to January 2024. Exposure MBH insurance legislation comprehensiveness defined by State Mental Health Insurance Laws Dataset (SMHILD) scores (range, 0-7). Main Outcomes and Measures Perceived poor access to MBH care and perceived inadequacy of MBH insurance were assessed. Multivariable regression models adjusted for individual-level characteristics. Results There were 29 876 caregivers of children and adolescents with MBH conditions during the study period representing 14 292 300 youths nationally (7 816 727 aged 12-17 years [54.7%]; 8 455 171 male [59.2%]; 292 543 Asian [2.0%], 2 076 442 Black [14.5%], and 9 942 088 White [69.6%%]; 3 202 525 Hispanic [22.4%]). A total of 3193 caregivers representing 1 770 492 children and adolescents (12.4%) perceived poor access to MBH care, and 3517 caregivers representing 1 643 260 of 13 175 295 children and adolescents (12.5%) perceived inadequate MBH insurance coverage. In multivariable models, there were higher odds of perceived poor access to MBH care among caregivers of Black (adjusted odds ratio [aOR], 1.35; 95% CI, 1.04-1.75) and Asian (aOR, 1.69; 95% CI, 1.01-2.84) compared with White children and adolescents. As exposures to adverse childhood experiences (ACEs) increased, the odds of perceived poor access to MBH care increased (aORs ranged from 1.68; 95%, CI 1.32-2.13 for 1 ACE to 4.28; 95% CI, 3.17-5.77 for ≥4 ACEs compared with no ACEs). Compared with living in states with the least comprehensive MBH insurance legislation (SMHILD score, 0-2), living in states with the most comprehensive legislation (SMHILD score, 5-7) was associated with lower odds of perceived poor access to MBH care (aOR, 0.79; 95% CI, 0.63-0.99), while living in states with moderately comprehensive legislation (score, 4) was associated with higher odds of perceived inadequate MBH insurance coverage (aOR, 1.23; 95% CI, 1.01-1.49). Conclusions and Relevance In this study, living in states with the most comprehensive MBH insurance legislation was associated with lower odds of perceived poor access to MBH care among caregivers for children and adolescents with MBH conditions. This finding suggests that advocacy for comprehensive mental health parity legislation may promote improved child and adolescent access to MBH services.
Collapse
Affiliation(s)
- Ashley A. Foster
- Department of Emergency Medicine, University of California, San Francisco
| | - Jennifer A. Hoffmann
- Division of Emergency Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Megan D. Douglas
- Department of Community Health and Preventive Medicine, National Center for Primary Care, Morehouse School of Medicine, Atlanta, Georgia
| | - Michael C. Monuteaux
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Katherine E. Douglas
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Teal W. Benevides
- Institute of Public and Preventive Health, Augusta University, Augusta, Georgia
| | - Joel D. Hudgins
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Amanda M. Stewart
- Division of Emergency Medicine, Children’s National Hospital, Washington, District of Columbia
| |
Collapse
|
2
|
O'Brien MJ, Pauls AM, Cates AM, Larson PD, Zorn AN. Psychotropic Medication Use and Polypharmacy Among Children and Adolescents Initiating Intensive Behavioral Therapy for Severe Challenging Behavior. J Pediatr 2024; 271:114056. [PMID: 38615943 DOI: 10.1016/j.jpeds.2024.114056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 03/27/2024] [Accepted: 04/08/2024] [Indexed: 04/16/2024]
Abstract
OBJECTIVE To evaluate the prevalence, trends, and factors associated with psychotropic medication use and polypharmacy among children and adolescents initiating intensive behavioral therapy for severe challenging behavior over a 10-year period. STUDY DESIGN In this retrospective observational study, we examined data from caregiver interviews and patient medical records on the number and types of psychotropic medications prescribed to patients initiating intensive behavioral therapy between January 1, 2013, and December 31, 2022. Trends in medication use and polypharmacy across the 10-year period were analyzed using regression analysis, while differences in demographics and clinical factors for patients with use and polypharmacy were analyzed using nonparametric statistical analysis with odds ratios presented for significant factors. RESULTS Data from all 302 pediatric patients initiating intensive behavioral therapy across the 10-year period were analyzed. Among all patients and all years, 83.8% were taking at least 1 psychotropic medication and 68.2% experienced polypharmacy. There were no changes in the prevalence of use, mean number of medications taken, or polypharmacy across the 10-year period. Patients diagnosed with attention-deficit/hyperactivity disorder or anxiety disorder, as well as those exhibiting self-injurious behavior had higher use of psychotropic medication and polypharmacy and were taking more medications overall. CONCLUSIONS Psychotropic medication use and polypharmacy were extremely high for children and adolescents with severe challenging behavior, but use and polypharmacy did not change over the 10-year period of data collection. Further research is needed to establish the generality of these findings to other regions of the US.
Collapse
Affiliation(s)
- Matthew J O'Brien
- The University of Iowa, Iowa City, IA; The University of Iowa Stead Family Department of Pediatrics, Iowa City, IA.
| | | | | | - Priya D Larson
- The University of Iowa, Iowa City, IA; The University of Iowa Department of Child and Adolescent Psychiatry, Iowa City, IA
| | - Alithea N Zorn
- The University of Iowa, Iowa City, IA; Center for Public Health Statistics, Iowa City, IA; College of Public Health, Iowa City, IA
| |
Collapse
|
3
|
Kang S, Thiem KC, Huff NR, Dixon JS, Harvey EA. Black and White Adults' Racial and Gender Stereotypes of Psychopathology Symptoms in Black and White Children. Res Child Adolesc Psychopathol 2024; 52:1023-1036. [PMID: 38492192 DOI: 10.1007/s10802-024-01189-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2024] [Indexed: 03/18/2024]
Abstract
Adults' judgments of children's behaviors play a critical role in assessment and treatment of childhood psychopathology. Judgments of children's psychiatric symptoms are likely influenced by racial biases, but little is known about the specific racial biases adults hold about children's psychiatric symptoms, which could play a critical role in childhood mental health disparities. This study examined one form of such biases, racial stereotypes, to determine if White and Black adults hold implicit and explicit racial stereotypes about common childhood psychopathology symptoms, and if these stereotypes vary by child gender and disorder type. Participants included 82 self-identified Black men, 84 Black woman, 1 Black transgender individual, 1 Black genderfluid individual, 81 White men, and 85 White women. Analyses of implicit stereotypes revealed that White adults associated psychopathology symptoms more strongly with Black children than did Black adults (p < .001). All adults held stronger implicit racial stereotypes for oppositional defiant disorder, anxiety, and depression than for attention-deficit/hyperactivity disorder (p < .001). For explicit stereotypes, White adults generally associated psychopathology symptoms more with Black children than did Black adults but effects varied across child gender and disorder type. As the first study to examine racial and gender stereotypes across common childhood psychopathology symptoms, these findings point to a need for further investigation of the presence and impact of racial biases in the mental healthcare system for Black youth and to identify interventions to mitigate the impacts of racial biases to inform racial equity in mental healthcare in the United States.
Collapse
Affiliation(s)
- Sungha Kang
- Department of Psychology, Loyola University Chicago, 1032 W Sheridan Rd, Chicago, IL, USA.
| | - Kelsey C Thiem
- Department of Psychology, Nebraska Wesleyan University, 5000 Sait Paul Ave, Lincoln, NE, USA
| | - Nathan R Huff
- Psychological and Brain Sciences, University of Massachusetts Amherst, 135 Hicks Way, Amherst, MA, USA
| | - Jasmine S Dixon
- Department of Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Elizabeth A Harvey
- Psychological and Brain Sciences, University of Massachusetts Amherst, 135 Hicks Way, Amherst, MA, USA
| |
Collapse
|
4
|
Rast JE, Tao S, Schott W, Shea LL, Brodkin ES, Kerns CM, Leonard CE, Murray MJ, Lee BK. Psychotropic Medication Use in Children and Youth with Autism Enrolled in Medicaid. J Autism Dev Disord 2023:10.1007/s10803-023-06182-5. [PMID: 38113012 PMCID: PMC11228548 DOI: 10.1007/s10803-023-06182-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2023] [Indexed: 12/21/2023]
Abstract
Children with autism frequently present with complex mental health diagnoses and psychotropic medications are often a component of comprehensive biopsychosocial treatment plans for these conditions. The purpose of this study is to provide rates and patterns of psychotropic medication use, and predictors thereof, in children and youth with autism enrolled in Medicaid across the US. This study examined national Medicaid claims from 2008 to 2016 of all children and youth with autism ages 0-21 years enrolled in Medicaid. Psychotropic medication use was examined across several child and youth characteristics, including age, co-occurring mental health conditions, sex, and race and ethnicity. About half of children and youth with autism enrolled in Medicaid had at least one psychotropic prescription in a year, a number that decreased slightly across the study period due to decreases in the prescription of antipsychotics. As new medications for autism or co-occurring conditions are developed and deployed, and as the understanding of the characteristics of the population of children with autism evolves, studying rates of medication usage helps to understand utilization patterns and differences in access to quality care.
Collapse
Affiliation(s)
- Jessica E Rast
- A.J. Drexel Autism Institute, Drexel University, Philadelphia, PA, USA.
| | - Sha Tao
- A.J. Drexel Autism Institute, Drexel University, Philadelphia, PA, USA
| | - Whitney Schott
- A.J. Drexel Autism Institute, Drexel University, Philadelphia, PA, USA
| | - Lindsay L Shea
- A.J. Drexel Autism Institute, Drexel University, Philadelphia, PA, USA
| | - Edward S Brodkin
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Connor M Kerns
- Department of Psychology, University of British Columbia, Vancouver, BC, Canada
| | - Charles E Leonard
- Center for Real-World Effectiveness and Safety of Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael J Murray
- Department of Psychiatry, College of Medicine, Pennsylvania State University, Hershey, PA, USA
| | - Brian K Lee
- A.J. Drexel Autism Institute, Drexel University, Philadelphia, PA, USA
- Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, USA
| |
Collapse
|
5
|
Gardea-Resendez M, Ortiz-Orendain J, Miola A, Fuentes Salgado M, Ercis M, Coombes BJ, Gruhlke PM, Bostwick JM, Michel I, Vande Voort JL, Ozerdem A, McKean A, Frye MA, Taylor-Desir M. Racial differences in pathways to care preceding first episode mania or psychosis: a historical cohort prodromal study. Front Psychiatry 2023; 14:1241071. [PMID: 37732076 PMCID: PMC10507622 DOI: 10.3389/fpsyt.2023.1241071] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 08/16/2023] [Indexed: 09/22/2023] Open
Abstract
Background There is evidence suggesting racial disparities in diagnosis and treatment in bipolar disorder (BD) and schizophrenia (SZ). The purpose of this study is to compare psychiatric diagnoses and psychotropic use preceding a first episode of mania (FEM) or psychosis (FEP) in racially diverse patients. Methods Using a comprehensive medical records linkage system (Rochester Epidemiology Project, REP), we retrospectively identified individuals diagnosed with BD or SZ and a documented first episode of mania or psychosis. Illness trajectory before FEP/FEM were characterized as the time from first visit for a mental health complaint to incident case. Pathways to care and clinical events preceding FEP/FEM were compared based on subsequent incident case diagnosis (BD or SZ) and self-reported race (White vs. non-White). Results A total of 205 (FEM = 74; FEP = 131) incident cases were identified in the REP. Duration of psychiatric antecedents was significantly shorter in non-White patients, compared to White patients (2.2 ± 4.3 vs. 7.4 ± 6.6 years; p < 0.001) with an older age at time of first visit for a mental health complaint (15.7 ± 6.3 vs. 11.1 ± 6.0 years; p = 0.005). There were no significant differences by race in FEM pathway to care or age of first seeking mental health. Overall non-White patients had lower rates of psychotropic use. Conclusion These data are unable to ascertain reasons for shorter duration of psychiatric antecedents and later age of seeking care, and more broadly first age of initial symptom presentation. If symptoms are confirmed to be earlier than first time seeking care in both groups, it would be important to identify barriers that racial minorities face to access timely psychiatric care and optimize early intervention strategies.
Collapse
Affiliation(s)
- Manuel Gardea-Resendez
- Department of Psychiatry, Universidad Autónoma de Nuevo León, Monterrey, Mexico
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
| | - Javier Ortiz-Orendain
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
- Department of Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque, NM, United States
| | - Alessandro Miola
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
- Department of Neuroscience (DNS), University of Padova, Padua, Italy
| | | | - Mete Ercis
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
| | - Brandon J. Coombes
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, United States
| | - Peggy M. Gruhlke
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
| | - J. Michael Bostwick
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
| | - Ian Michel
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, MN, United States
| | | | - Aysegul Ozerdem
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
| | - Alastair McKean
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
| | - Mark A. Frye
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
| | - Monica Taylor-Desir
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
| |
Collapse
|
6
|
Hoffmann JA, Pulcini CD, Hall M, De Souza HG, Alpern ER, Chaudhary S, Ehrlich PF, Fein JA, Fleegler EW, Goyal MK, Hargarten S, Jeffries KN, Zima BT. Timing of Mental Health Service Use After a Pediatric Firearm Injury. Pediatrics 2023; 152:e2023061241. [PMID: 37271760 PMCID: PMC10694862 DOI: 10.1542/peds.2023-061241] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/10/2023] [Indexed: 06/06/2023] Open
Abstract
OBJECTIVES To examine how timing of the first outpatient mental health (MH) visit after a pediatric firearm injury varies by sociodemographic and clinical characteristics. METHODS We retrospectively studied children aged 5 to 17 years with a nonfatal firearm injury from 2010 to 2018 using the IBM Watson MarketScan Medicaid database. Logistic regression estimated the odds of MH service use in the 6 months after injury, adjusted for sociodemographic and clinical characteristics. Cox proportional hazard models, stratified by previous MH service use, evaluated variation in timing of the first outpatient MH visit by sociodemographic and clinical characteristics. RESULTS After a firearm injury, 958 of 2613 (36.7%) children used MH services within 6 months; of these, 378 of 958 (39.5%) had no previous MH service use. The adjusted odds of MH service use after injury were higher among children with previous MH service use (adjusted odds ratio, 10.41; 95% confidence interval [CI], 8.45-12.82) and among non-Hispanic white compared with non-Hispanic Black children (adjusted odds ratio, 1.29; 95% CI, 1.02-1.63). The first outpatient MH visit after injury occurred sooner among children with previous MH service use (adjusted hazard ratio, 6.32; 95% CI, 5.45-7.32). For children without previous MH service use, the first MH outpatient visit occurred sooner among children with an MH diagnosis made during the injury encounter (adjusted hazard ratio, 2.72; 95% CI, 2.04-3.65). CONCLUSIONS More than 3 in 5 children do not receive MH services after firearm injury. Previous engagement with MH services and new detection of MH diagnoses during firearm injury encounters may facilitate timelier connection to MH services after injury.
Collapse
Affiliation(s)
- Jennifer A. Hoffmann
- Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Christian D. Pulcini
- Department of Emergency Medicine & Pediatrics, University of Vermont Medical Center and Children’s Hospital, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Matt Hall
- Children’s Hospital Association, Lenexa, KS, USA
| | | | - Elizabeth R. Alpern
- Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sofia Chaudhary
- Department of Pediatrics and Emergency Medicine, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Peter F. Ehrlich
- Section of Pediatric Surgery, CS Mott Children’s Hospital University of Michigan Ann Arbor, Michigan, USA
| | - Joel A. Fein
- Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Eric W. Fleegler
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School; Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA, USA
| | - Monika K. Goyal
- Department of Pediatrics, Children’s National Hospital, George Washington University, Washington, DC, USA
| | - Stephen Hargarten
- Department of Emergency Medicine, Comprehensive Injury Center, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kristyn N. Jeffries
- Department of Pediatrics, Section of Hospital Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Bonnie T. Zima
- UCLA-Semel Institute for Neuroscience and Human Behavior, University of California at Los Angeles, Los Angeles, CA, USA
| |
Collapse
|
7
|
Bushnell G, Lloyd J, Olfson M, Cook S, Das H, Crystal S. Antipsychotic Medication Use In Medicaid-Insured Children Decreased Substantially Between 2008 And 2016. Health Aff (Millwood) 2023; 42:973-980. [PMID: 37406239 PMCID: PMC10845053 DOI: 10.1377/hlthaff.2022.01625] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
After the rapid growth of pediatric antipsychotic prescribing in the early 2000s, especially in the Medicaid population, concerns regarding the safety and appropriateness of such prescribing increased. Many states implemented policy and educational initiatives aimed at safer and more judicious antipsychotic use. Antipsychotic use leveled off in the late 2000s, but there have been no recent national estimates of trends in antipsychotic use in children enrolled in Medicaid, and it is unclear how use varied by race and ethnicity. This study observed a sizable decline in antipsychotic use among children ages 2-17 between 2008 and 2016. Although the magnitude of change varied, declines were observed across foster care status, age, sex, and racial and ethnic groups studied. The proportion of children with an antipsychotic prescription who received any diagnosis associated with a pediatric indication that was approved by the Food and Drug Administration increased from 38 percent in 2008 to 45 percent in 2016, which may indicate a trend toward more judicious prescribing.
Collapse
Affiliation(s)
- Greta Bushnell
- Greta Bushnell , Rutgers University, New Brunswick, New Jersey
| | | | - Mark Olfson
- Mark Olfson, Columbia University and New York State Psychiatric Institute, New York, New York
| | | | | | | |
Collapse
|
8
|
French A, Jones KA, Bush C, Greiner MA, Copeland JN, Davis NO, Franklin MS, Heilbron N, Maslow GR. Racial and Ethnic Differences in Psychotropic Prescription Receipt Among Pediatric Patients Enrolled in North Carolina Medicaid. Psychiatr Serv 2022; 73:1401-1404. [PMID: 36039550 DOI: 10.1176/appi.ps.202100473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The authors aimed to examine racial-ethnic differences in filled psychotropic prescriptions among a pediatric Medicaid population. METHODS This retrospective cohort study included patients ages 0-21 with at least one North Carolina Medicaid claim from October 1, 2017, through September 30, 2018 (N=983,886). The primary outcome was a filled psychotropic prescription. Separate multivariable modified Poisson regression models generated adjusted risk ratios (ARRs) and 95% confidence intervals (CIs), adjusted for patient demographic characteristics. RESULTS Black and Hispanic patients were significantly less likely to receive any filled psychotropic prescription (ARR=0.61, 95% CI=0.60-0.62; ARR=0.29, 95% CI=0.28-0.29, respectively) compared with White and non-Hispanic patients. Furthermore, Black and Hispanic patients were less likely to receive filled prescriptions in the four included drug classes compared with White and non-Hispanic patients. CONCLUSIONS Future studies should focus on understanding the factors contributing to racial and ethnic differences among pediatric patients receiving filled psychotropic prescriptions.
Collapse
Affiliation(s)
- Alexis French
- Department of Psychiatry and Behavioral Sciences (French, Copeland, Davis, Heilbron, Maslow), Department of Population Health Sciences (Jones, Greiner), and Department of Pediatrics (Maslow), Duke University School of Medicine, Durham, North Carolina; Aetion, New York City (Bush); Duke-Margolis Center for Health Policy, Durham, North Carolina (Franklin); Carolina Institute for Developmental Disabilities, University of North Carolina School of Medicine, Chapel Hill (Franklin)
| | - Kelley A Jones
- Department of Psychiatry and Behavioral Sciences (French, Copeland, Davis, Heilbron, Maslow), Department of Population Health Sciences (Jones, Greiner), and Department of Pediatrics (Maslow), Duke University School of Medicine, Durham, North Carolina; Aetion, New York City (Bush); Duke-Margolis Center for Health Policy, Durham, North Carolina (Franklin); Carolina Institute for Developmental Disabilities, University of North Carolina School of Medicine, Chapel Hill (Franklin)
| | - Christopher Bush
- Department of Psychiatry and Behavioral Sciences (French, Copeland, Davis, Heilbron, Maslow), Department of Population Health Sciences (Jones, Greiner), and Department of Pediatrics (Maslow), Duke University School of Medicine, Durham, North Carolina; Aetion, New York City (Bush); Duke-Margolis Center for Health Policy, Durham, North Carolina (Franklin); Carolina Institute for Developmental Disabilities, University of North Carolina School of Medicine, Chapel Hill (Franklin)
| | - Melissa A Greiner
- Department of Psychiatry and Behavioral Sciences (French, Copeland, Davis, Heilbron, Maslow), Department of Population Health Sciences (Jones, Greiner), and Department of Pediatrics (Maslow), Duke University School of Medicine, Durham, North Carolina; Aetion, New York City (Bush); Duke-Margolis Center for Health Policy, Durham, North Carolina (Franklin); Carolina Institute for Developmental Disabilities, University of North Carolina School of Medicine, Chapel Hill (Franklin)
| | - J Nathan Copeland
- Department of Psychiatry and Behavioral Sciences (French, Copeland, Davis, Heilbron, Maslow), Department of Population Health Sciences (Jones, Greiner), and Department of Pediatrics (Maslow), Duke University School of Medicine, Durham, North Carolina; Aetion, New York City (Bush); Duke-Margolis Center for Health Policy, Durham, North Carolina (Franklin); Carolina Institute for Developmental Disabilities, University of North Carolina School of Medicine, Chapel Hill (Franklin)
| | - Naomi O Davis
- Department of Psychiatry and Behavioral Sciences (French, Copeland, Davis, Heilbron, Maslow), Department of Population Health Sciences (Jones, Greiner), and Department of Pediatrics (Maslow), Duke University School of Medicine, Durham, North Carolina; Aetion, New York City (Bush); Duke-Margolis Center for Health Policy, Durham, North Carolina (Franklin); Carolina Institute for Developmental Disabilities, University of North Carolina School of Medicine, Chapel Hill (Franklin)
| | - Michelle S Franklin
- Department of Psychiatry and Behavioral Sciences (French, Copeland, Davis, Heilbron, Maslow), Department of Population Health Sciences (Jones, Greiner), and Department of Pediatrics (Maslow), Duke University School of Medicine, Durham, North Carolina; Aetion, New York City (Bush); Duke-Margolis Center for Health Policy, Durham, North Carolina (Franklin); Carolina Institute for Developmental Disabilities, University of North Carolina School of Medicine, Chapel Hill (Franklin)
| | - Nicole Heilbron
- Department of Psychiatry and Behavioral Sciences (French, Copeland, Davis, Heilbron, Maslow), Department of Population Health Sciences (Jones, Greiner), and Department of Pediatrics (Maslow), Duke University School of Medicine, Durham, North Carolina; Aetion, New York City (Bush); Duke-Margolis Center for Health Policy, Durham, North Carolina (Franklin); Carolina Institute for Developmental Disabilities, University of North Carolina School of Medicine, Chapel Hill (Franklin)
| | - Gary R Maslow
- Department of Psychiatry and Behavioral Sciences (French, Copeland, Davis, Heilbron, Maslow), Department of Population Health Sciences (Jones, Greiner), and Department of Pediatrics (Maslow), Duke University School of Medicine, Durham, North Carolina; Aetion, New York City (Bush); Duke-Margolis Center for Health Policy, Durham, North Carolina (Franklin); Carolina Institute for Developmental Disabilities, University of North Carolina School of Medicine, Chapel Hill (Franklin)
| |
Collapse
|
9
|
Hoffmann JA, Alegría M, Alvarez K, Anosike A, Shah PP, Simon KM, Lee LK. Disparities in Pediatric Mental and Behavioral Health Conditions. Pediatrics 2022; 150:e2022058227. [PMID: 36106466 PMCID: PMC9800023 DOI: 10.1542/peds.2022-058227] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/12/2022] [Indexed: 12/31/2022] Open
Abstract
Mental and behavioral health conditions are common among children and adolescents in the United States. The purpose of this state-of the-art review article is to describe inequities in mental and behavioral health care access and outcomes for children and adolescents, characterize mechanisms behind the inequities, and discuss strategies to decrease them. Understanding the mechanisms underlying these inequities is essential to inform strategies to mitigate these health disparities. Half of United States children with a treatable mental health disorder do not receive treatment from a mental health professional. Children and adolescents in racial, ethnic, sexual, sex, and other minority groups experience inequities in access to care and disparities in outcomes for mental and behavioral health conditions. Suicide rates are nearly twice as high in Black compared to White boys 5 to 11 years old and have been increasing disproportionately among adolescent Black girls 12 to 17 years old. Children identifying as a sexual minority have >3 times increased odds of attempting suicide compared to heterosexual peers. Adverse experiences of children living as part of a minority group, including racism and discrimination, have immediate and lasting effects on mental health. Poverty and an uneven geographic distribution of resources also contribute to inequities in access and disparities in outcomes for mental and behavioral health conditions. Strategies to address inequities in mental and behavioral health among United States children include investing in a diverse workforce of mental health professionals, improving access to school-based services, ensuring equitable access to telehealth, and conducting quality improvement with rigorous attention to equity.
Collapse
Affiliation(s)
- Jennifer A. Hoffmann
- . Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine; Chicago, IL
| | - Margarita Alegría
- . Disparities Research Unit, Massachusetts General Hospital, Boston, MA; Department of Medicine, Harvard Medical School, Boston, MA; Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Kiara Alvarez
- . Disparities Research Unit, Massachusetts General Hospital, Department of Medicine, Harvard Medical School, Boston, MA
| | - Amara Anosike
- . Office of Government Relations, Boston Children’s Hospital, Boston, MA
| | | | - Kevin M. Simon
- . Adolescent Substance use and Addiction Program, Boston Children’s Hospital, Boston, Massachusetts; Division of Developmental Medicine, Boston Children’s Hospital, Boston, Massachusetts; Department of Psychiatry and Behavioral Sciences, Boston Children’s Hospital, Boston, MA, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Lois K. Lee
- . Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA
| |
Collapse
|
10
|
Bilsky S, Blumenthal H, Ramadan B, Lewis S, Leen-Feldner EW. Pediatric Psychotropic Polypharmacy: An Evaluation of the Correlates and Prevalence Across Assessment Cycles in the National Health and Nutrition Examination Survey. J Child Adolesc Psychopharmacol 2022; 32:416-425. [PMID: 36074100 PMCID: PMC9639228 DOI: 10.1089/cap.2022.0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: Pediatric psychotropic polypharmacy (PPP) is the prescription of more than one medication targeting psychiatric disorders among people younger than 18 years. Recent data suggested that PPP rates may be plateauing. Few studies have evaluated this question in large, nationally recruited samples. Objective: The National Health and Nutrition Examination Survey was used to examine the correlates and prevalence of PPP across assessment cycles. Independent assessments were obtained biannually between 2013 and 2018. Methods: Eleven thousand four hundred thirty-nine participants (4-17 years; Mage = 8.69 years; standard deviation = 5.16) were included in analyses. The Anatomic Therapeutic Chemical coding scheme was employed to classify medications, and participants were characterized as taking psychotropic medication if the medication was associated with a psychiatric diagnosis code. Participants self-reported past month medication use. Logistic regressions were used to examine correlates of pediatric psychotropic monotherapy compared with psychotropic polypharmacy. Results: Across assessments, 1.2% of respondents reported using two or more psychotropic medications. This estimate is lower than has been observed in specialized samples, but higher than other work using national samples. There was a small, significant difference in PPP across assessment cycles, such that rates of PPP were higher at the latter assessments. Correlates of PPP accorded with prior work, including male gender, increasing age, and markers of low socioeconomic status. The most robust predictor was having seen a mental health professional in the past year. Conclusions: This study documents that ∼1% of U.S. participants from a nationally recruited sample endorsed PPP. Findings are situated in the broader literature and the need for additional, prospective data to better characterize those trends in the United States and around the world. Key Takeaway Points It is known that many children and adolescents in the United States take more than one psychotropic medication, although few studies have examined trends in large, nationally recruited datasets. This study adds to this literature by documenting the prevalence of pediatric psychotropic polypharmacy in a large, unselected sample (i.e., 1.2%) and shows that rates were slightly higher at subsequent assessment intervals. Plain Language Summary Many kids take more than one medication for psychological problems. We analyzed data from ∼11,000 children and adolescents from across the United States, evaluated between 2013 and 2018. The number of kids taking multiple medications for psychological problems was different (higher) when measured later in time. Being a boy, being older, living in poverty, and having seen a mental health professional in the past year were associated with taking multiple medications for psychological problems. Implications for Managed Care Pharmacy These findings suggest rates of pediatric psychotropic polypharmacy (PPP) remain high in the United States, and correlate with male gender, poverty, and having recently seen a mental health professional. Relative to White children and adolescents, Black participants were less likely and Hispanic participants more likely to endorse PPP. Policy considerations include fully educating families and practitioners about the benefits as well as potential downsides of PPP and additional intervention options for mental health problems.
Collapse
Affiliation(s)
- Sarah Bilsky
- Department of Psychology, University of Mississippi, University Park, Mississippi, USA
| | | | - Banan Ramadan
- Department of Psychology, University of North Texas, Denton, Texas, USA
| | - Sarah Lewis
- Center for Research, Assessment, and Treatment Efficacy (CReATE), Asheville, North Carolina, USA
| | - Ellen W. Leen-Feldner
- Department of Psychological Science, University of Arkansas, Fayetteville, Arkansas, USA
| |
Collapse
|
11
|
Rodgers CRR, Flores MW, Bassey O, Augenblick JM, Cook BL. Racial/Ethnic Disparity Trends in Children's Mental Health Care Access and Expenditures From 2010-2017: Disparities Remain Despite Sweeping Policy Reform. J Am Acad Child Adolesc Psychiatry 2022; 61:915-925. [PMID: 34627995 PMCID: PMC8986880 DOI: 10.1016/j.jaac.2021.09.420] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 09/08/2021] [Accepted: 09/30/2021] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To examine trends in mental health care use for Black and Latinx children and adolescents. METHOD Data from the Medical Expenditure Panel Survey for 2010-2017 were analyzed to assess trends among youth ages 5-17 in use and expenditures for any mental health care, outpatient mental health care, and psychotropic medication prescription fills. Unadjusted trends for all youth and the subpopulation of youth reporting need for mental health care and disparities adjusting for need were examined. RESULTS Between 2010 and 2017, Black youth rates of any past year mental health care use decreased (from 9% to 8%), while White (from 13% to 15%) and Latinx (from 6% to 8%) youth rates increased. Among the subpopulation with need and in regression analysis adjusting for need, we identified significant Black-White and Latinx-White disparities in any mental health care use and any outpatient mental health care use in 2010-2011 and 2016-2017, with significant worsening of Black-White disparities over time. White youth were more than twice as likely as Latinx youth to use psychotropic medications, and Latinx-White and Black-White disparities in psychotropic medication prescription fills persisted over time. Black-White disparities existed in overall mental health expenditures (2016-2017) and outpatient mental health expenditures (2010-2011 and 2016-2017). CONCLUSION Affordable, ubiquitous access to mental health care for Black and Latinx youth remains an elusive target. Significant disparities exist in receiving mental health care despite reforms and policies designed to increase mental health care access in the general population. Additional outreach and treatment strategies tailored to the cultural, linguistic, and structural needs of youth of color are required.
Collapse
Affiliation(s)
| | - Michael William Flores
- Harvard Medical School, Boston, Massachusetts; Health Equity Research Laboratory, Cambridge Health Alliance, Cambridge, Massachusetts
| | | | | | - Benjamin Lê Cook
- Albert Einstein College of Medicine, Bronx, New York; Harvard Medical School, Boston, Massachusetts; Health Equity Research Laboratory, Cambridge Health Alliance, Cambridge, Massachusetts
| |
Collapse
|
12
|
Bomberg EM, Palzer EF, Rudser KD, Kelly AS, Bramante CT, Seligman HK, Noni F, Fox CK. Anti-obesity medication prescriptions by race/ethnicity and use of an interpreter in a pediatric weight management clinic. Ther Adv Endocrinol Metab 2022; 13:20420188221090009. [PMID: 35432917 PMCID: PMC9005816 DOI: 10.1177/20420188221090009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 03/04/2022] [Indexed: 11/15/2022] Open
Abstract
Background Race/ethnicity and low English proficiency healthcare disparities are well established in the United States. We sought to determine if there are race/ethnicity differences in anti-obesity medication (AOM) prescription rates among youth with severe obesity treated in a pediatric weight management clinic and if, among youth from non-primary English speaking families, there are differences in prescriptions between those using interpreters during visits versus not. Methods We reviewed electronic health records of 2- to 18-year-olds with severe obesity seen from 2012 to 2021. Race/ethnicity was self-report, and AOMs included topiramate, stimulants (e.g. phentermine, lisdexamfetamine), naltrexone (±bupropion), glucagon-like peptide-1 agonists, and orlistat. We used general linear regression models with log-link to compare incidence rate ratios (IRRs) within the first 1 and 3 years of being followed, controlling for age, percent of the 95th BMI percentile (%BMIp95), number of obesity-related comorbidities (e.g. insulin resistance, hypertension), median household income, and interpreter use. We repeated similar analyses among youth from non-primary English speaking families, comparing those using interpreters versus not. Results 1,725 youth (mean age 11.5 years; %BMIp95 142%; 53% non-Hispanic White, 20% Hispanic/Latino, 16% non-Hispanic black; 6% used interpreters) were seen, of which 15% were prescribed AOMs within 1 year. The IRR for prescriptions was lower among Hispanic/Latino compared to non-Hispanic White youth at one (IRR 0.70; CI: 0.49-1.00; p = 0.047) but not 3 years. No other statistically significant differences by race/ethnicity were found. Among non-primary English speaking families, the IRR for prescriptions was higher at 1 year (IRR 2.49; CI: 1.32-4.70; p = 0.005) in those using interpreters versus not. Conclusions Among youth seen in a pediatric weight management clinic, AOM prescription incidence rates were lower in Hispanics/Latinos compared to non-Hispanic Whites. Interpreter use was associated with higher prescription incidence rates among non-primary English speakers. Interventions to achieve equity in AOM prescriptions may help mitigate disparities in pediatric obesity.
Collapse
Affiliation(s)
- Eric M. Bomberg
- Center for Pediatric Obesity Medicine, Department of Pediatrics, Medical School, University of Minnesota, 717 Delaware Street SE, Room 370, Minneapolis, MN 55414, USA
- Department of Pediatrics, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Elise F. Palzer
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Kyle D. Rudser
- Center for Pediatric Obesity Medicine, Department of Pediatrics, Medical School, University of Minnesota, Minneapolis, MN, USA
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Aaron S. Kelly
- Center for Pediatric Obesity Medicine, Department of Pediatrics, Medical School, University of Minnesota, Minneapolis, MN, USA
- Department of Pediatrics, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Carolyn T. Bramante
- Center for Pediatric Obesity Medicine, Department of Pediatrics, Medical School, University of Minnesota, Minneapolis, MN, USA
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Hilary K. Seligman
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Favour Noni
- University of Minnesota, Minneapolis, MN, USA
| | - Claudia K. Fox
- Center for Pediatric Obesity Medicine, Department of Pediatrics, Medical School, University of Minnesota, Minneapolis, MN, USA
- Department of Pediatrics, Medical School, University of Minnesota, Minneapolis, MN, USA
| |
Collapse
|
13
|
Gannon S, Abdelrazek A, Keller K, Rockhill C, Kim SJ. Psychotropic Medication Prescribing for Youth at a Regional Autism Center. J Child Adolesc Psychopharmacol 2021; 31:653-658. [PMID: 34242065 DOI: 10.1089/cap.2021.0017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objectives: The Seattle Children's Autism Center (SCAC) serves youth throughout Washington state (WA). The authors examined (1) whether the ethnicity and race of patients seen at the SCAC aligned with the demographics reported in the WA census, and (2) whether psychotropic medication prescriptions were associated with patient factors, including age, sex, ethnicity, race, insurance, visit number, and diagnoses. Methods: The authors extracted demographic and prescription data from electronic medical records for all patients (3-21 years) seen at the SCAC in 2018 for psychiatric medication evaluation in the context of autism spectrum disorder (ASD) and/or other related neurodevelopmental disorder (n = 1112), and used binary logistic regression to ascertain the effects of patient factors on psychotropic prescriptions. Results: The SCAC study sample appeared to align well with the WA census. Older age and higher visit number were among the most significant factors associated with psychotropic prescriptions. Psychotropic prescriptions increased with age, across all categories, except attention-deficit/hyperactivity disorder medications. There were no sex differences in prescribing rates. There were differences in prescribing rates by ethnicity and race. There were also increased prescription rates among those with Medicaid insurance. Conclusion: These demographic differences in prescribing for youth with ASD provide more specificity than prior studies about sex, ethnic, racial, and insurance-related differences, and can serve as an impetus to examine the reasons for variance.
Collapse
Affiliation(s)
- Shivaun Gannon
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA.,Seattle Children's Autism Center and Seattle Children's Hospital, Seattle, Washington, USA.,Department of Psychiatry, Seattle Children's Hospital, Seattle, Washington, USA
| | - Ahmed Abdelrazek
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Kylie Keller
- Seattle Children's Autism Center and Seattle Children's Hospital, Seattle, Washington, USA
| | - Carol Rockhill
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA.,Department of Psychiatry, Seattle Children's Hospital, Seattle, Washington, USA
| | | |
Collapse
|
14
|
Lu DH, Dopheide JA, Wang D, Jeffrey JK, Chen S. Collaboration Between Child and Adolescent Psychiatrists and Mental Health Pharmacists to Improve Treatment Outcomes. Child Adolesc Psychiatr Clin N Am 2021; 30:797-808. [PMID: 34538449 DOI: 10.1016/j.chc.2021.06.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Access to mental health care is a long-standing challenge. The high, rising prevalence of mental health disorders and a shortage of mental health professionals has further strained an already fragile system. The clinical pharmacy is underutilized within the mental health space. Interdisciplinary collaboration between child psychiatrists and mental health pharmacists gives the psychiatrist more time for patient evaluation and treatment, while the psychiatric pharmacist provides drug monitoring, medication coordination, and education for providers. This collaborative approach improves outcomes, prevents adverse drug events, reduces hospital stays, lessens emergency department visits, and improves engagement and adherence.
Collapse
Affiliation(s)
- Debbie H Lu
- Touro University California, College of Pharmacy, 1310 Club Drive, Vallejo, CA 94592, USA.
| | - Julie A Dopheide
- Psychiatry and the Behavioral Sciences, University of Southern California School of Pharmacy and Keck School of Medicine, 1985 Zonal Avenue, Los Angeles, CA 90089, USA
| | - Dri Wang
- Otsuka Pharmaceutical Development and Comercialization, 508 Carnegie Center Drive, Princeton, New Jersey 08540, USA
| | - Jessica K Jeffrey
- Division of Population Behavioral Health; Division of Child and Adolescent Psychiatry; UCLA Behavioral Health Associates; UCLA Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute of Neuroscience and Human Behavior, 760 Westwood Plaza, A7-372A, Los Angeles, CA 90024, USA
| | - Steven Chen
- Department of Clinical Pharmacy, University of Southern California School of Pharmacy, Los Angeles, CA 90089, USA
| |
Collapse
|
15
|
Agarwal S, Crespo-Ramos G, Long JA, Miller VA. "I Didn't Really Have a Choice": Qualitative Analysis of Racial-Ethnic Disparities in Diabetes Technology Use Among Young Adults with Type 1 Diabetes. Diabetes Technol Ther 2021; 23:616-622. [PMID: 33761284 PMCID: PMC8501459 DOI: 10.1089/dia.2021.0075] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background: Racial-ethnic disparities in diabetes technology use are well documented in young adults (YA) with type 1 diabetes (T1D), but modifiable targets for intervention still need to be identified. Our objective was to explore YA perspectives on technology access and support in routine clinical care. Materials and Methods: Participants were YA with T1D of Hispanic or non-Hispanic Black race-ethnicity from pediatric and adult endocrinology clinics in the Bronx, NY. We conducted semistructured individual interviews to explore how health care and personal experiences affected technology use. Interviews were audio-recorded and transcribed for analysis. We used a modified inductive coding approach with two independent coders and iterative coding processes to improve data reliability and validity. Results: We interviewed 40 YA with T1D: mean age 22 years; 62% female; 72% Medicaid insured; 72% Hispanic; 28% non-Hispanic Black; and mean hemoglobin A1C 10.3%. Themes were categorized into potentially exacerbating and alleviating factors of racial-ethnic disparities in technology use. Exacerbating factors included perceptions that providers were gatekeepers of information and prescription access to technology, providers did not employ shared decision making for use, and YA biases against technology were left unaddressed. Alleviating factors included provider optimism and tailoring of technology benefits to YA needs, and adequate Medicaid insurance coverage. Conclusions: Our results reveal potential intervention targets at the provider level to increase technology uptake among underrepresented YA with T1D. Diabetes health care providers need to be aware of inadvertent withholding of information and prescription access to technology. Provider approaches that address YA technology concerns and promote shared decision making help to mitigate racial/ethnic disparities in technology use.
Collapse
Affiliation(s)
- Shivani Agarwal
- Fleischer Institute for Diabetes and Metabolism, Montefiore Medical Center, Bronx, New York, USA
- NY-Regional Center for Diabetes Translation Research, Albert Einstein College of Medicine, Bronx, New York, USA
- Address correspondence to: Shivani Agarwal, MD, MPH, Fleischer Institute for Diabetes and Metabolism, Albert Einstein College of Medicine, 1180 Morris Park Avenue, Bronx, NY 10461, USA
| | - Gladys Crespo-Ramos
- Fleischer Institute for Diabetes and Metabolism, Montefiore Medical Center, Bronx, New York, USA
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, New York, USA
| | - Judith A. Long
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Victoria A. Miller
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| |
Collapse
|
16
|
Abstract
Ethnic differences may significantly influence the outcome of psychopharmacological treatment, in terms of prescription, adherence, clinical response, emergence of side effects, as well as pharmacokinetics and pharmacodynamics. The purpose of this review was to explore the available literature in order to provide general suggestions to help clinicians in choosing the best therapeutic option for patients, taking into account ethnicity. Although findings are sometimes controversial, the overall published studies suggest that ethnicities other than Caucasians tend to show a lower response to antidepressants and a reduced compliance. Africans tend to be more prescribed with antipsychotics, probably due to cultural stereotypes, except with clozapine, probably for their chronic benign neutropenia. Asians usually require less antipsychotic dosages than Caucasians. The differential response and side effect profile of antidepressants and antipsychotics have been related to individual intrinsic factors, to genetic make-up, but also to cultural and contextual variables. Interestingly, albeit limited data suggest ethnic-related genetic heterogeneity at the level of the serotonin transporters, the cytochromes and some neuroreceptors. Taken together, no conclusive findings are available about the role and impact of ethnicity in psychopharmacology. One of the main problems is that the majority of the studies in psychopharmacology have been conducted on Caucasians, so that there is an urgent need to have data in other populations. Furthermore, in the era of precision medicine, the role of ethnicity may be also supported by genetic analysis.
Collapse
|
17
|
Agarwal S, Schechter C, Gonzalez J, Long JA. Racial-Ethnic Disparities in Diabetes Technology use Among Young Adults with Type 1 Diabetes. Diabetes Technol Ther 2021; 23:306-313. [PMID: 33155826 PMCID: PMC7994432 DOI: 10.1089/dia.2020.0338] [Citation(s) in RCA: 92] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background: Recent studies highlight racial-ethnic disparities in insulin pump and continuous glucose monitor (CGM) use in people with type 1 diabetes (T1D), but drivers of disparities remain poorly understood beyond socioeconomic status (SES). Methods: We recruited a diverse sample of young adults (YA) with T1D from six diabetes centers across the United States, enrolling equal numbers of non-Hispanic (NH) White, NH Black, and Hispanic YA. We used multivariate logistic regression to examine to what extent SES, demographics, health care factors (care setting, clinic attendance), and diabetes self-management (diabetes numeracy, self-monitoring of blood glucose, and Self-Care Inventory score) explained insulin pump and CGM use in each racial-ethnic group. Results: We recruited 300 YA with T1D, aged 18-28 years. Fifty-two percent were publicly insured, and the mean hemoglobin A1c was 9.5%. Large racial-ethnic disparities in insulin pump and CGM use existed: 72% and 71% for NH White, 40% and 37% for Hispanic, and 18% and 28% for NH Black, respectively. After multiple adjustment, insulin pump and CGM use remained disparate: 61% and 53% for NH White, 49% and 58% for Hispanic, and 20 and 31% for NH Black, respectively. Conclusions: Insulin pump and CGM use was the lowest in NH Black, intermediate in Hispanic, and highest in NH White YA with T1D. SES was not the sole driver of disparities nor did additional demographic, health care, or diabetes-specific factors fully explain disparities, especially between NH Black and White YA. Future work should examine how minority YA preferences, provider implicit bias, systemic racism, and mistrust of medical systems help to explain disparities in diabetes technology use.
Collapse
Affiliation(s)
- Shivani Agarwal
- Fleischer Institute of Diabetes and Metabolism, New York-Regional Center for Diabetes Translation Research, Division of Endocrinology, Albert Einstein College of Medicine, Bronx, New York, USA
- Address correspondence to: Shivani Agarwal MD, MPH, Albert Einstein College of Medicine, 1180 Morris Park Avenue, Bronx, NY 10461, USA
| | - Clyde Schechter
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jeffrey Gonzalez
- Fleischer Institute of Diabetes and Metabolism, New York-Regional Center for Diabetes Translation Research, Division of Endocrinology, Albert Einstein College of Medicine, Bronx, New York, USA
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, New York, USA
| | - Judith A. Long
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| |
Collapse
|
18
|
Kenney-Riley K, Berkowitz SS, Rapoza K. Understanding patient-provider discordance in adolescents with lupus: The role of pain and antidepressant medication use. Health Psychol Open 2020; 7:2055102920977714. [PMID: 33343916 PMCID: PMC7727063 DOI: 10.1177/2055102920977714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The current study examines depression and pain as potential contributors to patient-provider discordance in the assessment of lupus disease activity. The study conducted a secondary analysis of data obtained from the Childhood Arthritis and Rheumatology Research Alliance registry, with N = 859 adolescent participants. Assessments of pain, disease activity, and antidepressant medication use were collected from the patient and provider. Results indicated that depression might be underdiagnosed in pediatric lupus patients. While psychotropic medication and pain scores were independently related to greater patient-provider discordance regarding health status, pain mediated this relationship. Implications for treatment outcomes are discussed.
Collapse
|
19
|
Agarwal S, Kanapka LG, Raymond JK, Walker A, Gerard-Gonzalez A, Kruger D, Redondo MJ, Rickels MR, Shah VN, Butler A, Gonzalez J, Verdejo AS, Gal RL, Willi S, Long JA. Racial-Ethnic Inequity in Young Adults With Type 1 Diabetes. J Clin Endocrinol Metab 2020; 105:dgaa236. [PMID: 32382736 PMCID: PMC7457963 DOI: 10.1210/clinem/dgaa236] [Citation(s) in RCA: 107] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 05/05/2020] [Indexed: 12/13/2022]
Abstract
CONTEXT Minority young adults (YA) currently represent the largest growing population with type 1 diabetes (T1D) and experience very poor outcomes. Modifiable drivers of disparities need to be identified, but are not well-studied. OBJECTIVE To describe racial-ethnic disparities among YA with T1D and identify drivers of glycemic disparity other than socioeconomic status (SES). DESIGN Cross-sectional multicenter collection of patient and chart-reported variables, including SES, social determinants of health, and diabetes-specific factors, with comparison between non-Hispanic White, non-Hispanic Black, and Hispanic YA and multilevel modeling to identify variables that account for glycemic disparity apart from SES. SETTING Six diabetes centers across the United States. PARTICIPANTS A total of 300 YA with T1D (18-28 years: 33% non-Hispanic White, 32% non-Hispanic Black, and 34% Hispanic). MAIN OUTCOME Racial-ethnic disparity in HbA1c levels. RESULTS Non-Hispanic Black and Hispanic YA had lower SES, higher HbA1c levels, and much lower diabetes technology use than non-Hispanic White YA (P < 0.001). Non-Hispanic Black YA differed from Hispanic, reporting higher diabetes distress and lower self-management (P < 0.001). After accounting for SES, differences in HbA1c levels disappeared between non-Hispanic White and Hispanic YA, whereas they remained for non-Hispanic Black YA (+ 2.26% [24 mmol/mol], P < 0.001). Diabetes technology use, diabetes distress, and disease self-management accounted for a significant portion of the remaining non-Hispanic Black-White glycemic disparity. CONCLUSION This study demonstrated large racial-ethnic inequity in YA with T1D, especially among non-Hispanic Black participants. Our findings reveal key opportunities for clinicians to potentially mitigate glycemic disparity in minority YA by promoting diabetes technology use, connecting with social programs, and tailoring support for disease self-management and diabetes distress to account for social contextual factors.
Collapse
Affiliation(s)
- Shivani Agarwal
- Fleischer Institute for Diabetes and Metabolism, New York-Regional Center for Diabetes Translational Research, Division of Endocrinology, Albert Einstein College of Medicine, Bronx, NY
| | | | | | | | - Andrea Gerard-Gonzalez
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO
| | | | - Maria J Redondo
- Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
| | - Michael R Rickels
- Institute for Diabetes, Obesity & Metabolism, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Viral N Shah
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Ashley Butler
- Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
| | - Jeffrey Gonzalez
- Fleischer Institute for Diabetes and Metabolism, New York-Regional Center for Diabetes Translational Research, Division of Endocrinology, Albert Einstein College of Medicine, Bronx, NY
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY
| | | | | | - Steven Willi
- Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Judith A Long
- Institute for Diabetes, Obesity & Metabolism, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| |
Collapse
|
20
|
Fernandes CSE, Lima MG, Barros MBDA. Emotional problems and the use of psychotropic drugs: investigating racial inequality. CIENCIA & SAUDE COLETIVA 2020; 25:1677-1688. [PMID: 32402020 DOI: 10.1590/1413-81232020255.33362019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 08/07/2019] [Indexed: 01/08/2023] Open
Abstract
The aim of the present study was to investigate the existence of racial inequalities in the prevalence of emotional problems, the search for healthcare services and the use of psychotropic drugs. A population-based, cross-sectional study was conducted with data from the 2014/15 Campinas Health Survey. Sample of 1953 individuals aged 20 years or older was analyzed. We estimated the prevalence of common mental disorders (CMDs), the reporting of emotional problems, insomnia, the search for and the use of healthcare services and the use of psychotropic drugs according to self-reported skin color (white and black/brown). Prevalence ratios were estimated using "Poisson" multiple regression. The prevalence of CMDs was higher among blacks/brown compared to whites but no difference was found regarding the reporting of emotional problems and insomnia. Whites sought healthcare services more due to emotional problems. The use of psychotropic drugs was also higher among whites. The results revealed racial inequalities in the presence of CMDs, the search for healthcare services and the use of psychotropics drugs, highlighting the need for actions to identify and overcome barriers that hinder access to mental health care by different racial segments of the population.
Collapse
Affiliation(s)
| | - Margareth Guimarães Lima
- Departamento de Saúde Coletiva, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, SP, Brazil,
| | | |
Collapse
|
21
|
Samsel C, Tapsak S, Thomson K, McKenna K, McGregor K, Forbes P, Ibeziako P. Psychotropic medication use trends in a large pediatric and young adult solid organ transplant population. Pediatr Transplant 2019; 23:e13380. [PMID: 30786113 DOI: 10.1111/petr.13380] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 01/08/2019] [Accepted: 01/18/2019] [Indexed: 01/30/2023]
Abstract
INTRODUCTION This study describes psychotropic medication use in a pediatric and young adult solid organ transplant population. METHODS We conducted a retrospective review of the lifetime incidence of psychotropic medication use and associated characteristics in patients seen over a 6-year period at a large pediatric transplant center utilizing univariate and multivariate statistical analyses. RESULTS The lifetime incidence of psychotropic medication use was 36.5% in 393 patients. Transplant psychiatry provided psychopharmacological consultation to 21.9% of patients. Controlling for age and sex, there were significant associations between psychotropic use and thoracic organ disease (heart/lung) (AOR = 2.14; 95% CI: 1.2-3.8; P = 0.01), White race (P = 0.0002), histories of depressive/mood disorders (AOR = 3.68; 95% CI: 1.8-7.7; P = 0.0005), attention/learning disorders (AOR = 3.30; 95% CI: 1.6-6.9; P = 0.001), acute and post-traumatic stress disorders (AOR = 10.54; 95% CI: 2.6-42.8; P = 0.001), and experiencing bullying (AOR = 2.16; 95% CI: 1.03-4.55; P = 0.04). In unadjusted tests, significant associations were found between lifetime psychotropic usage and patient anxiety history (OR = 2.26; 95% CI: 1.5-3.5; P = 0.0002), end-of-life disease progression (OR = 3.04; 95% CI: 1.7-5.4; P = 0.0002), family psychiatric history (OR = 2.17; 95% CI: 1.4-3.4; P = 0.0007), and adherence concerns (OR = 2.67; 95% CI: 1.7-4.1; P < 0.0001). DISCUSSION The lifetime incidence of psychotropic medication use among pediatric and young adult transplant patients is substantial. Patients with thoracic organ disease, end-of-life illness, individual/family psychiatric histories, trauma, and bullying histories have particularly high rates. Integrating child psychiatry as part of pediatric transplant teams should be an important consideration for the care of these patients.
Collapse
Affiliation(s)
- Chase Samsel
- Boston Children's Hospital Department of Psychiatry, Boston, Massachusetts.,Boston Children's Hospital Pediatric Transplant Center, Boston, Massachusetts.,Dana-Farber Cancer Institute Department of Psychosocial Oncology and Palliative Care, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Sara Tapsak
- Boston Children's Hospital Department of Psychiatry, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Katharine Thomson
- Boston Children's Hospital Department of Psychiatry, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Kristine McKenna
- Boston Children's Hospital Department of Psychiatry, Boston, Massachusetts.,Boston Children's Hospital Pediatric Transplant Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Kerry McGregor
- Boston Children's Hospital Department of Psychiatry, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Peter Forbes
- Boston Children's Hospital Clinical and Translational Research Program, Boston, Massachusetts
| | - Patricia Ibeziako
- Boston Children's Hospital Department of Psychiatry, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| |
Collapse
|