Understanding the Role of Past Health Care Discrimination in Help-Seeking and Shared Decision-Making for Depression Treatment Preferences

Patient perspectives for improving treatment initiation for new episodes of depression in historically minoritized racial and ethnic groups

OBJECTIVE

Depression is one of the costliest and most prevalent health conditions in the U.S. with 21 million adults having experienced at least one major depressive episode. Despite the availability of evidence-based treatments for depression, a large proportion of people with new diagnoses fail to initiate formal mental health treatment. Although individuals across all racial and ethnic groups fail to initiate treatment for depression, historically minoritized racial/ethnic groups are at even greater risk.

METHOD

Thirty-four participants representing historically underserved racial and ethnic populations from two large health care systems in the U.S. participated in qualitative interviews or focus group to identify factors that impede and facilitate depression treatment initiation in primary care settings.

RESULTS

Participants identified individual and systemic barriers and facilitators of treatment initiation for depression and suggested several ideas for increasing treatment engagement (i.e., increased communication and education from providers, community events, information on social media).

CONCLUSION

Novel interventions are needed to improve treatment initiation following initial diagnosis of depression in primary care settings. Findings from this study offer suggestions for improving treatment initiation in traditionally underserved communities.

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

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

Collaborative Care for Depression and Anxiety: Racial-Ethnic Differences in Treatment Engagement and Outcomes

OBJECTIVE

This study aimed to examine racial-ethnic differences in engagement with and clinical outcomes of a collaborative care model (CoCM) implemented in primary care outpatient clinics in an urban academic medical center.

METHODS

Adult patients (N=4,911) who screened positive for symptoms of depression, anxiety, or both on the Patient Health Questionnaire-9 or the Generalized Anxiety Disorder-7 scale and who identified as non-Hispanic Black, Hispanic, or non-Hispanic White were offered participation in a CoCM implementation. The primary outcome was treatment engagement, defined as receipt of any follow-up visit, minimally adequate 4-week follow-up (at least one visit), and minimally adequate 16-week follow-up (at least three visits) after initial assessment. Secondary outcomes were response and remission of depression or anxiety.

RESULTS

After adjustment of analyses for sociodemographic covariates, Black and Hispanic participants were significantly less likely than White participants to have received any or minimally adequate follow-up. Black and Hispanic participants who received any or minimally adequate 16-week follow-up were more likely than White participants to demonstrate depression symptom response and remission of anxiety symptoms.

CONCLUSIONS

This CoCM implementation appears to have been effective in treating depression and anxiety among Black and Hispanic patients. However, significant disparities in receipt of follow-up care were observed. Efforts must be made to improve the retention of patients from racial-ethnic minority groups in collaborative care.

Trust, discrimination and preference for shared decision-making in adolescents diagnosed with depression: Implications from Chinese mental health professionals

BACKGROUND

While evidence suggests that the attitudes of healthcare providers toward medical decision-making in adolescents diagnosed with depression merit exploration, research on their preferences for Shared Decision-Making (SDM) and the factors affecting these preferences remains limited.

OBJECTIVE

To investigate Chinese mental health professionals' (MHPs) preferences for SDM in adolescents with depression and identify the relationships between their preference for SDM and trust and discrimination.

METHODS

A cross-sectional design was used in this study. Clinical Decision-making Style-Staff (CDMS-S) was applied to evaluate their preferences for SDM. Physician Trust in the Patient Scale (PTPS) was utilised to assess their trust in consumers. Social Distance Scale to Mental Illness (SDSMI) was utilised to measure their discrimination against people with mental illness.

RESULTS

A total of 581 MHPs were identified in China. MHPs rated their preference for participation in decision making (PD) as shared (1.89 ± 0.472), information (IN) as moderate (2.62 ± 0.682), and family involvement (FI) as high (3.13 ± 0.840). The preferences for three decision topics ranked from the highest to the lowest score were working-related decision (2.35 ± 0.681), general preferences in decision (1.82 ± 0.581) and medication-related decision (1.74 ± 0.826). The mean score of PTPS and SDSMI were 34.71 (SD=9.709) and 15.17 (SD=4.299), respectively. Logistic regression indicated that the preference for PD was associated with discrimination; the preference for IN was associated with trust, discrimination and SDM-related training experience; and the preference for FI was associated with both trust and discrimination.

CONCLUSIONS

While MHPs generally exhibit a favourable attitude toward SDM, this positivity is not universally observed across all contexts. There remains room for improvement in the willingness to co-develop medication regimens and share health information. Rational recognition of depression, and building trusting and friendly therapeutic relationships are key to promoting MHPs' preferences for SDM.

PRACTICAL VALUE

MHPs' preferences for SDM have a significant impact on SDM implementation, which will be promoted by implementing SDM-related training.

Shared decision-making in the treatment of adolescents diagnosed with depression: A cross-sectional survey of mental health professionals in China

WHAT IS ALREADY KNOWN?: SDM improves clinical outcomes by increasing attendance and treatment adherence in adolescents diagnosed with depression. SDM could reduce treatment disagreements and enhance consumers' and their families' satisfaction with mental healthcare services. Healthcare professionals are a critical part of SDM. However, MHPs' practices of SDM in the daily management of adolescents diagnosed with depression need to be clarified. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: From the viewpoints of MHPs, SDM was not extensively applied in the daily management of adolescents diagnosed with depression. MHPs who trust their consumers and have received training related to SDM are more likely to practice SDM in the daily management of adolescents diagnosed with depression. The positive preferences for providing information and family involvement in treatment decision-making are facilitators; working in closed inpatient mental health wards and open inpatient mental health wards are hindering factors for MHPs' practices of SDM. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: MHPs should encourage information sharing with consumers and their family members to help them participate in treatment decision-making actively. A trusting and friendly therapeutic relationship with consumers should be maintained in the daily management of adolescents diagnosed with depression. SDM-related training should be encouraged for MHPs to promote widespread SDM.

ABSTRACT

INTRODUCTION: Shared decision-making (SDM) is an ideal model for a therapeutic relationship that can improve health outcomes. Healthcare professionals are a critical part of SDM, and they play an important role in the practices of SDM in the clinical setting. Evidence suggests that adolescents diagnosed with depression can benefit substantially from SDM. However, mental health professionals' (MHPs) practices of SDM for adolescents diagnosed with depression in China are not well-documented.

AIM

This study aimed to investigate the practices of SDM for adolescents diagnosed with depression from the viewpoints of MHPs in China.

METHOD

In this cross-sectional study, we recruited a total of 581 MHPs by convenience sampling. The Shared Decision-Making Questionnaire-Physician Version (SDM-Q-Doc) was used to evaluate the MHPs' practices of SDM for adolescents diagnosed with depression.

RESULTS

The mean SDM-Q-Doc was 80.47 (±16.31). Within the six specific decision-making situations, most MHPs selected non-SDM (52.7%-71.6%). Substantial numbers of respondents believed that MHPs made the final decision, especially with regard to the development (37%) and adjustment of medication regimens (42%). The practice of SDM was predicted by MHPs' preference for providing information, their trust in consumers, preference for family involvement in treatment decision-making, working in an outpatient clinic and receiving SDM training (F = 23.582; p = .000; R2  = .198; adjusted R2  = .189).

DISCUSSION

Although the MHPs' self-rated score of SDM-Q-Doc was high, SDM was not extensively applied in the daily management of adolescents diagnosed with depression. Thus, SDM needs to be further promoted by enhancing SDM-related training for MHPs, thereby actively promoting the involvement of families, facilitating the information sharing for consumers and families, and building an active, trusting consumer-practitioner relationship.

IMPLICATIONS FOR PRACTICE

MHPs should prioritise information sharing with consumers and families, as well as build trusting and friendly therapeutic relationships. Family involvement in treatment decisions should be encouraged when adolescents diagnosed with depression are in need. Actively participating in training related to SDM is also important. Future high-quality evidence is still needed to explore the facilitators and barriers to SDM practices from a tripartite perspective of MHPs, adolescents diagnosed with depression and their families.

Realigning theory with evidence to understand the role of care coordination in mental health services research

Current theoretical models intended to guide health services research and evaluation lack care coordination-its features and impacts. These aspects are critical for understanding the role of care coordination in healthcare use, quality, and outcomes. In this Focus article, we briefly review the well-known Andersen individual behavioral model (IBM) of healthcare use and the Donabedian health system and quality model (HSQM) together with recent practice-based evidence. We propose a new integrated theoretical model of healthcare and care coordination. The model can serve as a guide for future research to better understand the variation in care coordination services and delivery and its added value to improving mental health in different real-world settings.

Achieving mental health equity in Black male suicide prevention

Despite a steady decrease in suicide rates in the United States, the rate among Black males has increased in recent decades. Moreover, suicide is now positioned as the third leading cause of death in this population, signaling a public health crisis. Enhancing the ability for future suicide prevention scholars to fully characterize and intervene on suicide risk factors is an emerging health equity priority, yet there is little empirical evidence to robustly investigate the alarming trends in Black male suicide. We present fundamental areas of expansion in suicide prevention research focused on establishing culturally responsive strategies to achieve mental health equity. Notably, we identify gaps in existing research and offer future recommendation to reduce suicide death among Black males. Our perspective aims to present important and innovative solutions for ensuring the inclusion of Black males in need of suicide prevention and intervention efforts.

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

Background

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

Methods

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

Results

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

Conclusions

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

Bias reported by family caregivers in support received when assisting patients with cancer-related decision-making

BACKGROUND

Family caregivers play an increasing role in cancer treatment decision-making. We examined bias reported by family caregivers in the support they and their patient received from their healthcare team when making these decisions, including associations with distress.

METHODS

Analysis of 2021 national survey data of family caregivers of patients with cancer (N = 2703). Bias experienced in decision support was assessed with the item: "Have you felt that the support you and the person with cancer have received for making cancer-related decisions by your doctor or healthcare team has been negatively affected by any of the following?" Check-all-that-apply response options included: age, race, language, education, political affiliation, body weight, insurance type or lack of insurance, income, religion, sexual orientation, and gender/sex. Chi-square and regression analyses assessed associations between bias and caregiver distress (GAD-2, PHQ-2).

RESULTS

Of 2703 caregiver respondents, 47.4% (n = 1281) reported experiencing ≥1 bias(es) when receiving decision support for making cancer-related decisions. Bias was more prevalent among younger caregivers, males, transwomen/men or gender non-conforming caregivers, racial/ethnic minorities, and those providing care over a longer time period. The odds of having high anxiety (GAD-2 scores ≥ 3) were 2.1 times higher for caregivers experiencing one type of bias (adjusted OR, 2.1; 95% CI, 1.6-2.8) and 4.2 times higher for caregivers experiencing ≥2 biases (adjusted OR, 4.2; 95% CI, 3.4-5.3) compared to none. Similar results were found for high depression scores (PHQ-2 scores ≥ 3).

CONCLUSIONS

Nearly half of caregivers involved in their care recipients' cancer-related decisions report bias in decision support received from the healthcare team. Experiencing bias was strongly associated with high psychological distress.

Life Events, Barriers to Care, and Outcomes Among Minority Women Experiencing Depression: A Longitudinal, Mixed-Method Examination

ABSTRACT

The long-term course of depression is not well-understood among minority women. We assessed depression trajectory, barriers to depression care, and life difficulties among minority women accessing health and social service programs as part of the Community Partners in Care study. Data include surveys ( N = 339) and interviews ( n = 58) administered at 3-year follow-up with African American and Latina women with improved versus persistent depression. The majority of the sample reported persistent depression (224/339, 66.1%), ≥1 barrier to mental health care (226/339, 72.4%), and multiple life difficulties (mean, 2.7; SD, 2.3). Many barriers to care ( i.e. , related to stigma and care experience, finances, and logistics) and life difficulties ( i.e. , related to finances, trauma, and relationships) were more common among individuals reporting persistent depression. Results suggest the importance of past experiences with depression treatment, ongoing barriers to care, and negative life events as contributors to inequities in depression outcomes experienced by minority women.

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

OBJECTIVE

To examine trends in mental health care use for Black and Latinx children and adolescents.

METHOD

Data from the Medical Expenditure Panel Survey for 2010-2017 were analyzed to assess trends among youth ages 5-17 in use and expenditures for any mental health care, outpatient mental health care, and psychotropic medication prescription fills. Unadjusted trends for all youth and the subpopulation of youth reporting need for mental health care and disparities adjusting for need were examined.

RESULTS

Between 2010 and 2017, Black youth rates of any past year mental health care use decreased (from 9% to 8%), while White (from 13% to 15%) and Latinx (from 6% to 8%) youth rates increased. Among the subpopulation with need and in regression analysis adjusting for need, we identified significant Black-White and Latinx-White disparities in any mental health care use and any outpatient mental health care use in 2010-2011 and 2016-2017, with significant worsening of Black-White disparities over time. White youth were more than twice as likely as Latinx youth to use psychotropic medications, and Latinx-White and Black-White disparities in psychotropic medication prescription fills persisted over time. Black-White disparities existed in overall mental health expenditures (2016-2017) and outpatient mental health expenditures (2010-2011 and 2016-2017).

CONCLUSION

Affordable, ubiquitous access to mental health care for Black and Latinx youth remains an elusive target. Significant disparities exist in receiving mental health care despite reforms and policies designed to increase mental health care access in the general population. Additional outreach and treatment strategies tailored to the cultural, linguistic, and structural needs of youth of color are required.

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

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

Racism in healthcare: a scoping review

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Developing new ways to listen: the value of narrative approaches in empirical (bio)ethics

The use of qualitative research in empirical bioethics is becoming increasingly popular, but its implementation comes with several challenges, such as difficulties in aligning moral epistemology and methods. In this paper, we describe some problems that empirical bioethics researchers may face; these problems are related to a tension between the different poles on the spectrum of scientific paradigms, namely a positivist and interpretive stance. We explore the ideas of narrative construction, ‘genres’ in medicine and dominant discourses in relation to empirical research. We also reflect on the loss of depth and context that may occur with thematic or content analyses of interviews, and discuss the need for transparency about methodologies in empirical bioethics. Drawing on insights from narrative approaches in the social sciences and the clinical-educational discipline of Narrative Medicine, we further clarify these problems and suggest a narrative approach to qualitative interviewing in empirical bioethics that enables researchers to ‘listen (and read) in new ways’. We then show how this approach was applied in the first author’s research project about euthanasia decision-making. In addition, we stress the important ethical task of scrutinizing methodologies and meta-ethical standpoints, as they inevitably impact empirical outcomes and corresponding ethical judgments. Finally, we raise the question whether a ‘diagnostic’, rather than a ‘problem-solving’, mindset could and should be foregrounded in empirical ethics, albeit without losing a commitment to ethics’ normative task, and suggest further avenues for theorizing about listening and epistemic (in)justice in relation to empirical (bio)ethics.

Racism and Poverty are Barriers to the Treatment of Youth Mental Health Concerns

OBJECTIVE

Traditional studies of treatment moderators have focused largely on psychological factors such as clinical severity. Racial and economic inequity exert large effects on youth mental health, on treatment efficacy, and on the likelihood of receiving treatment altogether. Yet, these factors are studied less often by clinical psychological scientists.

METHOD

We conducted a narrative review of literature on racial and economic inequities and their impact on youth mental health.

RESULTS

First, systemic problems such as racism and poverty increase the risk of developing complex health issues and decrease the likelihood of benefiting from treatment. Second, attitudinal barriers, such as mistrust associated with treatments provided by researchers and government agencies, decrease the likelihood that minoritized groups will engage with or benefit from evidence-based treatments. Third, minoritized and underserved communities are especially unlikely to receive evidence-based treatment.

CONCLUSION

Clinical psychological science has unique insights that can help address systemic inequities that can decrease treatment efficacy for youth mental health treatment. Psychological scientists can help eliminate disparities in accessing evidence-based treatment and help end violent policies in underserved minoritized communities by at the very least (1) building and supporting scalable community-based treatments as well as (2) publicly advocating for an end to violent policies that impose negative social costs.