Psychiatric Illnesses and Ethnic Minorities

Foster Care Assessment Program, University of Washington, School of Social Work

January 28, 2009

Jeanne Miranda, Ph.D.UCLA Neuropsychiatric Institute

Disclosure

At this time, I have no actual or potential conflict of interest in relation to this program.

We will cover:

Minorities in the U.S. Rates of mental disorders of minorities Disparities in mental health care of minorities Response to evidence-based care Bringing care to ethnic minority communities

Minorities in the U.S.

1924 Immigration Act - national origins system - 2% of foreign-born in 1890.

Until 1960, majority of all legal immigrants were from Europe and Canada.

1965 Immigration Act - 20,000 from each country in Eastern Hemisphere.

Minorities in U.S.

14% Hispanic American

13% African American

5% Asian American

1.5% American Indian/Alaskan Native

Minorities in the U.S.

30% of population.

In 50 years - 57% of under 18.

Immigration now worldwide.

Growing percentage of population and growing more diverse

Minorities in the U.S.

• Racism and Race

Indirect effects through stress, segregation, poorer education.

Direct effects through inequitable distribution of medical resources

Minorities in the U.S.

Historical perspective essential Legally sanctioned discrimination and

exclusion of ethnic minorities is the rule, rather than the exception, for much of the history of this country.

Minorities in the U.S.

POVERTY 8.7% of White Americans 9.8% of Asian/Pacific Islanders21.9% of Hispanic Americans24.5% of Am Indians/Alaskans24.7% of African Americans

Rates of Mental Disorders

Income is not monotonically related to mental disorders.– more common among the impoverished.– serious and persistent disorders frequently

result in poverty.

Symptoms are monotonically related to SES.

Rates of Mental Disorders

Lifetime Past Year

Latino American % %

Puerto Rican 38.98 22.88

Cuban 28.38 15.91

Mexican 28.42 14.48

Other Latino 27.29 14.42

Asian American % %

Chinese 18.00 10.00

Filipino 16.74 8.99

Vietnamese 13.95 6.69

Other Asian 18.29 9.55

Black American % %

African American

30.54 14.79

Caribbean Black 27.87 16.38

White American 37.37 19.00

Rates of Mental Disorders

Disorders are not higher in minorities.– Rates of disorders

25% of Mexican immigrants 48% of U.S.- born Mexicans

– Rates of depression* U.S.-born black women – 10.5 African-born black women – 3.9 Caribbean-born black women – 4.8

Symptoms are higher in minorities Minorities recover less

Rates of Mental Disorders

Some evidence African Americans have increased rates of schizophrenia.

American Indians have higher rates of PTSD and alcoholism and lower rates of depression.

Southeast Asian refugees have extremely high rates of PTSD and depression

Disparities do exist in care

Minorities in need of care are less likely to get care than are white Americans.

Minorities getting care are less likely to get quality care than are white Americans.

Any depression treatmentPsychiatric Visits

Psychiatry Visits

85.0%

91.1%87.8%91.5% 91.1%

83.8%

92.9%

66.0%

69.5%

86.4%

92.5% 91.4%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1995 - 1996 1997 - 1999 2000 - 2002 2003 - 2005

Time period

Pe

rce

nt

WhiteBlackHispanic

Any depression treatmentPrimary Care Visits

Primary Care Visits

7.6%

10.4%10.8%

12.4%

6.1%

7.1%

8.5%9.0%

6.6%

9.5%

7.7%

9.8%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

1995 - 1996 1997 - 1999 2000 - 2002 2003 - 2005

Time Period

Pe

rce

nt

White

Black

Hispanic

Disparities in Mental Health Care

Logistic barriers– Insurance– Providers who speak language– Child care/work/life demands

Stigma Somatization

U.S. Department of Health and Human Services. (2001). Mental Health: Culture, Race, and Ethnicity—A Supplement to Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General.

People without Health Insurance Coverage by Race using 3-yr Average: 2003 to 2005

White 11.2%

Asian 17.7%

Black 19.5%

American Indian 29.9%

Hispanic 32.6%

Source: U.S Census Bureau, Central Population Report, Income, Poverty, and Health Insurance Coverage in the United States: 2005

RaceU.S.2005

Physician2005

Psychiatrist2002

Psychologist2004

SWorker2004

White 67% 77% 81% 93% 92%

Hispanic 14% 4% 5% 3% 3%

Black 13% 5% 3% 2% 4%

Asian 5% 14% 11% 2% 1%

Amer.Ind 1.5% 0.1% 0.1% 0.3% 0.2%

Nationally representative insured HCC sample

Friends Employers Insurers

n=5,930 N=5,589 N=5,589

Little/no concern

72% 26% 25%

Some/a lot of concern

28% 73% 76%

Stigma Concerns

Response to Evidence-based Care

Culturally competent care

– Evidence being culturally competent doesn’t improve outcomes

– Definitely not memorizing facts about culture, which continually shifts, but awareness of important issues

– Being sensitive to historical perspectives and power differences

– Being aware of the context of an individual’s life

Response to Evidence-based Care

African Americans and Latinos appear to respond similarly or better than do white Americans.

The few trials of Asians are promising.

American Indians/Alaskan Natives haven’t been studied.

Promise of Quality Improvement

Partner’s in Care – QI Study – 46 practices across U.S.*

Randomized resources to improve medication management or psychotherapy for depression

Latinos and African Americans– Less quality care at baseline

Miranda J, Duan N, Sherbourne C, Schoenbaum M, Lagomasino I,Jackson-Triche M, Wells KB. Can Quality Improvement Interventions Improve Care and Outcomes for Depressed Minorities? Results of a Randomized Controlled Trial. Health Services Research, 38(2):613-630. 2003.

Usual Care (UC)

QI-THERAPYsupport for

psychotherapy

QI-MEDSsupport formedication

management

Clinics Were RandomizedClinics Were RandomizedClinics Were RandomizedClinics Were Randomized

Interventions

• “Depression nurse” supported patient education, assessment, and getting started on treatment

• Primary care clinicians were taught about depression

• Patients and doctors could choose any treatment, or no treatment

• Provider networks were taught CBT

0 10 20 30 40 50 60 70 80% receiving appropriate care at 1 year

Interventions Increased Appropriate Care for All

QI programsQI programsUsual careUsual care

African American

Latino

White

Percentage with Probable Depression

0

10

20

30

40

50

60

70

%

De

pre

ss

ed

Latina Black White

6 Mo. Response to QI Resources

QI

Control

Implications

How we manage depressed patients for even one episode (information and treatment) can have long-term consequences over many years

– Patients may not need prolonged management by providers to reap some long-term gains

The most vulnerable depressed populations may have the most to gain from efforts to improve care

Similar Interventions Help:Youth Partners in Care

QI intervention for depressed youth in primary care increased rates of specialty care and counseling, improved depressive symptoms at 6 month follow-up - similar to PIC

Minorities benefited more than did white youth

WE Care for Impoverished Women

Randomized trial of 267 women screened in county entitlement clinics

– CBT– Guideline concordant medication (Paroxetine)– Referral to community care

9-11 telephone outreach calls necessary to engage women in care

Flexibility of care Babysitting and transportation provided

Miranda J, Chung JY, Green BL, Krupnick J, Siddique J, Revicki DA, Belin T. Treating Depression in Predominantly Low-Income Young Minority Women: A Randomized Controlled Trial. JAMA, 290(1):57-65. 2003.

Treatment Received

88 medication– 67 (76%) received appropriate care

90 CBT– 32 (35.5%) received appropriate care

89 referred– 15 (16.9%) received at least one session– 74 (83.1) did not attend care

Response to Care

6-month outcomes – asymptomatic

– 44.4% medication

– 32.2% CBT

– 28.1% referred

Response to Care

12-month outcomes – asymptomatic – 41.6% medication– 48.9% CBT– 30.3% referred

Cost-effectiveness ratios similar to those in advantaged populations

Public Sector Challenges for Young Mothers

Mental health departments prioritize severe mental illness

Primary care has limited resources “Depression is everyone’s problem…but nobody’s

business” Lack of insurance is a huge barrier to care Public sector services may not be places of trust

Conclusions

Understanding context of minorities lives are important to treatment.

For the most part, minorities do not have higher rates of disorders.

For the most part, evidence-based care works for African Americans and Hispanics and is promising for minorities.

Conclusions

Minorities with disorders are particularly unlikely to get care.– Treating minorities in settings the trust and

frequent.– Engaging in outreach to minorities.– Improving overall quality of care– Overcoming barriers, such as transportation,

babysitting, time of care, etc.– Increasing rates of minority providers.