Depression treatment preferences by race/ethnicity and gender and associations between past healthcare discrimination experiences and present preferences in a nationally representative sample

Discrete Choice Experiments to Elicit Patient Preferences for the Treatment of Major Depressive Disorder: A Systematic Review

BACKGROUND

Individual preferences for treatment options for major depressive disorder can impact therapeutic decision making, adherence, and ultimately outcomes.

OBJECTIVES

This systematic review of discrete choice experiments (DCEs) on patient preferences for major depressive disorder treatment assessed the range of DCE applications in major depressive disorder to document patient stakeholder involvement in DCE development and to identify the relative importance of treatment attributes.

METHODS

We searched MEDLINE via Ovid (1946-present), EMBASE (Elsevier interface), Cochrane Central Register of Controlled Trials (Wiley interface), and PsycINFO (EBSCO interface) databases on 29 May, 2024. Covidence software facilitated the review, which four members completed independently. The review was conducted in two phases: title and abstract and then a full-text review. We used an established quality reporting tool to evaluate selected articles. The Covidence extraction tool was adapted for this study.

RESULTS

A total of 19 articles were included in this review. Most studies elicited preferences for depression treatment (63.2%) and care delivery (10.5%). Two assessed willingness to pay. Individuals prefer a combination of medicine and counseling over each treatment alone. Treatment efficacy, relapse prevention, and symptom relief were among the most important attributes. Individuals were willing to accept larger risks to achieve symptom improvement. Few studies examined preference heterogeneity with latent subgroups.

CONCLUSIONS

Discrete choice experiments for major depressive disorder treatment preferences enable an assessment of trade-offs for first-line therapeutic options. Patient stakeholders are infrequently involved as collaborators in the DCE development. Few examined preference heterogeneity among subgroups.

Systematic Review and Meta-Analysis: Reporting and Representation of Race/Ethnicity in 310 Randomized Controlled Trials of Attention-Deficit/Hyperactivity Disorder Medications

OBJECTIVE

To evaluate the reporting of race/ethnicity data in randomized controlled trials (RCTs) of attention-deficit/hyperactivity disorder (ADHD) medications. Secondary objectives were to estimate temporal trends in the reporting, and to compare the pooled prevalence of racial/ethnic groups in RCTs conducted in the US to national estimates.

METHOD

We drew on, adapted, and updated the search of a network meta-analysis by Cortese et al. (2018) up to March 2022. We calculated the percentage of RCTs reporting data on race/ethnicity of participants in the published article or in related unpublished material. Temporal trends were estimated with logistic regression. The pooled prevalence of each racial/ethnic group across US RCTs was calculated using random-effects model meta-analyses.

RESULTS

We retained 310 RCTs (including 44,447 participants), of which 231 were conducted in children/adolescents, 78 in adults, and 1 in both. Data on race/ethnicity were reported in 59.3% of the RCTs (75% of which were conducted in children/adolescents and 25% in adults) in the published article, and in unpublished material in an additional 8.7% of the RCTs. Reporting improved over time. In the US RCTs, Asian and White individuals were under- and overrepresented, respectively, compared to national estimates in the most recent time period considered.

CONCLUSION

More than 30% of the RCTs of ADHD medications retained in this review did not include data on race/ethnicity in their published or unpublished reports, and more than 40% in their published articles, even though reporting improved over time. Results should inform investigators, authors, editors, regulators, and study participants in relation to efforts to tackle inequalities in ADHD research.

PLAIN LANGUAGE SUMMARY

A systematic review of 310 randomized controlled trials for attention-deficit/hyperactivity disorder (ADHD) medications found that race/ethnicity were reported in only 30% of trials. Compared to national estimates, Asian individuals were underrepresented and non-Hispanic Whites individuals were overrepresented, drawing attention to the inequities in participation in ADHD research.

DIVERSITY & INCLUSION STATEMENT

One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. We actively worked to promote sex and gender balance in our author group. While citing references scientifically relevant for this work, we also actively worked to promote sex and gender balance in our reference list. While citing references scientifically relevant for this work, we also actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our reference list. The author list of this paper includes contributors from the location and/or community where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work.

STUDY PREREGISTRATION INFORMATION

Reporting and representation of race/ethnicity in double blind randomised controlled trials of medications for ADHD; https://osf.io/; hfgz8.

Social Risk Factors and Racial and Ethnic Disparities in Health Care Resource Utilization Among Medicare Advantage Beneficiaries With Psychiatric Disorders

The intersection of social risk and race and ethnicity on mental health care utilization is understudied. This study examined disparities in health care treatment, adjusting for clinical need, among 25,780 Medicare Advantage beneficiaries with a diagnosis of a psychiatric disorder. We assessed contributions to disparities from racial and ethnic differences in the composition and returns of social risk variables. Black and Hispanic beneficiaries had lower rates of mental health outpatient visits than Whites. Assessing composition, Black and Hispanic beneficiaries experienced greater financial, food, and housing insecurity than White beneficiaries, factors associated with greater mental health treatment. Assessing returns, food insecurity was associated with an exacerbation of Hispanic-White disparities. Health care systems need to address the financial, food and housing insecurity of racial and ethnic minority groups with psychiatric disorder. Accounting for racial and ethnic differences in social risk adjustment-based payment reforms has significant implications for provider reimbursement and outcomes.

Values and Preferences of Patients With Depressive Disorders Regarding Pharmacologic and Nonpharmacologic Treatments : A Rapid Review

BACKGROUND

Developers of clinical practice guidelines need to take patient values and preferences into consideration when weighing benefits and harms of treatment options for depressive disorder.

PURPOSE

To assess patient values and preferences regarding pharmacologic and nonpharmacologic treatments of depressive disorder.

DATA SOURCES

MEDLINE (Ovid) and PsycINFO (EBSCO) were searched for eligible studies published from 1 January 2014 to 30 November 2022.

STUDY SELECTION

Pairs of reviewers independently screened 30% of search results. The remaining 70% of the abstracts were screened by single reviewers; excluded abstracts were checked by a second reviewer. Pairs of reviewers independently screened full texts.

DATA EXTRACTION

One reviewer extracted data and assessed the certainty of evidence, and a second reviewer checked for completeness and accuracy. Two reviewers independently assessed risk of bias.

DATA SYNTHESIS

The review included 11 studies: 4 randomized controlled trials, 5 cross-sectional studies, and 2 qualitative studies. In 1 randomized controlled trial, participants reported at the start of therapy that they expected supportive-expressive psychotherapy and antidepressants to yield similar improvements. A cross-sectional study reported that non-Hispanic White participants and men generally preferred antidepressants over talk therapy, whereas Hispanic and non-Hispanic Black participants and women generally did not have a preference. Another cross-sectional study reported that the most important nonserious adverse events for patients treated with antidepressants were insomnia, anxiety, fatigue, weight gain, agitation, and sexual dysfunction. For other comparisons and outcomes, no conclusions could be drawn because of the insufficient certainty of evidence.

LIMITATIONS

The main limitation of this review is the low or insufficient certainty of evidence for most outcomes. No evidence was available on second-step depression treatment or differences in values and preferences based on gender, race/ethnicity, age, and depression severity.

CONCLUSION

Low-certainty evidence suggests that there may be some differences in preferences for talk therapy or pharmacologic treatment of depressive disorders based on gender or race/ethnicity. In addition, low-certainty evidence suggests that insomnia, anxiety, fatigue, weight gain, agitation, and sexual dysfunction may be the most important nonserious adverse events for patients treated with antidepressants. Evidence is lacking or insufficient to draw any further conclusions about patients' weighing or valuation of the benefits and harms of depression treatments.

PRIMARY FUNDING SOURCE

American College of Physicians. (PROSPERO: CRD42020212442).

Coverage Parity And Racial And Ethnic Disparities In Mental Health And Substance Use Care Among Medicare Beneficiaries

Many older Americans do not receive needed care for mental health and substance use disorders (MHSUD), and there are substantial racial and ethnic disparities in receipt of this care across the lifespan. Medicare introduced cost-sharing parity for outpatient MHSUD care during the period 2010-14, reducing beneficiaries' out-of-pocket share of MHSUD spending from 50 percent to 20 percent. Among traditional Medicare beneficiaries ages sixty-five and older, we examined changes in MHSUD use and spending during the period 2008-18 for low-income beneficiaries with the cost-sharing reduction versus a control group of beneficiaries with free care throughout the study period among Black, Hispanic, Asian, and American Indian/Alaska Native versus White beneficiaries. Among older Medicare beneficiaries, overall use of MHSUD services increased during this period. For White beneficiaries, MHSUD cost-sharing parity was associated with an increased likelihood of having specialty MHSUD visits and medication use and a reduced likelihood of having unmonitored MHSUD medication use and MHSUD emergency department visits and hospitalizations. However, cost-sharing parity was associated with smaller or no gains in MHSUD services use for racial and ethnic minority beneficiaries compared with White beneficiaries, thus widening racial and ethnic disparities in MHSUD care.

Racial and Ethnic Disparities in Childhood ADHD Treatment Access and Utilization: Results From a National Study

OBJECTIVE

The study examined racial-ethnic disparities in access to and utilization of treatment for attention-deficit hyperactivity disorder (ADHD) and other psychiatric diagnoses among children with ADHD.

METHODS

Nationally representative, cross-sectional data from the Household Component of the Medical Expenditure Panel Survey 2011-2019 were used to examine racial-ethnic disparities in access to and utilization of treatment by children ages 5-17 with ADHD (N=5,838). Logistic regression models were estimated for access outcomes, and generalized linear models were estimated for utilization outcomes. Multivariable regression models adjusted for race-ethnicity, age, sex, and treatment need in accordance with the Institute of Medicine definition of health care disparities.

RESULTS

In adjusted analyses, compared with White children with ADHD, Black, Hispanic, and Asian children with ADHD had significantly lower rates of any past-year treatment visit for ADHD or for other psychiatric diagnoses. They also had lower rates of having accessed ADHD medication. Compared with White children, Black and Asian children with ADHD used fewer ADHD medications, and Black and Hispanic children with ADHD had lower overall mental health treatment expenditures.

CONCLUSIONS

Disparities in ADHD treatment among children from racial-ethnic minority populations may be driven primarily by disparities in access rather than in utilization. Once treatment had been accessed, disparities in utilization were largely accounted for by differences in socioeconomic status. These findings suggest that interventions targeting access to treatment among children from racial-ethnic minority populations may help close existing care gaps.

Typologies of mental healthcare discrimination experiences and associations with current provider care ratings: A latent class analysis

Background

Discrimination is experienced across demographic attributes (e.g., race and gender) and vantage points (e.g., personal and vicarious), yet few studies have classified these different experiences of discrimination within healthcare systems. Moreover, which discriminatory experiences have greater influence on patient-reported quality outcomes remains poorly understood. To address these gaps, we used latent class analysis (LCA) to identify typologies of past experiences with healthcare discrimination among adults with depression-who experience more frequent and stigmatizing healthcare interactions than the general population-and assess the relationship between class membership and current ratings of patient-reported quality outcomes.

Methods

We surveyed a nationally representative sample of adults with depression (n = 803) to assess past experiences of discrimination by medical providers in terms of both the characteristics targeted for discrimination and whether healthcare discrimination was experienced personally or by friends and family members. We conducted an LCA to identify discrimination-exposure classes and a modified Poisson regression to identify associations between class membership and patient-reported quality outcomes (e.g., overall medical provider quality, respect, clear communication, and careful listening), while adjusting for covariates.

Results

We identified four latent classes of healthcare discrimination: low discrimination (LD; referent class: 72.2% of total sample), vicarious linguistic discrimination (VL; 13.9%), elevated personal and vicarious racial discrimination (EPVR; 10.5%), and high racial/ethnic discrimination (HRE; 3.4%). Compared to those in the LD class, individuals in the EPVR class had higher rates of reporting their current medical provider's respect and careful listening skills as sometimes or never, (Respect aIRR: 1.90, 95% CI: 1.05-3.42; Listening aIRR: 2.18, 95% CI: 1.29-3.66). Those in the HRE class reported higher rates of reporting their medical provider's quality and communication as poor or fair and lower ratings of careful listening (Quality aIRR: 2.06, 95% CI: 1.08-3.93; Communication aIRR: 1.97, 95% CI: 1.00-3.63; Listening aIRR: 2.41, 95% CI: 1.27-4.59), compared to those in the LD class. Those in the VL class had higher rates of reporting that their medical provider never or sometimes respected or carefully listened to them (Respect aIRR: 2.12, 95% CI: 1.20-3.72; Listening aIRR:1.67, 95% CI:1.03-2.71) than those in, the LD class.

Conclusions

Healthcare organizations committed to providing equitable patient care should establish more robust quality improvement approaches to prevent discrimination at the medical provider level as well as structures of accountability to reconcile previously embedded social inequities within the healthcare system.

Promoting Racial/Ethnic Equity in Psychosocial Treatment Outcomes for Child and Adolescent Anxiety and Depression

Anxiety and depression are the most prevalent and least treated pediatric mental health problems. Racial/ethnic minority youths face greater risks for developing anxiety and depression and experience higher burden as they are less likely to receive adequate mental health services for these conditions or to have their needs met. Further, standard evidence‐based interventions for youth anxiety and depression may show diminished effects with racial/ethnic minority youths and with families of lower socioeconomic status. While community‐level interventions to combat structural racism and reduce population‐level risk are sorely needed, many youths will continue to require acute treatment services for anxiety and depression and interventionists must understand how to bring equity to the forefront of care. In this review, we adopt a health system framework to examine racial/ethnic disparities in system‐, intervention‐, provider‐, and patient‐level factors for psychosocial treatment of pediatric anxiety and depression. Current evidence on disparities in access and in efficacy of psychosocial intervention for anxious and depressed youths is summarized, and we use our work in primary care as a case example of adapting an intervention to mitigate disparities and increase equity. We conclude with recommendations for disparity action targets at each level of the health system framework and provide example strategies for intervening on these mechanisms to improve the outcomes of racial/ethnic minority youths.

Racial/ethnic minority youths face greater risks for developing anxiety and depression and experience higher burden from disorder as they are less likely to receive adequate mental health services for these conditions or to have their needs met.

Increasing access to services for anxiety and depression is of critical and immediate importance for racial/ethnic minority families. Issues of access may be associated with the physical location of services (e.g., primary care or telehealth) or with barriers of language, income, or financing.

Both service settings and research treatment protocols frequently require families of ethnic/racial minority youths to fit themselves to the demands of care, in ways that may not be culturally compatible (e.g., little parent involvement in treatment) or practically feasible (i.e., weekly sessions during parent working hours). Whenever possible, non‐essential aspects of intervention should be freed to match patient preferences and constraints, and interventions for anxiety and depression should be adopted that have broad impacts and options for personalization of goals.

Racial/Ethnic Disparity Trends in Children's Mental Health Care Access and Expenditures From 2010-2017: Disparities Remain Despite Sweeping Policy Reform

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.

Perceived healthcare discrimination and well-being among older adults in the United States and Brazil

Despite well-documented evidence illustrating the relationship between discrimination and health, less is known about the influence of unfair treatment when receiving medical care. Moreover, our current knowledge of cross-national and racial variations in healthcare discrimination is limited in aging populations. This article addresses these gaps using two harmonized data sets of aging populations to clarify the relationship between healthcare discrimination and health in the United States and Brazil. We use nationally representative, harmonized data from the Health and Retirement Study in the United States and the Brazilian Longitudinal Study of Aging to examine and compare perceived discrimination in the healthcare setting and its relationship to self-rated health, depression diagnosis, and depressive symptoms across national contexts. Using Poisson regression models and population attributable risk percent estimates, we found that aging adults reporting healthcare discrimination were at higher risk of poor self-rated health, diagnosed depression, and depressive symptoms. Our results also suggest that reducing perceived healthcare discrimination may contribute to improved self-rated health and mental well-being in later life across racialized societies. In two comparative settings, we highlight the differential impact of healthcare discrimination on self-rated health and depression. We describe the implications of our study's findings for national public health strategies focused on eliminating discrimination in the healthcare setting, particularly among aging countries.

Racism in healthcare: a scoping review

BACKGROUND

Racism constitutes a barrier towards achieving equitable healthcare as documented in research showing unequal processes of delivering, accessing, and receiving healthcare across countries and healthcare indicators. This review summarizes studies examining how racism is discussed and produced in the process of delivering, accessing and receiving healthcare across various national contexts.

METHOD

The PRISMA guidelines for scoping reviews were followed and databases were searched for peer reviewed empirical articles in English across national contexts. No starting date limitation was applied for this review. The end date was December 1, 2020. The review scoped 213 articles. The results were summarized, coded and thematically categorized in regards to the aim.

RESULTS

The review yielded the following categories: healthcare users' experiences of racism in healthcare; healthcare staff's experiences of racism; healthcare staff's racial attitudes and beliefs; effects of racism in healthcare on various treatment choices; healthcare staff's reflections on racism in healthcare and; antiracist training in healthcare. Racialized minorities experience inadequate healthcare and being dismissed in healthcare interactions. Experiences of racism are associated with lack of trust and delay in seeking healthcare. Racialized minority healthcare staff experience racism in their workplace from healthcare users and colleagues and lack of organizational support in managing racism. Research on healthcare staff's racial attitudes and beliefs demonstrate a range of negative stereotypes regarding racialized minority healthcare users who are viewed as difficult. Research on implicit racial bias illustrates that healthcare staff exhibit racial bias in favor of majority group. Healthcare staff's racial bias may influence medical decisions negatively. Studies examining healthcare staff's reflections on racism and antiracist training show that healthcare staff tend to construct healthcare as impartial and that healthcare staff do not readily discuss racism in their workplace.

CONCLUSIONS

The USA dominates the research. It is imperative that research covers other geo-political contexts. Research on racism in healthcare is mainly descriptive, atheoretical, uses racial categories uncritically and tends to ignore racialization processes making it difficult to conceptualize racism. Sociological research on racism could inform research on racism as it theoretically explains racism's structural embeddedness, which could aid in tackling racism to provide good quality care.

Psychometric evaluation of a decision quality instrument for medication decisions for treatment of depression symptoms

BACKGROUND

A high quality treatment decision means patients are informed and receive treatment that matches their goals. This research examined the reliability and validity of the Depression Decision Quality Instrument (DQI), a survey to measure the extent to which patients are informed and received preferred treatment for depression.

METHODS

Participants were aged 18 and older from 17 US cities who discussed medication or counseling with a physician in the past year, and physicians who treated patients with depression who practiced in the same cities. Participants were mailed a survey that included the Depression-DQI, a tool with 10 knowledge and 7 goal and concern items. Patients were randomly assigned to either receive a patient decision aid (DA) on treatment of depression or no DA. A matching score was created by comparing the patient's preferred treatment to their self-reported treatment received. Concordant scores were considered matched, discordant were not. We examined the reliability and known group validity of the Depression-DQI.

RESULTS

Most patients 405/504 (80%) responded, 79% (320/405) returned the retest survey, and 60% (114/187) of physicians returned the survey. Patients' knowledge scores on the 10-item scale ranged from 14.6 to 100% with no evidence of floor or ceiling effects. Retest reliability for knowledge was moderate and for goals and concerns ranged from moderate to good. Mean knowledge scores differentiated between patients and physicians (M = 63 [SD = 15] vs. M = 81 [SD = 11], p < 0.001), and between patients who did and didn't receive a DA (M = 64 [SD = 16] vs. M = 61 [SD = 14], p = 0.041). 60.5% of participants received treatment that matched their preference. Based on the multivariate logistic regression, 'avoiding taking anti-depressants' was the only goal that was predictive of taking mediation (OR = 0.73 [0.66, 0.80], p < 0.01). Shared Decision Making Process scores were similar for those who matched their preference and those who didn't (M = 2.18 [SD = 0.97] vs. M = 2.06 [SD = 1.07]; t(320) =  - 1.06, p = 0.29). Those who matched had lower regret scores (matched M = 1.72 [SD = 0.74] vs. unmatched M = 2.32 [SD = 0.8]; t(301) =  - 6.6, p < .001).

CONCLUSIONS

The Depression DQI demonstrated modest reliability and validity. More work is needed to establish validity of the method to determine concordance.

TRIAL REGISTRATION

NCT01152307.

Racial/Ethnic Disparities in the Performance of Prediction Models for Death by Suicide After Mental Health Visits

IMPORTANCE

Clinical prediction models estimated with health records data may perpetuate inequities.

OBJECTIVE

To evaluate racial/ethnic differences in the performance of statistical models that predict suicide.

DESIGN, SETTING, AND PARTICIPANTS

In this diagnostic/prognostic study, performed from January 1, 2009, to September 30, 2017, with follow-up through December 31, 2017, all outpatient mental health visits to 7 large integrated health care systems by patients 13 years or older were evaluated. Prediction models were estimated using logistic regression with LASSO variable selection and random forest in a training set that contained all visits from a 50% random sample of patients (6 984 184 visits). Performance was evaluated in the remaining 6 996 386 visits, including visits from White (4 031 135 visits), Hispanic (1 664 166 visits), Black (578 508 visits), Asian (313 011 visits), and American Indian/Alaskan Native (48 025 visits) patients and patients without race/ethnicity recorded (274 702 visits). Data analysis was performed from January 1, 2019, to February 1, 2021.

EXPOSURES

Demographic, diagnosis, prescription, and utilization variables and Patient Health Questionnaire 9 responses.

MAIN OUTCOMES AND MEASURES

Suicide death in the 90 days after a visit.

RESULTS

This study included 13 980 570 visits by 1 433 543 patients (64% female; mean [SD] age, 42 [18] years. A total of 768 suicide deaths were observed within 90 days after 3143 visits. Suicide rates were highest for visits by patients with no race/ethnicity recorded (n = 313 visits followed by suicide within 90 days, rate = 5.71 per 10 000 visits), followed by visits by Asian (n = 187 visits followed by suicide within 90 days, rate = 2.99 per 10 000 visits), White (n = 2134 visits followed by suicide within 90 days, rate = 2.65 per 10 000 visits), American Indian/Alaskan Native (n = 21 visits followed by suicide within 90 days, rate = 2.18 per 10 000 visits), Hispanic (n = 392 visits followed by suicide within 90 days, rate = 1.18 per 10 000 visits), and Black (n = 65 visits followed by suicide within 90 days, rate = 0.56 per 10 000 visits) patients. The area under the curve (AUC) and sensitivity of both models were high for White, Hispanic, and Asian patients and poor for Black and American Indian/Alaskan Native patients and patients without race/ethnicity recorded. For example, the AUC for the logistic regression model was 0.828 (95% CI, 0.815-0.840) for White patients compared with 0.640 (95% CI, 0.598-0.681) for patients with unrecorded race/ethnicity and 0.599 (95% CI, 0.513-0.686) for American Indian/Alaskan Native patients. Sensitivity at the 90th percentile was 62.2% (95% CI, 59.2%-65.0%) for White patients compared with 27.5% (95% CI, 21.0%-34.7%) for patients with unrecorded race/ethnicity and 10.0% (95% CI, 0%-23.0%) for Black patients. Results were similar for random forest models, with an AUC of 0.812 (95% CI, 0.800-0.826) for White patients compared with 0.676 (95% CI, 0.638-0.714) for patients with unrecorded race/ethnicity and 0.642 (95% CI, 0.579-0.710) for American Indian/Alaskan Native patients and sensitivities at the 90th percentile of 52.8% (95% CI, 50.0%-55.8%) for White patients, 29.3% (95% CI, 22.8%-36.5%) for patients with unrecorded race/ethnicity, and 6.7% (95% CI, 0%-16.7%) for Black patients.

CONCLUSIONS AND RELEVANCE

These suicide prediction models may provide fewer benefits and more potential harms to American Indian/Alaskan Native or Black patients or those with undrecorded race/ethnicity compared with White, Hispanic, and Asian patients. Improving predictive performance in disadvantaged populations should be prioritized to improve, rather than exacerbate, health disparities.

Impact of the Medicare Shared Savings Program on utilization of mental health and substance use services by eligibility and race/ethnicity

OBJECTIVE

To assess the impact of the Medicare Shared Savings Program (MSSP) ACOs on mental health and substance use services utilization and racial/ethnic disparities in care for these conditions.

DATA SOURCES

Five percent random sample of Medicare claims from 2009 to 2016.

STUDY DESIGN

We compared Medicare beneficiaries in MSSP ACOs to non-MSSP beneficiaries, stratifying analyses by Medicare eligibility (disability vs age 65+). We estimated difference-in-difference models of MSSP ACOs on mental health and substance use visits (outpatient and inpatient), medication fills, and adequate care for depression adjusting for age, sex, race/ethnicity, region, and chronic medical and behavioral health conditions. To examine the differential impact of MSSP on our outcomes by race/ethnicity, we used a difference-in-difference-in-differences (DDD) design.

DATA COLLECTION/EXTRACTION METHODS

Not applicable.

PRINCIPAL FINDINGS

MSSP ACOs were associated with small reductions in outpatient mental health (Coeff: -0.012, P < .001) and substance use (Coeff: -0.001, P < .01) visits in the disability population, and in adequate care for depression for both the disability- and age-eligible populations (Coeff: -0.028, P < .001; Coeff: -0.012, P < .001, respectively). MSSP ACO's were also associated with increases in psychotropic medications (Coeff: 0.007 and Coeff: 0.0213, for disability- and age-eligible populations, respectively, both P < .001) and reductions in inpatient mental health stays (Coeff:-0.004, P < .001, and Coeff:-0.0002, P < .01 for disability- and age-eligible populations, respectively) and substance use-related stays for disability-eligible populations (Coeff:-0.0005, P<.05). The MSSP effect on disparities varied depending on type of service.

CONCLUSIONS

We found small reductions in outpatient and inpatient stays and in rates of adequate care for depression associated with MSSP ACOs. As MSSP ACOs are placed at more financial risk for population-based treatment, it will be important to include more robust behavioral health quality measures in their contracts and to monitor disparities in care.

Racial and Ethnic Differences in Psychiatry Resident Prescribing: a Quality Improvement Education Intervention to Address Health Equity

OBJECTIVE

Quality improvement (QI) tools can identify and address health disparities. This paper describes the use of resident prescriber profiles in a novel QI curriculum to identify racial and ethnic differences in antidepressant and antipsychotic prescribing.

METHODS

The authors extracted medication orders written by 111 psychiatry residents over an 18-month period from an electronic medical record and reformatted these into 6133 unique patient encounters. Binomial logistic models adjusted for covariates assessed racial and ethnic differences in antipsychotic or antidepressant prescribing in both emergency and inpatient psychiatric encounters. A multinomial model adjusted for covariates then assessed racial and ethnic differences in primary diagnosis. Models also examined interactions between gender and race/ethnicity.

RESULTS

Black (adjusted OR 0.66; 95% CI, 0.50-0.87; p < 0.01) and Latinx (adjusted OR, 0.65; 95% CI, 0.49-0.86; p < 0.01) patients had lower odds of receiving antidepressants relative to White patients despite diagnosis. Black and Latinx patients were no more likely to receive antipsychotics than White patients when adjusted for diagnosis. Black (adjusted OR 3.85; 95% CI, 2.9-5.2) and Latinx (adjusted OR 1.60; 95% CI, 1.1-2.3) patients were more likely to receive a psychosis than a depression diagnosis when compared to White patients. Gender interactions with race/ethnicity did not significantly change results.

CONCLUSIONS

Our findings suggest that racial/ethnic differences in antidepressant prescription likely result from alternatively higher diagnosis of psychotic disorders and prescription of antipsychotics in Black and Latinx patients. Prescriber profiles can serve as a powerful tool to promote resident QI learning around the effects of structural racism on clinical care.