November 1st, 2013

Study uncovers disparity during stages of treatment

A recent study published in Health Services Research tracking mental health care episodes found that blacks and Latinos are much less likely to initiate treatment. And whites are much more likely to have care that consists solely of filling psychotropic drugs without checking in with a provider.

Benjamin Lê Cook, Ph.D., MPH, study author, is an assistant professor in the department of psychiatry at Harvard Medical School and senior scientist at the Center for Multicultural Mental Health Research at Cambridge Health Alliance. Cook says this research is unusual because it looked at the beginning, middle and end of episodes of care.

“We examined when an individual starts care, what happens when he/she is getting it and when care is terminated,” Cook explains.

The research involved 47,903 adults age 18 and older and of these, 5,161 people (2,594 non-Latino whites, 1,134 blacks and 1,433 Latinos) met the criteria for probable mental illness and were included in the sample.

In general, whites were more likely to initiate care, with 40 percent seeking treatment compared to 27 percent Latinos and 24 percent blacks. In addition, blacks were more prone to have an episode that involved a psychiatric ER or inpatient care (5.4 percent versus 3.4 percent) and also more likely to visit specialists.

Cook says that the differences in the “middle” phase were surprising. “More whites got antidepressants for two years and just kept re-filling pills without having outpatient visits or seeing a provider at all.”

The author says that he was also surprised that overall, there were not major disparities in the number of visits for each group. “Mental health care went fairly well once they gained access to it.” However, minorities are likely to have shorter duration of care because they drop out earlier and tend to start care later when they have already reached more severe stages of mental illness.

Follow up research will look at episodes of care starting at an acute event requiring an inpatient visit. Researchers will examine the level of care following the stay to see if there are differences among ethnic/racial groups.

Pinpointing the reasons why blacks and Latinos are reluctant to seek care to begin with can be “speculative,” although there are some causes that are clear cut.

Latinos and blacks are less likely to be insured and having quality insurance is a strong predictor of whether people will seek help. “There is potential for the Patient Protection and Affordable Care Act to improve coverage for minority patients,” Cook says. Other barriers to care include a lack of access to providers and long wait times, the stigma that still surrounds mental health issues and a “word of mouth” perception problem that can develop when patients are dissatisfied with their treatment.

“Some people have negative experiences with a mental health provider and that opinion gets out and has a chilling effect on the community. What happens when they are in care affects their willingness to seek it and they warn off others (from getting help),” he explains.

Cook suggests that it would be beneficial to have psychiatrists or psychologists located in the same facility with primary care or other health providers to improve access to treatment. Also beneficial would be “good, culturally appropriate treatment,” he says, in order to retain patients and avoid the “chilling effect,” bad reviews of a practitioner can generate.

“We need providers who try to understand patients’ lives rather than relying only on diagnostics. Adapt the treatment and it could improve and warm that chilling effect,” he adds.

A shortage of bilingual and bicultural mental health professionals exists at a national level and also contributes to the hesitation by minorities to initially seek care. Cook feels there has been “very little movement” in closing that gap, but an impact is felt where efforts are made.

“Creating new workforces is difficult to do,” he says, noting that he sees progress made toward that goal at the Cambridge Health Alliance’s center where master’s level mental health providers are trained to provide cognitive behavior therapy (CBT) interventions.

“More culturally relevant medical care is needed as is education and community outreach,” he says.

Other study authors from Harvard included Nicholas Carson, M.D., FRCPC; Andrew Vesper, M.S.; and Thomas McGuire, Ph.D. Additional collaborators were Geoffrey Ferris Wayne, M.A., consultant at the Center for Multicultural Mental Health Research and Samuel H. Zuvekas, Ph.D., a senior economist at the Center for Financing, Access and Cost Trends, Agency for Healthcare Research and Quality in Rockville, Maryland.

By Susan Gonsalves

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