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

Disparities Affecting Latino Populations in the United States

Educational Attainment (US 1996)

Median Family Income (US 1995)

“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

Disparities: The Federal Agenda

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

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

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

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

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

12 Month Prevalence of Mood and Addictive Disorders in Males (Vega et al, 1997) USAMEXICO Depression Dysthymia Mania Alcohol Drugs

Prevalence of Mood Disorders in Primary Care (Waitzkin, Escobar et al, 1997) US WhitesUS-born Latnos Mexicans Major Depr. Melancholia Dysthymia

Use of Substances in Several Countries MarihuanaCocaine USACanadaMexicoSouth AmericaAsia (Medina-Mora et al, 2002)

Hypertension in Mexican Americans (NHHANES III )

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

PSYCHOTIC SYMPTOMS BY SEX AND PLACE OF BIRTH Immigrants;Less than 13 Years Immigrants>13 years US-Born Females/DISORDERMales/DisorderFemales/NDMales/ND (Vega et al, 2003)

Study of a Large Mental Health System in New Jersey Minsky et al, Archives of General Psychiatry, 2003

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

Basis 32 Baseline Scores

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

Clinical Diagnosis for Patients Using MH Services (N=19,213) (Minsky et al, 2002) African Americans LatinosOther Major DepressionPsychotic Disorders

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

Possible Explanations of Observed Diagnostic Disparities Self-Selection: Latinos more likely to seek help for symptoms of depression? Self-Selection: Latinos more likely to seek help for symptoms of depression? Language: Issues of Translation and Interpretation? Language: Issues of Translation and Interpretation? Cultural Repertoire: Variation in Symptom Expression? Cultural Repertoire: Variation in Symptom 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 use of common symptom lists, or preferential scrutiny of certain symptoms with little or no regard to cultural considerations. 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.

Possible Explanations of Diagnostic Disparities African Americans more likely to present with psychotic symptoms? African Americans more likely to present with psychotic symptoms? Selective emphasis on certain symptoms (Focus on psychotic rather than mood symptoms). Selective emphasis on certain symptoms (Focus on psychotic rather than mood symptoms). Undue emphasis on Schneiderian Symptoms? Undue emphasis on Schneiderian Symptoms? African Americans more likely to present with Schneiderian Symptoms? (No!, according to Strakowsky’s recent paper) African Americans more likely to present with Schneiderian Symptoms? (No!, according to Strakowsky’s recent paper) Clinician’s Bias? Clinician’s Bias? Need for new, systematic research Need for new, systematic research

Disparities in Treatment seem to be improving

NAMCS and NHAMCS data on Atypical Antipsychotics WHITESBLACKSHISPANICS Odd Ratios (Whites = 1.0)

Some examples on inconsistencies in this area of research that complicate interpretation of data

H-HANES – Self Reports versus Health Assessment in Puerto Ricans (Angel and Guarnaccia, 1989) 0% 10% 20% 30% 40% 50% 60% 70% Self-EnglishMD-EnglishSelf-SpanishMD-Spanish Excellent/Very GoodPoor

Risk of Dying and Self Reported “Poor/Fair” Health (NHIS Data --Finch et al, 2002) Recent Immigrants Long-term Immigrants US-BORN

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