Effect of race and sex on primary care physicians' diagnosis and treatment of late-life depression

Individual, interpersonal, and organisational factors associated with discrimination in medical decisions affecting people with a migration background with mental health problems: the case of general practice

OBJECTIVES

Although people with a migration background (MB) have more unmet mental health needs than the general population, patients with a MB are still underrepresented in mental health care services. Provider bias towards these patients has been evidenced repeatedly but its driving factors remain elusive. We assessed the moderating effect of the individual (e.g. age and ethnicity), interpersonal (e.g. healthcare provider trust), and organisational (e.g. perceived workload) factors on general practitioners (GPs) differential decision-making regarding diagnosis, treatment, and referral for a depressed patient with or without a MB.

DESIGN

An experimental study was carried out in which GPs were shown one of two video vignettes featuring adult male depressed patients, one with a MB and the other without. Belgian GPs (n = 797, response rate was 13%) had to decide on their diagnosis, treatment, and referral. Analysis of variance and logistic regression were used to analyse the effect of a MB, adding interaction terms for the explanatory variables.

RESULTS

Overall, we found that there were ethnic differences in GPs' decisions regarding diagnosis and treatment recommendations. GPs perceived the symptoms of the patient with a MB as less severe (F = 7.68, p < 0.01) and demonstrated a reduced likelihood to prescribe a combination of medical and non-medical treatments (F = 11.55, p < 0.001). Those differences increased in accordance with the GP's age and perceived workload; at an interpersonal level, we found that differences increased when the GP thought the patient was exaggerating his distress.

CONCLUSION

This paper showed that lower levels of trust among GPs' towards their migrant patients and high GP workloads contribute to an increased ethnic bias in medical decision-making. This may perpetuate ethnic inequalities in mental health care. Future researchers should develop an intervention to decrease the ethnic inequities in mental health care by addressing GPs' trust in their migrant and ethnic minority patients.

Inequalities in the Incidence of Psychotic Disorders Among Racial and Ethnic Groups

OBJECTIVE

The authors examined recent trends in incidence of psychotic disorders, demographic characteristics, and comorbid psychiatric and medical conditions among six racial/ethnic groups.

METHOD

A retrospective cohort study design was used to examine the incidence of psychotic disorders across race/ethnicity groups and comorbid psychiatric and medical conditions among members of Kaiser Permanente Northern California from 2009 to 2019 (N=5,994,758). Poisson regression was used to assess changes in annual incidence, and Cox proportional hazards and logistic regression models adjusted for age and sex were used to test correlates and consequences.

RESULTS

Overall, the incidence of nonaffective psychotic disorders decreased slightly over the study period. Compared with White members, the risk of nonaffective psychosis diagnosis was higher among Black (hazard ratio=2.13, 95% CI=2.02-2.24) and American Indian or Alaskan Native (AIAN) (hazard ratio=1.85, 95% CI=1.53-2.23) members and lower among Asian (hazard ratio=0.72, 95% CI=0.68-0.76) and Hispanic (hazard ratio=0.91, 95% CI=0.87-0.96) members, as well as those whose race/ethnicity was categorized as "other" (hazard ratio=0.92, 95% CI=0.86-0.99). Compared with White members, the risk of affective psychosis diagnosis adjusted for age and sex was higher among Black (hazard ratio=1.76, 95% CI=1.62-1.91), Hispanic (hazard ratio=1.09, 95% CI=1.02-1.16), and AIAN (hazard ratio=1.38, 95% CI=1.00-1.90) members and lower among Asian (hazard ratio=0.77, 95% CI=0.71-0.83), Native Hawaiian or other Pacific Islander (hazard ratio=0.69, 95% CI=0.48-0.99), and "other" (hazard ratio=0.86, 95% CI=0.77-0.96) members. Psychotic disorders were associated with significantly higher odds of suicide (odds ratio=2.65, 95% CI=2.15-3.28), premature death (odds ratio=1.30, 95% CI=1.22-1.39), and stroke (odds ratio=1.64, 95% CI=1.55-1.72) and lower odds of health care utilization (odds ratio=0.44, 95% CI=0.42-0.47).

CONCLUSIONS

This study demonstrates racial and ethnic variation in incident psychotic disorder diagnoses in the United States, compared with non-Hispanic Whites. Individuals diagnosed with psychosis face a greater burden of other negative health outcomes and lower odds of health care utilization, reflecting personal and economic impacts. Identifying risk factors for elevated rates and protective influences in subgroups can inform strategies for prevention and interventions to ameliorate severe consequences of psychotic syndromes.

Examining racial disparity in psychotic disorders related ambulatory care visits: an observational study using national ambulatory medical care survey 2010-2015

BACKGROUND

One of the most consistent research findings related to race and mental health diseases is the disproportionately high rate of psychotic disorder diagnoses among people of color, specifically people of African descent. It is important to examine if a similar pattern exists among specific psychotic disorders. We aimed to examine the racial/ethnic differences in ambulatory care visits diagnosed with schizophrenia-spectrum disorders (SSDs).

METHODS

We analyzed data from the National Ambulatory Medical Care Survey (NAMCS) 2010-2015. The study sample included physician office-based visits by individuals diagnosed with SSDs, including schizophrenia, schizoaffective, and unspecified psychotic disorder (n = 1155). We used descriptive and bivariate analysis by race/ethnicity and three multinomial logistic regression models to test the association between the SSDs and race/ethnicity, adjusting for age, gender, insurance, disposition, medication Rx, and co-morbidity, considering the design and weight.

RESULT

Of the 1155 visits for SSDs, 44.8% had schizophrenia, 37.4% had schizoaffective disorder diagnosis, and 19.0% had unspecified psychosis disorder. We found significant racial disparities in the diagnosis of SSDs. Black patients were overrepresented in all three categories: schizophrenia (24%), schizoaffective disorder (17%), and unspecified psychosis disorder (26%). Also, a notable percentage of Black patients (20%) were referred to another physician in cases of schizophrenia compared to other ethnoracial groups (p < 0.0001). Moreover, we found a significant disparity in insurance coverage for schizoaffective disorder, with a higher percentage of Black patients (48%) having Medicaid insurance compared to patients from other ethnoracial groups (p < 0.0001). Black patients had nearly twice the odds of receiving a diagnosis of schizophrenia compared to White patients [AOR = 1.94; 95% CI: 1.28-2.95; P = 0.001]. However, they had significantly lower odds of being diagnosed with schizoaffective disorder [AOR = 0.42, 95% CI: 0.26-0.68; P = 0.003]. Race/ethnicity was not associated with receiving an unspecified psychosis disorder.

CONCLUSIONS

Our results show that SSDs, more specifically schizophrenia, continue to burden the mental health of Black individuals. Validation of our findings requires rigorous research at the population level that reveals the epidemiological difference of SSDs diagnoses in different race/ethnicity groups. Also, advancing our understanding of the nature of disparity in SSDs diagnoses among the Black population requires disentangling etiologic and systemic factors in play. This could include psychological stress, the pathway to care, services use, provider diagnostic practice, and experiencing discrimination and institutional and structural racism.

The influence of racial-ethnic discrimination on women's health care outcomes: A mixed methods systematic review

BACKGROUND

In the U.S, a wide body of evidence has documented significant racial-ethnic disparities in women's health, and growing attention has focused on discrimination in health care as an underlying cause. Yet, there are knowledge gaps on how experiences of racial-ethnic health care discrimination across the life course influence the health of women of color. Our objective was to summarize existing literature on the impact of racial-ethnic health care discrimination on health care outcomes for women of color to examine multiple health care areas encountered across the life course.

METHODS

We systematically searched three databases and conducted study screening, data extraction, and quality assessment. We included quantitative and qualitative peer-reviewed literature on racial-ethnic health care discrimination towards women of color, focusing on studies that measured patient-perceived discrimination or differential treatment resulting from implicit provider bias. Results were summarized through narrative synthesis.

RESULTS

In total, 84 articles were included spanning different health care domains, such as perinatal and cancer care. Qualitative studies demonstrated the existence of racial-ethnic discrimination across care domains. Most quantitative studies reported a mix of positive and null associations between discrimination and adverse health care outcomes, with variation by the type of health care outcome. For instance, over three-quarters of the studies exploring associations between discrimination/bias and health care-related behaviors or beliefs found significant associations, whereas around two-thirds of the studies on clinical interventions found no significant associations.

CONCLUSIONS

This review shows substantial evidence on the existence of racial-ethnic discrimination in health care and its impact on women of color in the U.S. However, the evidence on how this phenomenon influences health care outcomes varies in strength by the type of outcome investigated. High-quality, targeted research using validated measures that is grounded in theoretical frameworks on racism is needed. This systematic review was registered [PROSPERO ID: CRD42018105448].

Assessing Provider Bias in General Practitioners' Assessment and Referral of Depressive Patients with Different Migration Backgrounds: Methodological Insights on the Use of a Video-Vignette Study

Although the prevalence of common mental health conditions such as depression and anxiety, is higher among people with a migration background, these groups are generally underrepresented in all forms of institutionalized mental health care. At the root of this striking discrepancy might be unequal referral by health care practitioners. In this article we describe the development of a quasi-experimental video vignette methodology to assess potential forms of unequal diagnosing, treatment and referral patterns, based on clients' migration background and asylum status. The presented methodology also allows to explore whether potential differences are related to provider bias, i.e. underlying attitudes and expectations held by general practitioners. Potential assets and drawbacks of this methodology are discussed in detail.

The Role of Culture/Ethnicity in Communicating with Cancer Patients About Mental Health Distress and Suicidality

To explore the role of culture in communicating with cancer patients about mental health distress and suicidality. The Grounded Theory method of data collection and analysis was used. Healthcare professionals (HCPs) reported that language competency was a facilitator while being unable to speak the language or understand the nuances of their patient's communication could be a barrier. HCPs noted that being culturally matched with their patients helped them communicate effectively. HCPs also spoke about religious taboos on suicide as being a barrier to having conversations, either because patients did not feel comfortable discussing these issues, or because they perceived that this was not a topic they could bring up. Some HCPs reported that the culture/ethnicity of their patients had no effect on their ability to communicate effectively with them about mental health distress or suicidality. Advancing effective cross-cultural communication is a challenge faced by HCPs. Raising awareness about communication styles is an important step in addressing communication gaps about mental health and suicide with cancer patients. Training should facilitate skill development to engage in a culturally humble approach to cross-cultural communication including diversity training which encourages asking and actively listening to patients' needs and preferences.

Patterns and predictors of self-reported clinical diagnosis and treatment for depression in prostate cancer survivors

Background

Appropriate depression care is a cancer‐care priority. However, many cancer survivors live with undiagnosed and untreated depression. Prostate cancer survivors may be particularly vulnerable, but little is known about their access to depression care. The goal of this study was to describe patterns and predictors of clinical diagnosis and treatment of depression in prostate cancer survivors.

Methods

Generalized estimating equations were used to evaluate indicators of self‐reported clinical diagnosis and treatment depression as a function of individual‐level characteristics within a longitudinal dataset. The data were from a population‐based cohort of North Carolinian prostate cancer survivors who were enrolled from 2004 to 2007 on the North Carolina‐Louisiana Prostate Cancer Project (N = 1,031), and prospectively followed annually from 2008 to 2011 on the Health Care Access and Prostate Cancer Treatment in North Carolina (N = 805).

Results

The average rate of self‐reported clinical diagnosis of depression was 44% (95% CI: 39%‐49%), which declined from 60% to 40% between prostate cancer diagnosis and 5‐7 years later. Factors associated with lower odds of self‐reported clinical diagnosis of depression include African‐American race, employment, age at enrollment, low education, infrequent primary care visits, and living with a prostate cancer diagnosis for more than 2 years. The average rate of self‐reported depression treatment was 62% (95% CI: 55%‐69%). Factors associated with lower odds of self‐reported depression treatment included employment and living with a prostate cancer diagnosis for 2 or more years.

Conclusion

Prostate cancer survivors experience barriers when in need of depression care.

A qualitative comparison of DSM depression criteria to language used by older church-going African-Americans

OBJECTIVE

Depression in late life is associated with substantial suffering, disability, suicide risk, and decreased health-related quality of life. According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), a depression diagnosis is derived from a constellation of symptoms that may be described differently by different people. For example, the DSM language may be inadequate in capturing these symptoms in certain populations such as African-Americans, whose rates of depression misdiagnosis is high.

METHODS

This study reports the findings from a church-based, qualitative study with older African-Americans (n = 50) regarding the language they use when discussing depression and depression treatment, and how this compares to the DSM-IV depression criteria. Content analyses of the in-depth discussions with African-American male and female focus group participants resulted in a deeper understanding of the language they used to describe depression. This language was then mapped onto the DSM-IV depression criteria.

RESULTS

While some words used by the focus group participants mapped well onto the DSM-IV criteria, some of the language did not map well, such as language describing irritability, negative thought processes, hopelessness, loneliness, loss of control, helplessness, and social isolation.

CONCLUSIONS

The focus group setting provided insight to the language used by older, church-going African-Americans to describe depression. Implications include the advantages of using qualitative data to help inform clinical encounters with older African-Americans.

"Down in the Sewers": Perceptions of Depression and Depression Care Among African American Men

Depression is one of the most common, costly, and debilitating psychiatric disorders in the United States. One of the most persistent mental health disparities is the underutilization of treatment services among African American men with depression. Little is known about appropriateness or acceptability of depression care among African American men. The purpose of this study was to examine perceptions of depression and determine barriers to depression treatment among African American men. A series of four focus groups were conducted with 26 African American men. The average age of the sample was 41 years and most participants reported that they had completed high school. Nearly half of the participants reported that they are currently unemployed and most had never been married. The most common descriptions of depression in this study were defining depression as feeling down, stressed, and isolated. A small group of participants expressed disbelief of depression. The majority of participants recognized the need to identify depression and were supportive of depression treatment. Nonetheless, most men in this sample had never sought treatment for depression and discussed a number of barriers to depression care including norms of masculinity, mistrust of the health care system, and affordability of treatment. Men also voiced their desire to discuss stress in nonjudgmental support groups. Research findings highlight the need to increase the awareness of symptoms some African American men display and the need to provide appropriate depression treatment options to African American men.

Implicit bias in healthcare professionals: a systematic review

Background

Implicit biases involve associations outside conscious awareness that lead to a negative evaluation of a person on the basis of irrelevant characteristics such as race or gender. This review examines the evidence that healthcare professionals display implicit biases towards patients.

Methods

PubMed, PsychINFO, PsychARTICLE and CINAHL were searched for peer-reviewed articles published between 1st March 2003 and 31st March 2013. Two reviewers assessed the eligibility of the identified papers based on precise content and quality criteria. The references of eligible papers were examined to identify further eligible studies.

Results

Forty two articles were identified as eligible. Seventeen used an implicit measure (Implicit Association Test in fifteen and subliminal priming in two), to test the biases of healthcare professionals. Twenty five articles employed a between-subjects design, using vignettes to examine the influence of patient characteristics on healthcare professionals’ attitudes, diagnoses, and treatment decisions. The second method was included although it does not isolate implicit attitudes because it is recognised by psychologists who specialise in implicit cognition as a way of detecting the possible presence of implicit bias. Twenty seven studies examined racial/ethnic biases; ten other biases were investigated, including gender, age and weight. Thirty five articles found evidence of implicit bias in healthcare professionals; all the studies that investigated correlations found a significant positive relationship between level of implicit bias and lower quality of care.

Discussion

The evidence indicates that healthcare professionals exhibit the same levels of implicit bias as the wider population. The interactions between multiple patient characteristics and between healthcare professional and patient characteristics reveal the complexity of the phenomenon of implicit bias and its influence on clinician-patient interaction. The most convincing studies from our review are those that combine the IAT and a method measuring the quality of treatment in the actual world. Correlational evidence indicates that biases are likely to influence diagnosis and treatment decisions and levels of care in some circumstances and need to be further investigated. Our review also indicates that there may sometimes be a gap between the norm of impartiality and the extent to which it is embraced by healthcare professionals for some of the tested characteristics.

Conclusions

Our findings highlight the need for the healthcare profession to address the role of implicit biases in disparities in healthcare. More research in actual care settings and a greater homogeneity in methods employed to test implicit biases in healthcare is needed.

Do attitudes and behavior of health care professionals exacerbate health care disparities among immigrant and ethnic minority groups? An integrative literature review

OBJECTIVES

Recent investigations of ethnicity related disparities in health care have focused on the contribution of providers' implicit biases. A significant effect on health care outcomes is suggested, but the results are mixed. The purpose of this integrative literature review is to provide an overview and synthesize the current empirical research on the potential influence of health care professionals' attitudes and behaviors towards ethnic minority patients on health care disparities.

DESIGN

Integrative literature review.

DATA SOURCES

Four internet-based literature indexes - MedLine, PsychInfo, Sociological Abstracts and Web of Science - were searched for articles published between 1982 and 2012 discussing health care professionals' attitudes or behaviors towards ethnic minority patients.

REVIEW METHODS

Thematic analysis was used to synthesize the relevant findings.

RESULTS

We found 47 studies from 12 countries. Six potential barriers to health care for ethnic minorities were identified that may be related to health care professionals' attitudes or behaviors: Biases, stereotypes and prejudices; Language and communication barriers; Cultural misunderstandings; Gate-keeping; Statistical discrimination; Specific challenges of delivering care to undocumented migrants.

CONCLUSIONS

Data on health care professionals' attitudes or behaviors are both limited and inconsistent. We thus provide reflections on methods, conceptualization, interpretation and the importance of the geographical or socio-political settings of potential studies. More empirical data is needed, especially on health care professionals' attitudes or behaviors towards (irregular) migrant patients.

What are tests for? The implications of stuttering steps along the US patient pathway

This article explores the implications of how US family physicians make decisions about ordering diagnostic tests for their patients. Data is based on a study of 256 physicians interviewed after viewing a video vignette of a presenting patient. The qualitative analysis of 778 statements relating to trustworthiness of evidence for their decision making, the use of any kind of technology and diagnostic testing suggests a range of internal and external constraints on physician decision making. Test-ordering for family physicians in the United States is significantly influenced by both hidden cognitive processes related to the physician's calculation of patient resources and a health insurance system that requires certain types of evidence in order to permit further tests or particular interventions. The consequence of the need for physicians to meet multiple forms of proof that may not always relate to relevant treatment delays a diagnosis and treatment plan agreed not only by the physician and patient but also the insurance company. This results in a patient journey that is made up of stuttering steps to a confirmed diagnosis and treatment undermining patient-centred practice, compromising patient care, constraining physician autonomy and creating additional expense.

A systematic review of the extent and measurement of healthcare provider racism

BACKGROUND

Although considered a key driver of racial disparities in healthcare, relatively little is known about the extent of interpersonal racism perpetrated by healthcare providers, nor is there a good understanding of how best to measure such racism.

OBJECTIVES

This paper reviews worldwide evidence (from 1995 onwards) for racism among healthcare providers; as well as comparing existing measurement approaches to emerging best practice, it focuses on the assessment of interpersonal racism, rather than internalized or systemic/institutional racism.

METHODS

The following databases and electronic journal collections were searched for articles published between 1995 and 2012: Medline, CINAHL, PsycInfo, Sociological Abstracts. Included studies were published empirical studies of any design measuring and/or reporting on healthcare provider racism in the English language. Data on study design and objectives; method of measurement, constructs measured, type of tool; study population and healthcare setting; country and language of study; and study outcomes were extracted from each study.

RESULTS

The 37 studies included in this review were almost solely conducted in the U.S. and with physicians. Statistically significant evidence of racist beliefs, emotions or practices among healthcare providers in relation to minority groups was evident in 26 of these studies. Although a number of measurement approaches were utilized, a limited range of constructs was assessed.

CONCLUSION

Despite burgeoning interest in racism as a contributor to racial disparities in healthcare, we still know little about the extent of healthcare provider racism or how best to measure it. Studies using more sophisticated approaches to assess healthcare provider racism are required to inform interventions aimed at reducing racial disparities in health.

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.

Clinical practice patterns among native and immigrant doctors doing out-of-hours work in Norway: a registry-based observational study

OBJECTIVES

To evaluate whether immigrant and native Norwegian doctors differ in their practice patterns.

DESIGN

Observational study.

SETTING

Out-of-hours (OOH) emergency primary healthcare in Norway, 2008.

PARTICIPANTS

All primary care physicians doing OOH work, altogether 4165 physicians.

MAIN OUTCOME MEASURES

Number of patient contacts per doctor. Use of laboratory tests, minor surgery, sickness certification and length of consultations. Use of diagnoses related to psychiatric and sexual health. Choice of management strategy with psychiatric patients (psychotherapy or hospitalisation).

RESULTS

21.4% of the physicians were immigrants, and they had 30.6% of the patient contacts. Immigrant doctors from Asia, Africa and Latin America had most patient contacts, 633 (95% CI 549 to 716), while native Norwegian doctors had 306 (95% CI 288 to 325). In multivariate analyses, immigrant physicians did not differ significantly from native Norwegians regarding use of laboratory tests, minor surgery or length of consultations, but immigrant doctors wrote more sickness certificates, OR 1.75 (95% CI 1.24 to 2.47) for immigrant doctors from Europe, North America and Oceania versus native Norwegian doctors and OR 1.56 (95% CI 1.15 to 2.11) for immigrant doctors from Asia, Africa and Latin America versus native Norwegians. Immigrant physicians from Europe, North America and Oceania used more diagnoses related to pregnancy, family planning and female genitals, OR 1.55 (95% CI 1.11 to 2.16), versus native Norwegian physicians. Immigrant doctors from Asia, Africa and Latin America used less psychiatric diagnoses, OR 0.71 (95% CI 0.53 to 0.95), versus native Norwegian doctors but did not differ significantly in their management of recognised psychiatric illness.

CONCLUSIONS

Immigrant doctors make an important contribution to OOH emergency primary healthcare in Norway. The authors found only modest evidence that their clinical practice patterns are different from that of native Norwegian doctors.

Race and the clinical diagnosis of depression in new primary care patients

OBJECTIVE

The objective was to determine whether the effects of new patient status on primary care depression diagnoses differ by patient race.

METHOD

Primary care visits (n=168,482) from the National Ambulatory Medical Care Survey were analyzed. Logistic regression was used to evaluate main effects of new patient status on depression diagnoses and interactions with race.

RESULTS

Among Whites, approximately 2% of new visits and 3% of return visits resulted in depression diagnoses, whereas among African Americans, these corresponding proportions were 0.5% and 2%, respectively. The lower likelihood of receiving a depression diagnosis during new versus return primary care visits was significantly greater among African Americans than Whites (P=.04).

CONCLUSION

For African American primary care patients, first visits may be a high-risk period for missed diagnoses of depression.

Attitudes about depression and its treatment among mental health professionals, lay persons and immigrants and refugees in Norway

BACKGROUND

Internationally, depression is a common psychological disorder whose treatment depends upon its identification by treating professionals as well as patient utilization of mental health care systems; the latter often being hampered by cultural differences between patients and health professionals.

METHOD

The current study used vignettes of depressed patients which varied the culture and/or social circumstances of the patient to assess whether these variables influenced the conceptualization of depression and its treatment. Participants (N=722) included mental health professionals, lay people, immigrants, and refugees in Norway.

RESULTS

We found that immigrants and refugees, particularly those of non-western origin, endorsed different types of depression treatments from native Norwegians and mental health professionals, and judged who deserved treatment and who was overreacting based on the patient's culture and social circumstances, while native Norwegians did not.

LIMITATIONS

While widely used cross-culturally, vignette methodology is limited in its generalizability to real clinical situations. Acculturation was not evaluated, which may have influenced the results.

CONCLUSIONS

Findings support the integration of cultural competency ideals not only into treatment, but also into public health promotions of mental health services for lay people.

Access to adequate outpatient depression care for mothers in the USA: a nationally representative population-based study

Maternal depression is often untreated, resulting in serious consequences for mothers and their children. Factors associated with receipt of adequate treatment for depression were examined in a population-based sample of 2,130 mothers in the USA with depression using data from the 1996-2005 Medical Expenditure Panel Survey. Chi-squared analyses were used to evaluate differences in sociodemographic and health characteristics by maternal depression treatment status (none, some, and adequate). Multivariate regression was used to model the odds of receiving some or adequate treatment, compared to none. Results indicated that only 34.8% of mothers in the USA with depression received adequate treatment. Mothers not in the paid workforce and those with health insurance were more likely to receive treatment, while minority mothers and those with less education were less likely to receive treatment. Understanding disparities in receipt of adequate treatment is critical to designing effective interventions, reducing treatment inequities, and ultimately improving the mental health and health of mothers and their families.

Self-report of depressive symptoms in African American and white women in primary care

OBJECTIVES

Depressive symptoms are frequently seen among female patients in primary care. The majority of screening instruments are cumbersome for a busy clinic.

METHOD

The effectiveness of a 2-item depression screening questionnaire was compared to the mental health section of the 36-Item Short Form Health Survey (SF-36). A total of 127 consecutive patients who presented for primary care service agreed to participate and completed the questionnaire.

RESULTS

Of the final sample, 65.4% were African American and 44.9% of all women reported having depressive symptoms, with no significant difference in the prevalence of reported depressive symptoms between African American and white women (chi2 = 1.97, p = .16). The women reporting depressive symptoms were more likely to be in the lower-income group (chi2 = 9.02, p = .01); however, in stratified analysis this was only significant for the African American women (chi2 = 8.69, p = .01). Analysis of variance demonstrated that the women with depressive symptoms were more likely to score low on the mental health subscales of the SF-36 when adjusted for income (F = 58.32, P < .0001). Within race groups, the mean Mental Health Index scores were higher among African American women (t = -6.45, P <.0001) and White women (t = -3.59, P = .002) who reported depressive symptoms than among those who did not report depressive symptoms. The sensitivity and specificity of the 2-item depression symptom questions compared to the overall SF-36 mental health score were 70% and 77%, respectively.

CONCLUSION

A simple 2-item questionnaire can be used to identify depressive symptoms in white and African American women in a primary care clinic.

Are providers more likely to contribute to healthcare disparities under high levels of cognitive load? How features of the healthcare setting may lead to biases in medical decision making

Systematic reviews of healthcare disparities suggest that clinicians' diagnostic and therapeutic decision making varies by clinically irrelevant characteristics, such as patient race, and that this variation may contribute to healthcare disparities. However, there is little understanding of the particular features of the healthcare setting under which clinicians are most likely to be inappropriately influenced by these characteristics. This study delineates several hypotheses to stimulate future research in this area. It is posited that healthcare settings in which providers experience high levels of cognitive load will increase the likelihood of racial disparities via 2 pathways. First, providers who experience higher levels of cognitive load are hypothesized to make poorer medical decisions and provide poorer care for all patients, due to lower levels of controlled processing (H1). Second, under greater levels of cognitive load, it is hypothesized that healthcare providers' medical decisions and interpersonal behaviors will be more likely to be influenced by racial stereotypes, leading to poorer processes and outcomes of care for racial minority patients (H2). It is further hypothesized that certain characteristics of healthcare settings will result in higher levels of cognitive load experienced by providers (H3). Finally, it is hypothesized that minority patients will be disproportionately likely to be treated in healthcare settings in which providers experience greater levels of cognitive load (H4a), which will result in racial disparities due to lower levels of controlled processing by providers (H4b) and the influence of racial stereotypes (H4c).The study concludes with implications for research and practice that flow from this framework.

Physician clinical information technology and health care disparities

The authors develop a conceptual framework regarding how information technology (IT) can alter within-physician disparities, and they empirically test some of its implications in the context of coronary heart disease. Using a random experiment on 256 primary care physicians, the authors analyze the relationships between three IT functions (feedback and two types of clinical decision support) and five process-of-care measures. Endogeneity is addressed by eliminating unobserved patient characteristics with vignettes and by proxying for omitted physician characteristics. The results indicate that IT has no effects on physicians' diagnostic certainty and treatment of vignette patients overall. The authors find that treatment and certainty differ by patient age, gender, and race. Consistent with the framework, IT's effects on these disparities are complex. Feedback eliminated the gender disparities, but the relationships differed for other IT functions and process measures. Current policies to reduce disparities and increase IT adoption may be in discord.

Primary care physicians' evaluation and treatment of depression: Results of an experimental study using video vignettes

Little is known about how patient and primary care physician characteristics are associated with quality of depression care. The authors conducted structured interviews of 404 randomly selected primary care physicians after their interaction with CD-ROM vignettes of actors portraying depressed patients. Vignettes varied along the dimensions of medical comorbidity, attributions regarding the cause of depression, style, race/ethnicity, and gender. Results show that physicians showed wide variation in treatment decisions; for example, most did not inquire about suicidal ideation, and most did not state that they would inform the patient that there can be a delay before an antidepressant is therapeutic. Several physician characteristics were significantly associated with management decisions. Notably, physician age was inversely correlated with a number of quality-of-care measures. In conclusion, quality of care varies among primary care physicians and appears to be associated with physician characteristics to a greater extent than patient characteristics.

Is certainty more important than diagnosis for understanding race and gender disparities?: an experiment using coronary heart disease and depression case vignettes

OBJECTIVES

To (1) examine the influence of patient and provider attributes on physicians' diagnostic certainty and (2) assess the effect of diagnostic certainty on clinical therapeutic actions.

METHODS

Factorial experiment of 128 generalist physicians using identical clinically authentic videotaped vignettes depicting patients with coronary heart disease (CHD) or depression.

RESULTS

For CHD, physicians were least certain for Black patients (p=.003) and for younger female patients (p=.013). For depression, average certainty was higher than for the CHD presentation (74.0 vs. 57.9 on of scale of 0-100, p<.001) and there were no main effects of patient or provider characteristics. Increasing diagnostic certainty was a significant predictor of subsequent clinical actions, and these varied according to physician and patient characteristics across both conditions.

CONCLUSIONS

Physicians were least certain of their CHD diagnoses for Black patients and for younger women, but patient characteristics alone did not affect physician certainty of depression diagnoses. Physicians responded differentially to diagnostic certainty in terms of their clinical therapeutic actions such as test ordering and writing prescriptions. Physician responses to certainty may be as important as their responses to patient characteristics for understanding variation in clinical decision-making.

Residential mobility among patients in the VA health system: associations with psychiatric morbidity, geographic accessibility, and continuity of care

This paper reports on residential mobility among patients treated in the Veterans Affairs (VA) health system. We examine mobility in relation to patients' psychiatric disorders, and we assess the impact of mobility on health system geographic accessibility and continuity of care following inpatient discharge. Subjects included 534,002 patients with schizophrenia, bipolar disorder, depression, or with none of these conditions, who received VA services in both FY 01 and FY 02. We report the frequency and predictors of residential moves; we examine distance moved and changes in the proximity of VA providers; and we evaluate associations with timely receipt of outpatient care following inpatient discharges. Approximately 25% of patients with bipolar disorder, 20% with schizophrenia, 16% with depression, and 9% of patients without these conditions completed a residential move in FY 2002. When relocating, patients with schizophrenia and bipolar disorder were more likely to move closer to providers, suggesting greater sensitivity to accessibility barriers.

Challenges and opportunities in the care of international patients: clinical and health services issues for academic medical centers

International visitors who travel to the United States for the express purpose of receiving medical care constitute a small, but unique and important, subset of patients in this country. These visitors have traditionally sought care at what are widely regarded as the premier U.S. academic medical centers. Their care may prove challenging due to logistical, medical, language, and cross-cultural issues, and has the potential to distract from the educational and research missions of these medical centers. The author reflects on how one academic medical center, the Johns Hopkins Medical Institutions, has experienced and responded to these challenges. Specific issues include scheduling and evaluation challenges, language and cultural differences, and arranging continuity care. The author concludes that when an institution invests the resources necessary to address these issues, and enlists physicians stimulated by this challenging group of patients, the arrangement is mutually beneficial to the international patients and the institution. Scholarly evaluation of this phenomenon has been virtually nonexistent, due to both the unique niche occupied by these programs and institutional competition for this group of patients. However, collaborative evaluation of international patient programs will provide the opportunity to assess similarities, differences, and effectiveness, benefiting both those providing and those receiving care by improving the appropriateness and quality of care.