OVERVIEW: DISPARITIES IN THE DIAGNOSIS AND TREATMENT OF MENTAL DISORDERS

1
OVERVIEW DISPARITIES IN THE DIAGNOSIS AND
TREATMENT OF MENTAL DISORDERS

• JAVIER I ESCOBAR MD
• UMDNJ-ROBERT WOOD JOHNSON MEDICAL SCHOOL

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Hispanic Population In the United States

• 1990 249 million total population
• 22.4 million Hispanics
• 9 of total population
• 2000 281 million total population
• 35.3 million Hispanics
• 12.5 of total population
• 1990 to 2000 change
• 13.0 million
• 58 increase since 1990

3
Disparities Affecting Latino Populations in the
United States
4
Educational Attainment (US 1996)
5
Median Family Income (US 1995)
6
Healthy People 2010

• Released by DHHS in January 2000
• Contains 467 Objectives grouped into 28 focus
  areas
• Major Goals are 1- Enhance life
  expectancy/quality of life and 2- Eliminate
  health disparities including those related to
  gender, race, ethnicity, education, income,
  disability, living in rural localities and sexual
  orientation

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Disparities The Federal Agenda
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National Assessment Tool 10 Leading Health
Indicators to Measure Health Status

• Mental health
• Injury and Violence
• Environmental Quality
• Immunization
• Access to health Care

• Physical Activity
• Overweight/Obesity
• Tobacco Use
• Substance Abuse
• Responsible Sexual Behavior

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Health Disparities in Medicine

• DIABETES (prevalence and outcomes -- e.g.
  amputations)
• HYPERTENSION
• AIDS
• OBESITY
• CHD prevalence and mortality
• STROKE (outcomes)

• INFANT MORTALITY
• IMMUNIZATION RATES
• BREAST EXAMINATIONS/ MAMMOGRAMS
• ACCESS TO PROCEDURES (e.g.
  bypass surgery)

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Other Major Health Disparities

• Insufficient information on Health Indexes,
  Treatment Adequacy and Response, etc.
• Lack of Access to and poor Quality of Services
• Low number of Minority Physicians, Dentists,
  Nurses
• Low number of Minority Faculty in Medical Schools
• Low number of Minority Researchers

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Mental Health Disparities

• Prevalence of Disorders
• Diagnostic Bias
  (Schizophrenia African Americans)
• Access to Services
• Quality of Services
• Cultural Competency
• Cultural Advantages
  (Latino immigrants)

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Paradoxical Findings The Health Advantages of
Latinos in the United States
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12 Month Prevalence of Mood and Addictive
Disorders in Males (Vega et al, 1997)
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Drugs
8
Alcohol
6
Mania
4
Dysthymia
2
Depression
0
USA
MEXICO
14
Prevalence of Mood Disorders in Primary Care
(Waitzkin, Escobar et al, 1997)
30
25
Major Depr.
20
Melancholia
15
Dysthymia
10
5
0
US Whites
US-born
Latnos
Mexicans
15
Use of Substances in Several Countries
(Medina-Mora et al, 2002)
USA
Canada
Mexico
South America
Asia
9
8
7
6
5
4
3
2
1
0
Marihuana
Cocaine
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Hypertension in Mexican Americans
(NHHANES III-1988-1994)
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Mortality (Hazard Ratios) Latinos vs. Non Latino
Whites in the US (NLMS Data)
(Abraido-Lanza et al AJPH 1999)
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PSYCHOTIC SYMPTOMS BY SEX AND PLACE OF BIRTH
(Vega et al, 2003)
Females/DISORDER
Males/Disorder
Females/ND
Males/ND
40
35
30
25
20
15
10
5
0
ImmigrantsLess
Immigrantsgt13
US-Born
than 13 Years
years
19
Study of a Large Mental Health System in New
JerseyMinsky et al, Archives of General
Psychiatry, 2003
20
Consumer Satisfaction in a Large Mental
Health System in NJ (very good to
excellent)
21
Basis 32 Baseline Scores
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Percent With Serious Mental Illness
(Dementia, Schizophrenia, MDD, Bipolar)
Latinos
Blacks
Whites
50
45
40
35
30
25
20
15
10
5
0
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Clinical Diagnosis for Patients Using MH Services
(N19,213) (Minsky et al, 2002)
Major Depression
Psychotic Disorders
25
20
15
10
5
0
African
Latinos
Other
Americans
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Psychosis in African Americans

• The findings of a higher rate of psychotic
  diagnoses in African-Americans are supported by
  several other reports (Bell Mehta 1980
  Strakowski et al, 1993 Lawson 1994).
• Research and Clinical Diagnoses less likely
  to agree in AA compared to White patients

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Possible Explanations of Observed Diagnostic
Disparities

• Self-Selection Latinos more likely to seek help
  for symptoms of depression?
• Language Issues of Translation and
  Interpretation?
• Cultural Repertoire Variation in Symptom
  Expression?
• Format of the Interview ?
• Interviewer or Examiners Bias?
• Diagnostic Bias Systems like DSM may lead to
  rigid use of common symptom lists, or
  preferential scrutiny of certain symptoms with
  little or no regard to cultural considerations.

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Possible Explanations of Diagnostic Disparities

• African Americans more likely to present with
  psychotic symptoms?
• Selective emphasis on certain symptoms (Focus on
  psychotic rather than mood symptoms).
• Undue emphasis on Schneiderian Symptoms?
• African Americans more likely to present with
  Schneiderian Symptoms? (No!, according to
  Strakowskys recent paper)
• Clinicians Bias?
• Need for new, systematic research

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Disparities in Treatment seem to be improving
28
NAMCS and NHAMCS data on Atypical Antipsychotics
Odd Ratios (Whites 1.0)
WHITES
BLACKS
HISPANICS
1.2
1
0.8
0.6
0.4
0.2
0
1992-94
1995-97
1998-2000
29
Some examples on inconsistencies in this area of
research that complicate interpretation of data
30
H-HANES Self Reports versus Health Assessment
in Puerto Ricans (Angel and
Guarnaccia, 1989)
Excellent/Very Good
Poor
70
60
50
40
30
20
10
0
Self-English
MD-English
Self-Spanish
MD-Spanish
31
Risk of Dying and Self Reported Poor/Fair
Health
(NHIS Data --Finch et al,
2002)
2.5
2
1.5
1
0.5
0
Recent
Long-term
US-BORN
Immigrants
Immigrants
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Recommendations

• Increase awareness on diagnostic disparities
• Use systematic, standardized inventories for
  making diagnoses (research diagnoses less biased
  than clinical diagnoses)
• Provide Culturally Congruent Services (e.g.,
  bilingual, bicultural services for US Latinos)
• Audit/Monitor trends in clinical diagnoses vs.
  symptom self reports (Basis-32).