Mental health service utilization by African Americans and Whites: the Baltimore Epidemiologic Catchment Area Follow-Up

Implementation of an integrated primary care behavioral health training model on campus

In the last 15 years, demand has surged among college students for mental health care and many campuses are struggling to keep up with the demand for services. Primary care services represent a pathway where individuals can receive mental health care without accessing specialty mental health services. There is evidence that integrating mental health services into primary care can reduce racial disparities in access to mental health care and provide greater access to mental health care for underserved persons. This paper describes the development and implementation of a fully integrated model of mental health care services into Xavier University's (XU) primary care clinic. In partnership with TriHealth, a local healthcare provider, and following the primary care behavioral care model, XU integrated supervised psychology doctoral students as behavior health consultants into a campus primary care clinic. Administrative, clinical care, and training processes together with preliminary findings and recommendations are shared.

Seeking Professional Help for Mental Illness: A Mixed-Methods Study of Black Family Members in the UK and Nigeria

Seeking professional help for mental illness is a limited practice among Black family members in low and middle socioeconomic groups in the United Kingdom (UK) and Nigeria. Guided by the theory of planned behavior, we explored some factors restricting professional help-seeking practices among the target groups. This mixed-methods study recruited a heterogeneous sample of 105 ( ranging from 19–64 years) UK and Nigerian Black family members in low or middle socioeconomic groups. Data were collected using a standardized questionnaire and open-ended questions. Collected data were analyzed using IBM SPSS statistics (version 22.0) and thematic analysis. There was no statistically significant difference in professional help-seeking behavior among the UK and Nigerian Black family members in low and middle socioeconomic groups [F (3, 83) = 1.13; p > .05]. The qualitative data analysis revealed that respondents were limited from professional help-seeking due to high consultation fees to see a mental health professional, perceived accessibility to mental health services within their various locations, stigmatization and socio-cultural factors (such as, “The perception that a man should be strong” or “Mental health isn’t as important as physical health”), concerns about the safety of information shared during professional help-seeking or therapy sessions, poor knowledge about mental health services, long waiting time to see a professional in face-to-face therapy, and risk of contracting the infectious disease in the hospital setting. Implications of findings for theory and practice and direction for future research are thus discussed.

Reducing racial/ethnic disparities in mental health service use among emerging adults: community-level supply factors

Objectives: Emerging adulthood-spanning 18-29 years of age-is associated with the highest risk for onset of certain behavioral health disorders (e.g. major depression, bipolar disorder, psychosis, substance use disorders) and high prevalence of many behavioral health disorders. Yet, rates of mental health service use remain low in this age range. Racial/ethnic minorities are particularly impacted by individual, cultural/linguistic, and community-level barriers to mental health care. This study examined community-level factors associated with mental health service use and investigated whether these associations varied by race/ethnicity.Design: This study analyzed individual- and county-level data for emerging adults in the United States (N=3,294) from the nationally representative Collaborative Psychiatric Epidemiological Surveys (CPES). Using the Andersen Model of Health Care Utilization, analyses examined predisposing, enabling, and need factors utilized in prior studies with adult samples as well as novel community characteristics hypothesized to impact service use among emerging adults of diverse racial/ethnic backgrounds. Past-year use of both specialty and any mental health services were assessed, controlling for individual- and community-level variables, and adjusting for presence of past-year mental health disorder, overall health status, and functional impairment. Differences between racial/ethnic minority groups and Non-Latino Whites were tested through a multilevel model incorporating random intercepts logistic regression, with analysis focusing on the interaction between race/ethnicity and community-level supply variables.Results: For past-year use of specialty mental health services, density of hospitals with child wellness programs was linked to service use among Black emerging adults, whereas density of hospitals with linguistic/translation services was linked to service use among Latino emerging adults.Conclusions: This study expands on previous research in behavioral health disparities to examine ways to improve behavioral health services for an emerging adult population with unmet service needs and identifies specific community-level factors that can improve mental health for racial/ethnic minority emerging adults.

African American marital confiding relationships: A national survey and a test of an educational intervention

We present two related studies on confiding about relationships among African Americans. Study one examined how African Americans serve as confidants in their social networks for people having couple relationship concerns. Using a national survey of African American adults, this study documented the prevalence of confiding relationships, the kinds of problems brought to confidants, and which confidant behaviors are seen as helpful and not helpful. Study two was a randomized controlled trial of Marital First Responders-AA, a culturally adapted version of the Marital First Responders program. Results showed improved skills among African Americans participants who were already natural confidants, as well greater frequency of confiding interactions in their social networks. Enhancing the abilities of natural confidants may be particularly important in the African American community because of stresses on couple relationships and the relatively lower use of therapy services.

Social stigma of suicide in South Korea: A cultural perspective

This study examined suicide stigma in relation to Korean cultural characteristics, such as Collectivism, Chemyon sensitivity (concern about losing a socially acceptable face), the tendency toward conformity, and the emphasis on the interdependent self. We found that these characteristics were connected to suicide stigma in Korea. Those with high Chemyon sensitivity tended to perceive that suicidal people were incompetent, immoral, selfish, and deviated from society. Conformity tendency was positively associated with five stigma factors: incompetence, glorification, immorality, selfishness, and social exclusion. Those who perceived themselves as interdependent tended to consider suicidal people incompetent, lacking morality, self-centered, and deviant.

Trauma-informed Collaborative Care for African American Primary Care Patients in Federally Qualified Health Centers: A Pilot Randomized Trial

BACKGROUND

African Americans have nearly double the rate of posttraumatic stress disorder (PTSD) compared with other racial/ethnic groups.

OBJECTIVE

To understand whether trauma-informed collaborative care (TICC) is effective for improving PTSD among African Americans in New Orleans who receive their care in Federally Qualified Health Centers (FQHCs).

DESIGN AND METHOD

In this pilot randomized controlled trial, we assigned patients within a single site to either TICC or to enhanced usual care (EUC). We performed intent to treat analysis by nonparametric exact tests for small sample sizes.

PARTICIPANTS

We enrolled 42 patients from October 12, 2018, through July 2, 2019. Patients were eligible if they considered the clinic their usual source of care, had no obvious physical or cognitive obstacles that would prevent participation, were age 18 or over, self-identified as African American, and had a provisional diagnosis of PTSD.

MEASURES

Our primary outcome measures were PTSD measured as both a symptom score and a provisional diagnosis based on the PTSD Checklist for DSM-5 (PCL-5).

KEY RESULTS

Nine months following baseline, both PTSD symptom scores and provisional PTSD diagnosis rates decreased substantially more for patients in TICC than in EUC. The decreases were by 26 points in EUC and 36 points in TICC for symptoms (P=0.08) and 33% in EUC and 57% in TICC for diagnosis rates (P=0.27). We found no effects for mediator variables.

CONCLUSIONS

TICC shows promise for addressing PTSD in this population. A larger-scale trial is needed to fully assess the effectiveness of this approach in these settings.

SNO 2020 diversity survey: defining demographics, racial biases, career success metrics and a path forward for the field of neuro-oncology

BACKGROUND

Neuro-oncology has grown tremendously since 2010, marked by increasing society membership, specialized clinical expertise, and new journals. Yet, modest improvement in racial/ethnic diversity amongst clinical trial participants, researchers and clinicians led us to conduct a survey to identify opportunities to enhance diversity and inclusiveness amongst neuro-oncology professionals.

METHODS

In summer 2020, the Women and Diversity Committee of the Society for Neuro-Oncology (SNO) distributed an anonymous online survey to members and affiliates including European Association of Neuro-Oncology (EANO), Asian Society for Neuro-Oncology (ASNO), Society for Neuro-Oncology Latin America (SNOLA) and Society for Neuro-Oncology Sub-Saharan Africa (SNOSSA). The survey captured personal and professional characteristics, biases, effective mentorship qualities, career service metrics and suggested field/society changes. Results were analyzed by geography, profession, age, racial/ethnic and sexual identity. Standard descriptive statistics characterized the study population.

RESULTS

The 386 respondents were predominantly female (58%) with a median age range of 40-49 years (31%), White (65%), and SNO members (97%). Most worked in North America (77%) in a research profession (67%). A majority of White respondents reported never experiencing biases (64%), while the majority of non-White respondents reported unconscious biases/microaggressions, followed by a lack of/limited mentorship. Qualitative assessments showcased that personal/professional success metrics were linked to needed improvements in diversity and inclusion efforts within the neuro-oncology field.

CONCLUSIONS

The prevalence of racial/ethnic biases and poor mentorship rates amongst underrepresented groups in neuro-oncology is high and potentially linked to the limited diverse representation amongst members and affiliates. These findings warrant a swift implementation of equity and inclusion practices within the neuro-oncology field.

Long-term depression incidence and associated mortality among African American and White prostate cancer survivors

BACKGROUND

Depression is common after a diagnosis of prostate cancer and may contribute to poor outcomes, particularly among African Americans. The authors assessed the incidence and management of depression and its impact on overall mortality among African American and White veterans with localized prostate cancer.

METHODS

The authors used the Veterans Health Administration Corporate Data Warehouse to identify 40,412 African American and non-Hispanic White men diagnosed with localized prostate cancer from 2001 to 2013. Patients were followed through 2019. Multivariable logistic regression was used to measure associations between race and incident depression, which were ascertained from administrative and depression screening data. Cox proportional hazards models were used to measure associations between incident depression and all-cause mortality, with race-by-depression interactions used to assess disparities.

RESULTS

Overall, 10,013 veterans (24.5%) were diagnosed with depression after a diagnosis of prostate cancer. Incident depression was associated with higher all-cause mortality (adjusted hazard ratio [aHR], 1.27; 95% confidence interval [CI], 1.23-1.32). African American veterans were more likely than White veterans to be diagnosed with depression (29.3% vs 23.2%; adjusted odds ratio [aOR], 1.15; 95% CI, 1.09-1.21). Among those with depression, African Americans were less likely to be prescribed an antidepressant (30.4% vs 31.7%; aOR, 0.85; 95% CI, 0.77-0.93). The hazard of all-cause mortality associated with depression was greater for African American veterans than White veterans (aHR, 1.32 [95% CI, 1.26-1.38] vs 1.15 [95% CI, 1.07-1.24]; race-by-depression interaction P < .001).

CONCLUSIONS

Incident depression is common among prostate cancer survivors and is associated with higher mortality, particularly among African American men. Patient-centered strategies to manage incident depression may be critical to reducing disparities in prostate cancer outcomes.

Results from a community mental health assessment in a historically black church: A call for action

African Americans' rates of mental illness are similar to those of the general population, however, their rates of utilization of any mental health service is lower than many other ethnic/racial groups, specifically, non-Hispanic, Whites. Many African Americans do not receive adequate treatment for mental health issues due to several barriers to help-seeking behavior. Despite these barriers, African American communities have traditionally sought support from pastors or ministers of historically black churches in times of crises or when experiencing mental health issues. Research has shown that African Americans rely on faith, family, and their churches for emotional support rather than turning to health care professionals. To address the stigma of mental health and identify barriers to seeking mental health care in African American communities in Wichita, KS, a local Wichita historically black church, developed and hosted a mental/emotional health awareness conference. Approximately 30% of the 249 participants who attended the conference were surveyed to assess conference impact, conference satisfaction, and barriers to seeking mental health services. Results indicated approximately 37% of those surveyed lived in lower-income neighborhoods. Conference impact and satisfaction were both rated favorably. Lastly, the top three barriers to mental health care were: (1) "I don't want to be labeled," (2) "I can't afford it," and (3) "I don't know where to go for care." These data highlight the need for stigma reducing interventions and for additional policy changes to address the disparity in health-seeking behaviors of African Americans.

Preferences, use of and satisfaction with mental health services among a sample of Puerto Rican cancer patients

OBJECTIVE

The purpose of this study was to describe the preferences, the use, satisfaction of mental health services (MHS) among a sample of Puerto Rican patients with cancer undergoing oncology treatment.

METHODS

A convenience sample of 120 patients diagnosed with cancer was recruited. Self-report questionnaires assessed socio-demographic and background questions, and the Mental Health Service Preference, Utilization and Satisfaction Questionnaire (MHSPUS). The Socio-demographic and Background Questionnaire inquired about participants' demographic and socioeconomic characteristics, and included questions such as history of psychiatric diagnosis and spiritual practices. Univariate and Chi square analyses were used for descriptive purposes. Logistic regressions were used to explore associations between sociodemographic factors and MHS preferences and use.

RESULTS

The majority of the sample were females (53.8%), 61 and older (53.8%), and married or living with partner (57.1%), and reported an income equal to or less than $12,000 per year (44.4%), which places them under the US federal poverty line. Most of the participants (66.7%) reported being receptive to seeking services. Findings showed a significant association between living situation and past (p < .05) and lifetime use (p < .05) of MHS and past use of MHS. Participants living alone were more like to have used MHS in the past and during their lifetime. Adjusted logistic regression analyses revealed that living with someone was a protective factor for not using MHS in their lifetime (OR = 0.28; C1 = 0.08-0.95). Participants preferred to receive MHS at the oncology clinic, preferably on the date of their oncology appointments and during morning hours.

CONCLUSION

Findings support the integration of mental health services within the oncology practice setting.

Factors Associated with Postrelapse Rehabilitation Use in Multiple Sclerosis: A Pilot Survey

Background

Most people with multiple sclerosis (MS) have periodic and unpredictable relapses as part of their disease course. Relapses often affect functional abilities, resulting in diminished productivity and lower quality of life. Considering the effects, rehabilitation can play an important role in facilitating recovery; yet, the current literature suggests a lack of postrelapse rehabilitation services use. This study aims to document postrelapse rehabilitation services use and estimate the extent to which predisposing characteristics, perceived need, and enabling resources were associated with postrelapse rehabilitation services use in adults with MS.

Methods

This cross-sectional study used convenience sampling, and data from 73 adults with MS who recently had a relapse in the United States and Canada were analyzed.

Results

A total of 25 participants (34.2%) reported using postrelapse rehabilitation services. The regression model identified three variables associated with postrelapse rehabilitation services use: age (odds ratio [OR], 1.075), self-reported quality of life (considerably affected by the most recent relapse [OR, 5.717]), and presence of helpful health care providers (for obtaining postrelapse rehabilitation services [OR, 5.382]).

Conclusions

Most participants experienced a range of symptoms or limitations because of their most recent relapse, affecting their daily activity and quality of life. However, only one-third of the participants reported using postrelapse rehabilitation services, which focused on the improvement of their physical health. Regression modeling revealed that three population characteristics of the Andersen Behavioral Model of Health Services Utilization were associated with postrelapse rehabilitation services use.

Willingness to Seek Treatment Among Black Students With Anxiety or Depression: The Synergistic Effect of Sociocultural Factors With Symptom Severity and Intolerance of Uncertainty

Anxiety and depressive disorders are among the most commonly diagnosed psychiatric disorders, yet they remain largely undertreated in the U.S. and Black adults are especially unlikely to seek or receive mental health services. Symptom severity has been found to impact treatment-seeking behaviors as have sociocultural factors. Yet no known research has tested whether these factors work synergistically to effect willingness to seek treatment. Further, emerging data point to the importance of transdiagnostic risk factors such as intolerance of uncertainty (IU). IU may be negatively related to seeking treatment given that Black adults may be uncertain whether treatment might benefit them. Thus, the current study examined the relations between symptom severity/IU and willingness to seek treatment for anxiety/depression problems and the impact of key sociocultural variables (i.e., cultural mistrust-interpersonal relations [CMI-IR], perceived discrimination [PED]) on these relations among 161 (85% female) Black undergraduates. Consistent with prediction, symptom severity was positively related to willingness, but unexpectedly, IU was positively related. There was a significant Symptom Severity × CMI-IR interaction such that severity was positively related to willingness among students with lower cultural mistrust, but not higher mistrust. There were also significant IU × PED interaction such that IU was positively related to willingness among students with lower PED, but not higher PED. Results highlight the importance of considering the interplay between symptom severity, transdiagnostic vulnerability factors, and sociocultural variables when striving to identify factors related to treatment seeking behaviors among anxious and/or depressed Black students.

Racial, Ethnic, and Nativity Differences in Mental Health Visits to Primary Care and Specialty Mental Health Providers: Analysis of the Medical Expenditures Panel Survey, 2010-2015

Background. Black and Latino minorities have traditionally had poorer access to primary care than non-Latino Whites, but these patterns could change with the Affordable Care Act (ACA). To guide post-ACA efforts to address mental health service disparities, we used a nationally representative sample to characterize baseline race-, ethnicity-, and nativity-associated differences in mental health services in the context of primary care. Methods. Data were obtained from the Medical Expenditures Panel Survey (MEPS), a two-year panel study of healthcare use, satisfaction with care, and costs of services in the United States (US). We pooled data from six waves (14–19) of participants with serious psychological distress to examine racial, ethnic, and nativity disparities in medical and mental health visits to primary care (PC) and specialty mental health (SMH) providers around the time of ACA reforms, 2010–2015. Results. Of the 2747 respondents with serious psychological distress, 1316 were non-Latino White, 632 non-Latino Black, 532 identified as Latino with Mexican, Central American, or South American (MCS) origins, and 267 as Latino with Caribbean island origins; 525 were foreign/island born. All racial/ethnic groups were less likely than non-Latino Whites to have any PC visit. Of those who used PC, non-Latino Blacks were less likely than Whites to have a PC mental health visit, while foreign born MCS Latinos were less likely to visit an SMH provider. Conditional on any mental health visit, Latinos from the Caribbean were more likely than non-Latino Whites to visit SMH providers versus PC providers only, while non-Latino Blacks and US born MCS Latinos received fewer PC mental health visits than non-Latino Whites. Conclusion. Racial-, ethnic-, and nativity-associated disparities persist in PC provided mental health services.

Informed and patient-centered decision-making in the primary care visits of African Americans with depression

OBJECTIVE

We examined the prevalence and extent of informed decision-making (IDM) and patient-centered decision-making (PCDM) in primary care visits of African Americans with depression.

METHODS

We performed a cross-sectional analysis of audiotaped clinical encounters and post-visit surveys of 76 patients and their clinicians. We used RIAS to characterize patient-centeredness of visit dialogue. IDM entailed discussion of 3 components: the nature of the decision, alternatives, and pros/cons. PCDM entailed discussion of: lifestyle/coping strategies, knowledge/beliefs, or treatment concerns. We examined the association of IDM and PCDM with visit duration, overall patient-centeredness, and patient/clinician interpersonal ratings.

RESULTS

Approximately one-quarter of medication and counseling decisions included essential IDM elements and 40% included at least one PCDM element. In high patient-centered visits, IDM was associated with patients feeling respected in counseling and liking clinicians in medication decisions. IDM was not related to clinician ratings. In low patient-centered visits, PCDM in counseling decisions was positively associated with patients feeling respected and clinicians respecting patients.

CONCLUSIONS

The associations between IDM and PCDM with interpersonal ratings was moderated by overall patient-centeredness of the visit, which may be indicative of broader cross-cultural communication issues.

PRACTICE IMPLICATIONS

Strengthening partnerships between depressed African Americans and their clinicians may improve patient-engaged decision-making.

Discrimination against people with mental illness: what can psychiatrists do?

This article discusses the evidence that experiences of stigmatisation and discrimination among people with mental illnesses are common and may be severe. Furthermore, there are growing concerns that people with mental illness receive second-class physical healthcare. Beyond this, some aspects of psychiatric practice are reported as being insensitive, disrespectful or even disabling. We consider whether such claims are justified and what psychiatrists can do, directly and indirectly, to reduce stigma and discrimination and improve our practice.

Predictors of Mental Health Services Use Across the Life Course among Racially-Ethnically Diverse Adults

OBJECTIVE

Little is known about key factors associated with use of mental health services across the life course. This study determined key socioeconomic, social support, psychiatric, and medical predictors of services use in younger, middle, and older age.

DESIGN, SETTING, PARTICIPANTS, MEASUREMENTS

The sample included 3,708 adults with DSM-IV-based mood, anxiety, and substance use disorders in the Collaborative Psychiatric Epidemiology Surveys. Key predictors of mental health services use for each age group were systematically determined by multivariable models, and exploratory analyses examining potential effect modification by race-ethnicity and sex were assessed by interaction terms. Statistical analyses included complex design-corrected and weighted logistic regression analyses that provide results generalizable to the United States.

RESULTS

Psychiatric and medical issues such as prior suicidal behavior, comorbid psychiatric disorders, and perceived cognitive impairment increased odds of mental health services use in younger, middle, and older age. Chronic medical conditions also influenced services use in younger and older age, with their impact on use across age potentially modified by racial-ethnic disparities (p interaction = 0.01). Moreover, socioeconomic factors like marital status influenced use in middle and older age, where being divorced, separated, widowed, or never married encouraged use. The effect of marital status on use across age was also potentially modified by racial-ethnic disparities (p interaction = 0.02).

CONCLUSIONS

Key socioeconomic, social support, psychiatric, and medical predictors uniquely influence use of mental health services across the life course. These findings will help inform efforts to encourage greater services use by adults across the life course in need of care.

Racial and ethnic differences in mental healthcare utilization consistent with potentially effective care: The role of patient preferences

OBJECTIVE

Ethnic minorities are less likely than Whites to initiate and continue mental healthcare. Minorities also prefer non-medical approaches to address mental health issues. We evaluated sector-type as a modifier of the association of race/ethnicity with service utilization for mental health. We hypothesized that minorities utilize non-mental health sectors at rates consistent with guidelines and similar to Whites.

METHODS

We examined data from the Collaborative Psychiatric Epidemiologic Studies (CPES) (n=3803). We used logistic regression to assess the association of race/ethnicity with utilization consistent with potentially effective care across sectors-psychiatry, medical, non-medical mental health, human services, and spiritual.

RESULTS

Asians [OR: 0.56 CI: 0.39, 0.82] and Blacks [OR: 0.74 CI: 0.60, 0.92] had lower odds of having ≥1 visit compared to Whites. Blacks also had lower odds of ≥4 [OR: 0.66 CI: 0.50, 0.87] and ≥12 visits [OR: 0.58 CI: 0.41, 0.83]. Sector-type modified these associations. Compared to Whites, Asians [OR: 0.49 CI: 0.30, 0.82] and Blacks [OR: 0.71 CI: 0.54, 0.94] had lower odds of ≥1 visit to the medical sector. Asians had lower odds of seeing psychiatrists for ≥8 visits [OR: 0.15 CI: 0.04, 0.54] and ≥12 visits [OR: 0.21 CI: 0.06, 0.77]. Asians and Blacks demonstrated similar utilization to Whites in non-medical mental health and spiritual settings.

CONCLUSION

Racial/ethnic differences in utilization consistent with treatment guidelines are ameliorated in sectors preferred by minorities.

Trends in Racial-Ethnic Disparities in Access to Mental Health Care, 2004-2012

OBJECTIVE

This study compared trends in racial-ethnic disparities in mental health care access among whites, blacks, Hispanics, and Asians by using the Institute of Medicine definition of disparities as all differences except those due to clinical appropriateness, clinical need, and patient preferences.

METHODS

Racial-ethnic disparities in mental health care access were examined by using data from a nationally representative sample of 214,597 adults from the 2004-2012 Medical Expenditure Panel Surveys. The main outcome measures included three mental health care access measures (use of any mental health care, any outpatient care, and any psychotropic medication in the past year).

RESULTS

Significant disparities were found in 2004-2005 and in 2011-2012 for all three racial-ethnic minority groups compared with whites in all three measures of access. Between 2004 and 2012, black-white disparities in any mental health care and any psychotropic medication use increased, respectively, from 8.2% to 10.8% and from 7.6% to 10.0%. Similarly, Hispanic-white disparities in any mental health care and any psychotropic medication use increased, respectively, from 8.4% to 10.9% and 7.3% to 10.3%.

CONCLUSIONS

No reductions in racial-ethnic disparities in access to mental health care were identified between 2004 and 2012. For blacks and Hispanics, disparities were exacerbated over this period. Clinical interventions that improve identification of symptoms of mental illness, expansion of health insurance, and other policy interventions that remove financial barriers to access may help to reduce these disparities.

Somatic Symptoms and Anxiety Among African American Adolescents

Somatic symptoms are an associated feature of anxiety disorders that have received little research attention among non-White samples. In addition, the majority of previous studies have examined the influence of somatic symptoms in a cross-sectional rather than a prospective manner. This study examines the prevalence of 12 somatic symptoms, the association of somatic and anxiety symptoms (both concurrently and prospectively) with psychosocial functioning, and gender differences in somatic symptoms among a community sample of 114 African American adolescents (57 girls). In all, 83% of the sample reported at least one somatic symptom (some or most of the time within the past 2 weeks), and on average, adolescents reported 2.5 somatic symptoms. Somatic symptoms correlated positively with severity of anxiety symptoms and negatively with aspects of perceived competence. After the initial level of anxiety symptoms was controlled for, somatic symptoms were a unique predictor of perceived competence (at initial assessment) and anxiety symptoms (at 6-month follow-up). Overall, girls endorsed significantly more somatic symptoms than did boys. Findings replicate those of studies with White samples and suggest that somatic symptoms may be a risk factor for anxiety disorders among African American youth.

Preferences for Mental Health Care: A Comparison of Older African Americans and Older Caucasians

Research on mental health service utilization patterns has shown that older adults underutilize outpatient services, particularly in minority populations. Greater reliance on inpatient services may result when a mental health problem can no longer be ignored. The goal of this study was to compare the attitudes and beliefs of African American and Caucasian older adults about mental health care and preferred providers. A 47-item survey was administered to a convenience sample of 1,598 primarily African Americans, recruited at 40 sites, including the study sample of 726 people older than age 50. Results showed that respondents of both races preferred advice from their family doctor, clergy, or a family member. African Americans preferred services in their doctor’s or clergy’s office, whereas Caucasians preferred a professional service provider’s office. Findings suggest that providers and policy makers consider the impact of age, culture, and ethnicity on mental health services provision.

Mental Health Service Use Across the Life Course Among Adults With Psychiatric Disorders and Prior Suicidal Behavior

OBJECTIVE

Little is known about mental health service use by adults with prior suicidal behavior and current mood or anxiety disorders. This study determined nationally representative prevalence estimates of current mental health service use by these adults, examining racial-ethnic, age, and gender differences.

METHODS

Service use across the life course was examined with Collaborative Psychiatric Epidemiology Survey data from 1,139 adults with a history of suicidal behavior and current mood or anxiety disorders.

RESULTS

Overall service use was 47.3%. Across the life course, African Americans showed increasing service use that paralleled use by non-Hispanic whites, Hispanics, and others, whereas use by these three groups decreased in the latter half of the life course (p interaction=.01).

CONCLUSIONS

Adults with prior suicidal behavior and current mood or anxiety disorders have low mental health service use. Findings of racial-ethnic disparities in use can help identify those in need of care.

Insurance status, use of mental health services, and unmet need for mental health care in the United States

OBJECTIVE

The purpose of this study was to provide updated national estimates and correlates of service use, unmet need, and barriers to mental health treatment among adults with mental disorders.

METHODS

The sample included 36,647 adults ages 18-64 (9,723 with any mental illness and 2,608 with serious mental illness) from the 2011 National Survey on Drug Use and Health. Logistic regression models were used to examine predictors of mental health treatment and perceived unmet need.

RESULTS

Substantial numbers of adults with mental illness did not receive treatment (any mental illness, 62%; serious mental illness, 41%) and perceived an unmet need for treatment (any mental illness, 21%; serious mental illness, 41%). Having health insurance was a strong correlate of mental health treatment use (any mental illness: private insurance, adjusted odds ratio [AOR]=1.63, 95% confidence interval [CI]=1.29-2.06; Medicaid, AOR=2.66, CI=2.04-3.46; serious mental illness: private insurance, AOR=1.65, CI=1.12-2.45; Medicaid, AOR=3.37, CI=2.02-5.61) and of lower odds of perceived unmet need (any mental illness: private insurance, AOR=.78, CI=.65-.95; Medicaid, AOR=.70, CI=.54-.92). Among adults with any mental illness and perceived unmet need, 72% reported at least one structural barrier and 47% reported at least one attitudinal barrier. Compared with respondents with insurance, uninsured individuals reported significantly more structural barriers and fewer attitudinal barriers.

CONCLUSIONS

Low rates of treatment and high unmet need persist among adults with mental illness. Strategies to reduce both structural barriers, such as cost and insurance coverage, and attitudinal barriers are needed.

Childhood trauma, PTSD, and problematic alcohol and substance use in low-income, African-American men and women

Previous studies demonstrate that PTSD mediates the relationship between childhood trauma and alcohol and substance use disorders and that PTSD and alcohol/substance use comorbidity is greater in men than in women. We sought to replicate and extend these findings in a predominantly low-income, African-American sample recruited from a public hospital. We administered measures of childhood trauma, PTSD symptoms, problematic alcohol use, and problematic substance use to 803 men and 2084 women. We examined rates of comorbidity in men and women. Next, two bootstrap analyses were used to test whether PTSD is a mediator between childhood trauma and problematic alcohol use and between childhood trauma and problematic substance use. Finally, two bootstrap analyses were used to test whether gender would moderate the indirect effect of PTSD in both the alcohol and substance use models. Results showed that although men and women reported similar overall PTSD symptom frequency, men were more likely than women to report PTSD comorbid with alcohol and/or substance use problems. In addition, PTSD partially mediated the relationship between childhood trauma and problematic alcohol use and between childhood trauma and problematic substance use. The indirect effects of PTSD on the relationship between childhood trauma and problematic alcohol use and between childhood trauma and problematic substance use were greater in men. This study demonstrates the important interplay of gender, childhood trauma, PTSD, and alcohol and substance use. Mental health providers should consider childhood trauma histories and diagnostic comorbidities when treatment planning.

Geographic and racial-ethnic differences in satisfaction with and perceived benefits of mental health services

OBJECTIVE

This study examined whether racial-ethnic differences in satisfaction with and perceived benefits from mental health services vary by geographic region among U.S. adults.

METHODS

Drawn from the Collaborative Psychiatric Epidemiology Surveys (CPES), selected samples consisted of 2,160 adults age 18 and older from diverse racial-ethnic groups (Asian, black, Hispanic/Latino, and white) who had used mental health services in the past 12 months. Generalized linear model analysis was conducted for the United States as a whole and separately by geographic region (Northeast, South, Midwest, and West) after adjustment for covariates.

RESULTS

In the national sample, no significant main effects of race-ethnicity and geographic region were found in either satisfaction with or perceived benefits from mental health services. In the stratified analyses for geographic regions, however, significant racial-ethnic differences were observed in the West; blacks in the West were significantly more likely to report higher satisfaction and perceived benefits, whereas Hispanics/Latinos in the West were significantly less likely to do so.

CONCLUSIONS

The findings suggest that there are regional variations of racial-ethnic differences in satisfaction with and perceived benefits from mental health services among U.S. adults and that addressing needs of Hispanics/Latinos in the West may help reduce racial-ethnic disparities in mental health care. Clinical and policy implications are discussed.

Mental health service use among African-American emerging adults, by provider type and recency of use

OBJECTIVE

This study examined factors associated with mental health service utilization among African-American emerging adults, specifically, when services were used (recency) and the types of providers visited (mental health versus non-mental health).

METHODS

Guided by the behavioral model for vulnerable populations, secondary analysis of responses to the National Survey of American Life (2001-2003) was conducted. A nationally representative sample of African-American emerging adults, ages 18-29 (N=806), were assessed with the Composite International Diagnostic Interview. "Evaluated need" was determined by endorsement of mood, anxiety, substance use, or impulse control diagnoses. Respondents who reported a need for services for emotional or substance use problems were considered to have a "perceived need." Those who reported voluntary use of mental health or general medical services to address these problems were considered to have utilized services.

RESULTS

Twenty-five percent of the sample utilized services in their lifetime, whereas 9% utilized services in the past 12 months. Females were more likely than males to utilize services in three of the four service use categories (lifetime, mental health sector, and non-mental health sector). Respondents with an evaluated need for services were two to 12 times more likely to have used services compared with those without a need for them.

CONCLUSIONS

Little is known about why African-American emerging adults underutilize mental health services. Being female and having an evaluated need for services were associated with greater odds of service use, which would suggest the need for additional examination of gender differences in service utilization and greater mental health outreach and education among African-American males.

Emotion dysregulation as a mediator between childhood emotional abuse and current depression in a low-income African-American sample

Abuse and neglect in childhood are well-established risk factors for later psychopathology. Past research has suggested that childhood emotional abuse may be particularly harmful to psychological development. The current cross-sectional study employed multiple regression techniques to assess the effects of childhood trauma on adulthood depression and emotion dysregulation in a large sample of mostly low-income African Americans recruited in an urban hospital. Bootstrap analyses were used to test emotion dysregulation as a potential mediator between emotional abuse in childhood and current depression. Childhood emotional abuse significantly predicted depressive symptoms even when accounting for all other childhood trauma types, and we found support for a complementary mediation of this relationship by emotion dysregulation. Our findings highlight the importance of emotion dysregulation and childhood emotional abuse in relation to adult depression. Moving forward, clinicians should consider the particular importance of emotional abuse in the development of depression, and future research should seek to identify mechanisms through which emotional abuse increases risk for depression and emotion dysregulation.

The associations of race/ethnicity and suicidal ideation among college students: a latent class analysis examining precipitating events and disclosure patterns

The aim of this paper was to examine precipitating events for suicidal ideation and how these experiences relate to disclosure in a diverse sample of college students were examined. Among non-Hispanic White students, relationship/academic problems were most associated with ideation. A romantic break-up increased the odds of getting help. Among racial/ethnic minority students, family/academic problems were most associated with ideation and students who reported multiple events were less likely to get help compared with those not reporting events. Future research should examine the reasons for interpersonal conflict among this high-risk group and their attitudes about help-seeking, and identify cultural norms associated with disclosure.

Assessing racial/ethnic disparities in treatment across episodes of mental health care

OBJECTIVE

To investigate disparities in mental health care episodes, aligning our analyses with decisions to start or drop treatment, and choices made during treatment.

STUDY DESIGN

We analyzed whites, blacks, and Latinos with probable mental illness from Panels 9-13 of the Medical Expenditure Panel Survey, assessing disparities at the beginning, middle, and end of episodes of care (initiation, adequate care, having an episode with only psychotropic drug fills, intensity of care, the mixture of primary care provider (PCP) and specialist visits, use of acute psychiatric care, and termination).

FINDINGS

Compared with whites, blacks and Latinos had less initiation and adequacy of care. Black and Latino episodes were shorter and had fewer psychotropic drug fills. Black episodes had a greater proportion of specialist visits and Latino episodes had a greater proportion of PCP visits. Blacks were more likely to have an episode with acute psychiatric care.

CONCLUSIONS

Disparities in adequate care were driven by initiation disparities, reinforcing the need for policies that improve access. Many episodes were characterized only by psychotropic drug fills, suggesting inadequate medication guidance. Blacks' higher rate of specialist use contradicts previous studies and deserves future investigation. Blacks' greater acute mental health care use raises concerns over monitoring of their treatment.

Recruitment of older African American males for depression research: lessons learned

Depression is projected to become the leading cause of disability and the second leading contributor to the global burden of disease in approximately 10years. Few studies have explored the signs and symptoms of depression experienced by older African American men. Therefore, a pilot study was developed with the goal of addressing this gap in knowledge. Despite a variety of recruitment strategies, the study yielded no participants after 9months of effort. Lessons learned from the recruitment efforts and other researchers' successful techniques and strategies are discussed.

Addressing the mental health needs of pregnant and parenting adolescents

Adolescent parenthood is associated with a range of adverse outcomes for young mothers, including mental health problems such as depression, substance abuse, and posttraumatic stress disorder. Teen mothers are also more likely to be impoverished and reside in communities and families that are socially and economically disadvantaged. These circumstances can adversely affect maternal mental health, parenting, and behavior outcomes for their children. In this report, we provide an overview of the mental health challenges associated with teen parenthood, barriers that often prevent teen mothers from seeking mental health services, and interventions for this vulnerable population that can be integrated into primary care services. Pediatricians in the primary care setting are in a unique position to address the mental health needs of adolescent parents because teens often turn to them first for assistance with emotional and behavioral concerns. Consequently, pediatricians can play a pivotal role in facilitating and encouraging teen parents' engagement in mental health treatment.

Late-life depression in older African Americans: a comprehensive review of epidemiological and clinical data

OBJECTIVE

The population of older African Americans is expected to triple by 2050, highlighting the public health importance of understanding their mental health needs. Despite evidence of the negative impact of late-life depression, less is known of how this disorder affects the lives of older African Americans. Lack of studies focusing on how depression presents in older African Americans and their subsequent treatment needs lead to a gap in epidemiologic and clinical knowledge for this population. In this review, we aim to present a concise report of prevalence, correlates, course, outcomes, symptom recognition, and treatment of depression for these individuals.

METHOD

We performed a literature review of English-language articles identified from PubMed and Medline published between January 1990 and June 2012. Studies included older adults and contained the key words 'geriatric depression in African Americans', 'geriatric depression in Blacks', and 'geriatric depression in minorities'.

RESULTS

Although in most studies, older African Americans had higher or equivalence prevalence of depression compared with Caucasian Americans, we also found lower rates of recognition of depression and treatment. Many studies reported worse outcomes associated for depression among older African Americans compared with older Caucasians.

CONCLUSIONS

Serious racial and ethnic disparities persist in the management of older African Americans with depression. Understanding their unmet needs and improving depression care for these individuals is necessary to reduce these disparities.

A home-based intervention to reduce depressive symptoms and improve quality of life in older African Americans: a randomized trial

BACKGROUND

Effective care models for treating older African Americans with depressive symptoms are needed.

OBJECTIVE

To determine whether a home-based intervention alleviates depressive symptoms and improves quality of life in older African Americans.

DESIGN

Parallel, randomized trial stratified by recruitment site. Interviewers assessing outcomes were blinded to treatment assignment. (ClinicalTrials.gov: NCT00511680).

SETTING

A senior center and participants' homes from 2008 to 2010.

PATIENTS

African Americans aged 55 years or older with depressive symptoms.

INTERVENTION

A multicomponent, home-based intervention delivered by social workers or a wait-list control group that received the intervention at 4 months.

MEASUREMENTS

Self-reported depression severity at 4 months (primary outcome) and depression knowledge, quality of life, behavioral activation, anxiety, function, and remission at 4 and 8 months.

RESULTS

Of 208 participants (106 and 102 in the intervention and wait-list groups, respectively), 182 (89 and 93, respectively) completed 4 months and 160 (79 and 81, respectively) completed 8 months. At 4 months, participants in the intervention group showed reduced depression severity (difference in mean change in Patient Health Questionnaire-9 score from baseline, -2.9 [95% CI, -4.6 to -1.2]; difference in mean change in Center for Epidemiologic Studies Depression Scale score from baseline, -3.7 [CI, -5.4 to -2.1]); improved depression knowledge, quality of life, behavioral activation, and anxiety (P < 0.001); and improved function (P = 0.014) compared with wait-list participants. More intervention than wait-list participants entered remission at 4 months (43.8% vs. 26.9%). After treatment, control participants showed benefits similar in magnitude to those of participants in the initial intervention group. Those in the initial intervention group maintained benefits at 8 months.

LIMITATION

The study had a small sample, short duration, and differential withdrawal rate.

CONCLUSION

A home-based intervention delivered by social workers could reduce depressive symptoms and enhance quality of life in most older African Americans.

PRIMARY FUNDING SOURCE

National Institute of Mental Health.

African American women living with mental disorders: factors associated with help seeking from professional services and informal supports

This study utilized data from the National Survey of American Life to investigate the use of professional services and informal support among Black women with a lifetime mood, anxiety, or substance use disorder. Forty-seven percent combined professional services and informal support, 14% relied on professional services only, 2% used informal support only, and 16% did not seek help. Co-occurring disorders, recent episodes, social networks, marital status, age, and level of education were significantly related to help seeking from professional and informal helpers, demonstrating the importance of both. Targeting interventions in these areas will likely increase treatment effectiveness.

Regional variation of racial disparities in mental health service use among older adults

PURPOSE

Given the paucity of research on the role of geography in mental health care, this study examined whether racial differences in mental health service use varied across geographic regions among older adults.

DESIGN AND METHODS

Drawn from the Collaborative Psychiatric Epidemiology Surveys (CPES), blacks (n = 1,008) and whites (n = 1,870) aged 60 and older were selected for analysis. Logistic regression analyses were conducted.

RESULTS

Results showed significant racial disparities in mental health service use in the overall sample, as well as significant variation by region. Although no racial differences were observed in the Northeast, West, or Midwest regions, black elders in the South were significantly less likely than whites to use mental health services (odds ratios [OR], 2.08; 95% confidence interval [CI], 1.34-3.23).

IMPLICATIONS

The findings suggest that improving the access to mental health care in certain regions, the South in particular, may be essential to reduce racial disparities at the national level. Policy implications are discussed.

Comparative effectiveness of standard versus patient-centered collaborative care interventions for depression among African Americans in primary care settings: the BRIDGE Study

OBJECTIVE

To compare the effectiveness of standard and patient-centered, culturally tailored collaborative care (CC) interventions for African American patients with major depressive disorder (MDD) over 12 months of follow-up.

DATA SOURCES/STUDY SETTING

Twenty-seven primary care clinicians and 132 African American patients with MDD in urban community-based practices in Maryland and Delaware.

STUDY DESIGN

Cluster randomized trial with patient-level, intent-to-treat analyses.

DATA COLLECTION/EXTRACTION METHODS

Patients completed screener and baseline, 6-, 12-, and 18-month interviews to assess depression severity, mental health functioning, health service utilization, and patient ratings of care.

PRINCIPAL FINDINGS

Patients in both interventions showed statistically significant improvements over 12 months. Compared with standard, patient-centered CC patients had similar reductions in depression symptom levels (-2.41 points; 95 percent confidence interval (CI), -7.7, 2.9), improvement in mental health functioning scores (+3.0 points; 95 percent CI, -2.2, 8.3), and odds of rating their clinician as participatory (OR, 1.48, 95 percent CI, 0.53, 4.17). Treatment rates increased among standard (OR = 1.8, 95 percent CI 1.0, 3.2), but not patient-centered (OR = 1.0, 95 percent CI 0.6, 1.8) CC patients. However, patient-centered CC patients rated their care manager as more helpful at identifying their concerns (OR, 3.00; 95 percent CI, 1.23, 7.30) and helping them adhere to treatment (OR, 2.60; 95 percent CI, 1.11, 6.08).

CONCLUSIONS

Patient-centered and standard CC approaches to depression care showed similar improvements in clinical outcomes for African Americans with depression; standard CC resulted in higher rates of treatment, and patient-centered CC resulted in better ratings of care.

Cultural beliefs and mental health treatment preferences of ethnically diverse older adult consumers in primary care

BACKGROUND

Beliefs concerning the causes of mental illness may help to explain why there are significant disparities in the rates of formal mental health service use among racial/ethnic minority elderly as compared with their white counterparts. This study applies the cultural influences on mental health framework to identify the relationship between race/ethnicity and differences in 1) beliefs on the cause of mental illness, 2) preferences for type of treatment, and 3) provider characteristics.

METHOD

Analyses were conducted using baseline data collected from participants who completed the cultural attitudes toward healthcare and mental illness questionnaire, developed for the Primary Care Research in Substance Abuse and Mental Health for the Elderly study, a multisite randomized trial for older adults (65+) with depression, anxiety, or at-risk alcohol consumption. The final sample consisted of 1,257 non-Latino whites, 536 African Americans, 112 Asian Americans, and 303 Latinos.

RESULTS

African Americans, Asian Americans, and Latinos had differing beliefs regarding the causes of mental illness when compared with non-Latino whites. Race/ethnicity was also associated with determining who makes healthcare decisions, treatment preferences, and preferred characteristics of healthcare providers.

CONCLUSIONS

This study highlights the association between race/ethnicity and health beliefs, treatment preferences, healthcare decisions, and consumers' preferred characteristics of healthcare providers. Accommodating the values and preferences of individuals can be helpful in engaging racial/ethnic minority patients in mental health services.

Assessment of depression among African American light smokers

Given the relationship between depression and smoking, we compared the two-item Patient Health Questionnaire (PHQ-2) and 10-item Center for Epidemiological Studies Depression Scale (CESD-10) in assessing depressive symptoms among African American light smokers in a clinical trial of bupropion. Of 539 participants, 21.3 percent reported significant depressive symptoms on the PHQ-2, 31.0 percent screened positive per CESD-10, 36.8 percent reported symptoms on either, and 15.6 percent screened positive on both (r = 0.47, p < .001). Having depressive symptoms was associated with less education, decreased positive affect and social support, and greater levels of negative affect and perceived stress. Cessation treatment should assess depression and address these symptoms.

A community-integrated home based depression intervention for older African Americans: [corrected] description of the Beat the Blues randomized trial and intervention costs

BACKGROUND

Primary care is the principle setting for depression treatment; yet many older African Americans in the United States fail to report depressive symptoms or receive the recommended standard of care. Older African Americans are at high risk for depression due to elevated rates of chronic illness, disability and socioeconomic distress. There is an urgent need to develop and test new depression treatments that resonate with minority populations that are hard-to-reach and underserved and to evaluate their cost and cost-effectiveness.

METHODS/DESIGN

Beat the Blues (BTB) is a single-blind parallel randomized trial to assess efficacy of a non-pharmacological intervention to reduce depressive symptoms and improve quality of life in 208 African Americans 55+ years old. It involves a collaboration with a senior center whose care management staff screen for depressive symptoms (telephone or in-person) using the Patient Health Questionnaire (PHQ-9). Individuals screened positive (PHQ-9 ≥ 5) on two separate occasions over 2 weeks are referred to local mental health resources and BTB. Interested and eligible participants who consent receive a baseline home interview and then are randomly assigned to receive BTB immediately or 4 months later (wait-list control). All participants are interviewed at 4 (main study endpoint) and 8 months at home by assessors masked to study assignment. Licensed senior center social workers trained in BTB meet with participants at home for up to 10 sessions over 4 months to assess care needs, make referrals/linkages, provide depression education, instruct in stress reduction techniques, and use behavioral activation to identify goals and steps to achieve them. Key outcomes include reduced depressive symptoms (primary), reduced anxiety and functional disability, improved quality of life, and enhanced depression knowledge and behavioral activation (secondary). Fidelity is enhanced through procedure manuals and staff training and monitored by face-to-face supervision and review of taped sessions. Cost and cost effectiveness is being evaluated.

DISCUSSION

BTB is designed to bridge gaps in mental health service access and treatments for older African Americans. Treatment components are tailored to specific care needs, depression knowledge, preference for stress reduction techniques, and personal activity goals. Total costs are $584.64/4 months; or $146.16 per participant/per month.

TRIAL REGISTRATION

ClinicalTrials.gov #NCT00511680.

Factors associated with use of community mental health services by schizophrenia patients using multilevel analysis

Background

Persons with schizophrenia and related disorders may be particularly sensitive to a number of determinants of service use, including those related with illness, socio-demographic characteristics and organizational factors. The objective of this study is to identify factors associated with outpatient contacts at community mental health services of patients with schizophrenia or related disorders.

Methods

This cross-sectional study analyzed 1097 patients. The main outcome measure was the total number of outpatient consultations during one year. Independent variables were related to socio-demographic, clinical and use of service factors. Data were collected from clinical records.

Results

The multilevel linear regression model explained 46.35% of the variance. Patients with significantly more contacts with ambulatory services were not working and were receiving welfare benefits (p = 0.02), had no formal education (p = 0.02), had a global level of severity of two or three (four being the most severe) (p < 0.001), with one or more inpatient admissions (p < 0.001), and in contact with both types of professional (nurses and psychiatrists) (p < 0.001). The patients with the fewest ambulatory contacts were those with diagnoses of persistent delusional disorders (p = 0.04) and those who were attended by four of the 13 psychiatrists (p < 0.001).

Conclusions

As expected, the variables that explained the use of community service could be viewed as proxies for severity of illness. The most surprising finding, however, was that a group of four psychiatrists was also independently associated with use of ambulatory services by patients with schizophrenia or related disorders. More research is needed to carefully examine how professional support networks interact to affect use of mental health.

Use of Professional and Informal Support by Black Men with Mental Disorders

This study utilized data from the National Survey of American Life to investigate the use of professional services and informal support among African American and Caribbean black men with a lifetime mood, anxiety, or substance use disorder. Thirty-three percent used both professional services and informal support, 14% relied on professional services only, 24% used informal support only, and 29% did not seek help. African American men were more likely than to rely on informal support alone. Having co-occurring mental and substance disorders, experiencing an episode in the past 12 months, and having more people in the informal network increased the likelihood of using professional services and informal supports. Marital status, age, and socioeconomic status were also significantly related to help-seeking. The results suggests potential unmet need. However, the reliance on informal support also suggests a strong protective role that informal networks play in the lives of black men.

Barriers to depression care for black older adults. Practice and policy implication

Late-life depression is a public health problem in the United States. Untreated, depression contributes to poorer health outcomes and increased mortality among older adults. Specifically, Black older adults are at higher risk for misdiagnosis, undertreatment, and more severe depressive symptomatology than other groups. Barriers to identification and treatment of depression in Black older adults include lack of access to quality mental health care, the stigma of mental illness, mistrust of mental health providers, and poor provider-client communication. Recommendations for gerontological nursing practice, education, and research to improve the care of depressed Black older adults are discussed. Implications for policy development are presented.

Electroconvulsive therapy for major depression within the Veterans Health Administration

OBJECTIVES

Electroconvulsive therapy (ECT) is the most effective treatment for severe or treatment resistant depression; however, the lack of widely accepted methods for determining when ECT is indicated may contribute to disparities and variation in use. We examined receipt of ECT among depressed patients in the largest coordinated health system in the US, the Veterans Health Administration.

METHODS

Using administrative data, we conducted a multivariable logistic regression to identify individual clinical and sociodemographic predictors of receiving ECT, including variables of geographic accessibility to ECT, among patients diagnosed with major depressive disorder between 1999 and 2004.

RESULTS

307 (0.16%) of 187,811 patients diagnosed with major depression received ECT during the study period. Black patients were less likely to receive ECT than whites (odds ratio 0.33; 95% confidence interval: 0.20, 0.55), and patients living in the South (OR: 0.71; 95% CI: 0.53, 0.95) or West (OR: 0.59; 95% CI: 0.42, 0.82) were less likely to receive ECT than patients living in the central US. Patients whose closest VA facility provided ECT had a higher likelihood of receiving ECT (OR: 3.02; 95% CI: 2.22, 4.10). Depressed patients with no major medical comorbidities were also more likely to receive ECT (OR: 2.42; 95% CI: 1.65, 3.55).

LIMITATIONS

Findings are not adjusted for depression severity.

CONCLUSIONS

ECT use for major depression was relatively uncommon. Race, US region, geographic accessibility, and general medical health were all associated with whether or not patients received ECT. Clinicians and health systems should work to provide equitable access and more consistent use of this safe and effective treatment.

Attitudes and beliefs about mental health among African American older adults suffering from depression

Depression among older adults is a major public health concern leading to increased disability and mortality. Less than 3% of older adults utilize professional mental health services for the treatment of depression, less than any other adult age group. And despite similar rates of depression, African Americans are significantly less likely to seek, engage and be retained in professional mental health services than their white counterparts. Cultural differences in the way depression symptoms are manifested, defined, interpreted and labeled may in part explain some of these racial differences in help-seeking behaviors. Focus group methodology was utilized to identify and explore attitudes and beliefs about depression and mental health treatment utilization among 42 older African Americans who had recently suffered a major depressive episode. Thematic analysis of identified six overarching themes: (a) perceptions of depression, (b) the African American experience, (c) seeking treatment as a last resort, (d) myths about treatment, (e) stigma associated with seeking treatment and (f) culturally appropriate coping strategies. We discuss implications for practice, education and research.

A comparison of the frequencies of risk factors for depression in older black and white participants in a study of indicated prevention

BACKGROUND

To compare the frequencies of risk factors, we describe risks for depression as a function of race among consecutively admitted participants in a randomized clinical trial of indicated depression prevention in later life.

METHODS

Seventy-two black and 143 white participants were screened for risk factors for depression.

RESULTS

Black participants were more likely to have fewer years of education and lower household income. They were more likely to be obese, live alone, experience functional disability, have a history of alcohol and drug abuse, and have lower scores on the Mini-mental State Examination and the Executive Interview (EXIT). White participants were not found to have greater prevalence or higher mean score on any risk factor. On average, black participants experienced approximately one more risk factor than white participants (t(213) = 3.32, p = 0.0011).

CONCLUSIONS

In our sample, black participants had higher frequencies of eight risk factors for depression and a greater mean number of risk factors compared to white participants.

The importance of examining movements within the US health care system: sequential logit modeling

BACKGROUND

Utilization of specialty care may not be a discrete, isolated behavior but rather, a behavior of sequential movements within the health care system. Although patients may often visit their primary care physician and receive a referral before utilizing specialty care, prior studies have underestimated the importance of accounting for these sequential movements.

METHODS

The sample included 6,772 adults aged 18 years and older who participated in the 2001 Survey on Disparities in Quality of Care, sponsored by the Commonwealth Fund. A sequential logit model was used to account for movement in all stages of utilization: use of any health services (i.e., first stage), having a perceived need for specialty care (i.e., second stage), and utilization of specialty care (i.e., third stage). In the sequential logit model, all stages are nested within the previous stage.

RESULTS

Gender, race/ethnicity, education and poor health had significant explanatory effects with regard to use of any health services and having a perceived need for specialty care, however racial/ethnic, gender, and educational disparities were not present in utilization of specialty care. After controlling for use of any health services and having a perceived need for specialty care, inability to pay for specialty care via income (AOR = 1.334, CI = 1.10 to 1.62) or health insurance (unstable insurance: AOR = 0.26, CI = 0.14 to 0.48; no insurance: AOR = 0.12, CI = 0.07 to 0.20) were significant barriers to utilization of specialty care.

CONCLUSIONS

Use of a sequential logit model to examine utilization of specialty care resulted in a detailed representation of utilization behaviors and patient characteristics that impact these behaviors at all stages within the health care system. After controlling for sequential movements within the health care system, the biggest barrier to utilizing specialty care is the inability to pay, while racial, gender, and educational disparities diminish to non-significance. Findings from this study represent how Americans use the health care system and more precisely reveals the disparities and inequalities in the U.S. health care system.

Factors associated with mental health service use in Latino and Asian immigrant elders

OBJECTIVES

The purpose of this study was to examine factors associated with the mental health service use of Latino and Asian immigrant elders. Adapting Andersen's behavioral health model of health service utilization, predisposing, enabling, and mental health need factors were considered as potential predictors for use of mental health services.

METHOD

Data were drawn from a nationally representative dataset, the National Latino and Asian American Survey (NLAAS). Hierarchical logistic regression analyses of mental health service use were conducted for Latino (N = 290) and Asian (N = 211) immigrant elders.

RESULTS

For both groups of immigrant elders, poor self-rated mental health was associated with significantly greater mental health service use, even after controlling for all other variables. For Latinos, use of mental health services was significantly associated with both predisposing factors (being younger and female) and mental health need factors (having any mood disorders and poor self-rated mental health). Among Asians, only mental health need factors (having any mood disorders and poor self-rated mental health) significantly affected mental health service use. In addition, poor self-rated mental health mediated the association between mood disorders and mental health service use only in Latino immigrant elders.

CONCLUSION

Results highlight an important role of self-rated mental health as a potential barrier in the use of mental health services, and suggest intervention strategies to enhance service use.

Conditions that influence a primary care clinician's decision to refer patients for depression care

The objective of this study was to identify conditions that influence primary care clinicians' referral decisions related to depression care. Forty primary care clinicians (15 general internists, 10 nurse practitioners, and 15 family practice physicians) were included in this study. The clinicians participated in semistructured interviews and completed two quantitative instruments (with 33 items on depression treatment decision making and 32 items on provider attitudes toward psychosocial care). Data analysis revealed that several conditions influence a clinician's decision to refer a depressed patient to a mental health specialist: the patient's resources, the clinician's comfort in prescribing antidepressants and counseling patients with depression, and familiarity with a mental health specialist and practice environment. The decision to refer a patient with depression to a mental health specialist is a complex process involving the clinician, patient, and practice-related issues. Understanding these relationships may provide strategies to improve depression care management and lead to the design of depression care quality-improvement interventions that accommodate primary care practice context. The findings from this study suggest a need to increase mental health training opportunities for primary care clinicians to strengthen their skills and comfort level in managing depressed patients and encourage the development of relationships between primary care clinicians and mental health specialists to facilitate timely and accessible mental health care for patients.