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

2. 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

7. Disparities: The Federal Agenda

8. Physical Activity Overweight/Obesity Tobacco Use Substance Abuse Responsible Sexual Behavior Mental health Injury and Violence Environmental Quality Immunization Access to health Care National Assessment Tool = 10 Leading Health Indicators to Measure Health Status

9. INFANT MORTALITY IMMUNIZATION RATES BREAST EXAMINATIONS/ MAMMOGRAMS ACCESS TO PROCEDURES (e.g. bypass surgery) DIABETES (prevalence and outcomes -- e.g. amputations) HYPERTENSION AIDS OBESITY CHD prevalence and mortality STROKE (outcomes) Health Disparities in Medicine

10. 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

11. Mental Health Disparities • Prevalence of Disorders • Diagnostic Bias (Schizophrenia & African Americans) • Access to Services • Quality of Services • Cultural Competency • Cultural Advantages (Latino immigrants)

12. Paradoxical Findings: The Health Advantages of Latinos in the United States

13. 12 Month Prevalence of Mood and Addictive Disorders in Males (Vega et al, 1997) 10 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

16. Hypertension in Mexican Americans (NHHANES III-1988-1994)

17. Mortality (Hazard Ratios) Latinos vs. Non Latino Whites in the US (NLMS Data)(Abraido-Lanza et al AJPH 1999)

18. 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 Immigrants;Less Immigrants>13 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

22. Percent With Serious Mental Illness(Dementia, Schizophrenia, MDD, Bipolar) Latinos Blacks Whites 50 45 40 35 30 25 20 15 10 5 0

23. Clinical Diagnosis for Patients Using MH Services(N=19,213) (Minsky et al, 2002) Major Depression Psychotic Disorders 25 20 15 10 5 0 African Latinos Other Americans

24. 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

25. 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 Examiner’s 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.

26. 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 Strakowsky’s recent paper) • Clinician’s Bias? • Need for new, systematic research

27. 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

32. 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).