OVERVIEW: DISPARITIES OVERVIEW: DISPARITIES IN THE DIAGNOSIS AND IN THE DIAGNOSIS AND TREATMENT OF MENTAL TREATMENT OF MENTAL

DISORDERSDISORDERS

JAVIER I ESCOBAR MDJAVIER I ESCOBAR MDUMDNJ-ROBERT WOOD UMDNJ-ROBERT WOOD

JOHNSON MEDICAL SCHOOLJOHNSON MEDICAL SCHOOL

2

Hispanic Population In the Hispanic Population In the United StatesUnited States

1990: 249 million total population1990: 249 million total population 22.4 million Hispanics22.4 million Hispanics 9% of total population9% of total population

2000: 281 million total population2000: 281 million total population 35.3 million Hispanics35.3 million Hispanics 12.5% of total population12.5% of total population

1990 to 2000 change:1990 to 2000 change: 13.0 million 13.0 million 58% increase since 199058% increase since 1990

Disparities Affecting Latino Disparities Affecting Latino Populations in the United StatesPopulations in the United States

Educational Attainment (US 1996)Educational Attainment (US 1996)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

High SchoolDiploma

CollegeDegree

Hispanic African American White

Median Family Income (US 1995)Median Family Income (US 1995)

$0

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

$35,000

$40,000

$45,000

Hispanic AfricanAmerican

White

““Healthy People 2010”Healthy People 2010” Released by DHHS in January 2000Released by DHHS in January 2000 Contains 467 Objectives grouped into Contains 467 Objectives grouped into

28 “focus areas”28 “focus areas” Major Goals are: 1- Enhance life Major Goals are: 1- Enhance life

expectancy/quality of life and 2- expectancy/quality of life and 2- Eliminate health disparitiesEliminate health disparities including including those related to gender, race, ethnicity, those related to gender, race, ethnicity, education, income, disability, living in education, income, disability, living in rural localities and sexual orientationrural localities and sexual orientation

Disparities: Disparities: The Federal AgendaThe Federal Agenda

National Assessment Tool = 10 Leading National Assessment Tool = 10 Leading Health Indicators to Measure Health StatusHealth Indicators to Measure Health Status

Physical ActivityPhysical Activity

Overweight/ObesityOverweight/Obesity

Tobacco UseTobacco Use

Substance AbuseSubstance Abuse

Responsible Sexual Responsible Sexual

BehaviorBehavior

Mental healthMental health

Injury and ViolenceInjury and Violence

Environmental QualityEnvironmental Quality

ImmunizationImmunization

Access to health Access to health

CareCare

Health Disparities in MedicineHealth Disparities in Medicine INFANT MORTALITYINFANT MORTALITY IMMUNIZATION RATESIMMUNIZATION RATES BREAST BREAST

EXAMINATIONS/ EXAMINATIONS/ MAMMOGRAMSMAMMOGRAMS

ACCESS TO ACCESS TO PROCEDURES PROCEDURES (e.g. bypass surgery) (e.g. bypass surgery)

DIABETES (prevalence DIABETES (prevalence and outcomes -- e.g. and outcomes -- e.g. amputations) amputations)

HYPERTENSIONHYPERTENSION AIDSAIDS OBESITYOBESITY CHD prevalence and CHD prevalence and

mortalitymortality STROKE (outcomes)STROKE (outcomes)

Other Major Health DisparitiesOther Major Health Disparities Insufficient information on Health Insufficient information on Health

Indexes, Treatment Adequacy and Indexes, Treatment Adequacy and Response, etc.Response, etc.

Lack of Access to and poor Quality of Lack of Access to and poor Quality of ServicesServices

Low number of Minority Physicians, Low number of Minority Physicians, Dentists, NursesDentists, Nurses

Low number of Minority Faculty in Low number of Minority Faculty in Medical SchoolsMedical Schools

Low number of Minority ResearchersLow number of Minority Researchers

Mental Health DisparitiesMental Health Disparities Prevalence of DisordersPrevalence of Disorders Diagnostic Bias Diagnostic Bias

(Schizophrenia & African Americans)(Schizophrenia & African Americans)

Access to ServicesAccess to Services Quality of ServicesQuality of Services Cultural CompetencyCultural Competency Cultural Advantages Cultural Advantages

(Latino immigrants)(Latino immigrants)

Paradoxical Findings: The Paradoxical Findings: The Health Advantages of Latinos Health Advantages of Latinos

in the United Statesin the United States

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

USA MEXICO0

2

4

6

8

10

Depression

Dysthymia

Mania

Alcohol

Drugs

Prevalence of Mood Disorders in Primary Prevalence of Mood Disorders in Primary Care Care (Waitzkin, Escobar et al, 1997)(Waitzkin, Escobar et al, 1997)

US Whites US-bornLatnos Mexicans

0

5

10

15

20

25

30

Major Depr.

Melancholia

Dysthymia

Use of Substances in Several CountriesUse of Substances in Several Countries

012

345678

9

Marihuana Cocaine

USA Canada MexicoSouth AmericaAsia

(Medina-Mora et al, 2002)

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

0%

5%

10%

15%

20%

25%

30%

35%

40%

Mexico-born

US-bornSpanish

US-born-English

Men Women

Mortality (Hazard Ratios) Latinos vs. Non Mortality (Hazard Ratios) Latinos vs. Non Latino Whites in the US (NLMS Data)Latino Whites in the US (NLMS Data)

(Abraido-Lanza et al AJPH 1999)(Abraido-Lanza et al AJPH 1999)

00.10.20.30.40.50.60.70.80.9

1

Males FemalesMexican Puerto Rican Cuban

Central/South Amer. Non-Latino Whites

PSYCHOTIC SYMPTOMS BY SEX PSYCHOTIC SYMPTOMS BY SEX AND PLACE OF BIRTHAND PLACE OF BIRTH

0

5

10

15

20

25

30

35

40

Immigrants;Lessthan 13 Years

Immigrants>13years

US-Born

Females/DISORDER Males/Disorder Females/ND Males/ND

(Vega et al, 2003)

Study of a Large Mental Study of a Large Mental Health System in New JerseyHealth System in New Jersey

Minsky et al, Archives of Minsky et al, Archives of General Psychiatry, 2003General Psychiatry, 2003

Consumer Satisfaction in a Large Mental Consumer Satisfaction in a Large Mental Health System in NJ (very good to excellent) Health System in NJ (very good to excellent)

52%

54%

56%

58%

60%

62%

64%

Latinos Blacks Whites

Basis 32 Baseline ScoresBasis 32 Baseline Scores

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

Total Psychoticism

Latinos Blacks Whites

Percent With Serious Mental IllnessPercent With Serious Mental Illness (Dementia, Schizophrenia, MDD, Bipolar)(Dementia, Schizophrenia, MDD, Bipolar)

0

5

10

15

20

25

30

35

40

45

50

Latinos Blacks Whites

Clinical Diagnosis for Patients Using Clinical Diagnosis for Patients Using MH ServicesMH Services (N=19,213) (Minsky et al, 2002)(N=19,213) (Minsky et al, 2002)

0

5

10

15

20

25

AfricanAmericans

Latinos Other

Major Depression Psychotic Disorders

Psychosis in African AmericansPsychosis in African Americans

The findings of a higher rate of The findings of a higher rate of psychotic diagnoses in African-psychotic diagnoses in African-Americans are supported by several Americans are supported by several other reports (Bell &Mehta 1980; other reports (Bell &Mehta 1980; Strakowski et al, 1993; Lawson 1994).Strakowski et al, 1993; Lawson 1994).

““Research” and “Clinical” Diagnoses Research” and “Clinical” Diagnoses less likely to agree in AA compared less likely to agree in AA compared to White patientsto White patients

Possible Explanations of Observed Possible Explanations of Observed Diagnostic DisparitiesDiagnostic Disparities

Self-Selection: Latinos more likely to seek help for Self-Selection: Latinos more likely to seek help for symptoms of depression?symptoms of depression?

Language: Issues of Translation and Interpretation?Language: Issues of Translation and Interpretation? Cultural Repertoire: Variation in Symptom Cultural Repertoire: Variation in Symptom

Expression?Expression? Format of the Interview ?Format of the Interview ? Interviewer or Examiner’s Bias?Interviewer or Examiner’s Bias? Diagnostic Bias: Systems like DSM may lead to rigid Diagnostic Bias: Systems like DSM may lead to rigid

use of common symptom lists, or preferential use of common symptom lists, or preferential scrutiny of certain symptoms with little or no regard scrutiny of certain symptoms with little or no regard to cultural considerations.to cultural considerations.

Possible Explanations of Possible Explanations of Diagnostic DisparitiesDiagnostic Disparities

African Americans more likely to present with African Americans more likely to present with psychotic symptoms?psychotic symptoms?

Selective emphasis on certain symptoms Selective emphasis on certain symptoms (Focus on psychotic rather than mood (Focus on psychotic rather than mood symptoms).symptoms).

Undue emphasis on Schneiderian Symptoms?Undue emphasis on Schneiderian Symptoms? African Americans more likely to present with African Americans more likely to present with

Schneiderian Symptoms? (No!, according to Schneiderian Symptoms? (No!, according to Strakowsky’s recent paper) Strakowsky’s recent paper)

Clinician’s Bias?Clinician’s Bias? Need for new, systematic researchNeed for new, systematic research

Disparities in Disparities in Treatment seem to be Treatment seem to be

improvingimproving

NAMCS and NHAMCS data on NAMCS and NHAMCS data on Atypical AntipsychoticsAtypical Antipsychotics

0

0.2

0.4

0.6

0.8

1

1.2

1992-94 1995-97 1998-2000

WHITES BLACKS HISPANICS

Odd Ratios (Whites = 1.0)

Some examples on Some examples on inconsistencies in this area of inconsistencies in this area of

research that complicate research that complicate interpretation of datainterpretation of data

H-HANES – Self Reports versus Health H-HANES – Self Reports versus Health

Assessment in Puerto RicansAssessment in Puerto Ricans (Angel and Guarnaccia, 1989)(Angel and Guarnaccia, 1989)

0%

10%

20%

30%

40%

50%

60%

70%

Self-English MD-English Self-Spanish MD-Spanish

Excellent/Very Good Poor

Risk of Dying and Self Reported Risk of Dying and Self Reported “Poor/Fair” Health“Poor/Fair” Health

(NHIS Data --Finch et al, 2002)(NHIS Data --Finch et al, 2002)

0

0.5

1

1.5

2

2.5

RecentImmigrants

Long-termImmigrants

US-BORN

RecommendationsRecommendations Increase awareness on diagnostic disparitiesIncrease awareness on diagnostic disparities Use systematic, standardized inventories for Use systematic, standardized inventories for

making diagnoses (research diagnoses less making diagnoses (research diagnoses less biased than clinical diagnoses)biased than clinical diagnoses)

Provide Culturally Congruent Services (e.g., Provide Culturally Congruent Services (e.g., bilingual, bicultural services for US Latinos)bilingual, bicultural services for US Latinos)

Audit/Monitor trends in clinical diagnoses vs. Audit/Monitor trends in clinical diagnoses vs. symptom self reports (Basis-32).symptom self reports (Basis-32).