Transcript overview: disparities in the diagnosis and treatment of mental

OVERVIEW: DISPARITIES
IN THE DIAGNOSIS AND
TREATMENT OF MENTAL
DISORDERS
JAVIER I ESCOBAR MD
UMDNJ-ROBERT WOOD
JOHNSON MEDICAL SCHOOL
Hispanic Population In the
United States

1990: 249 million total population
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
2000: 281 million total population
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
22.4 million Hispanics
9% of total population
35.3 million Hispanics
12.5% of total population
1990 to 2000 change:
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
13.0 million
58% increase since 1990
2
Disparities Affecting Latino
Populations in the United States
Educational Attainment (US 1996)
90%
Hispanic
African American
White
80%
70%
60%
50%
40%
30%
20%
10%
0%
High School
Diploma
College
Degree
Median Family Income (US 1995)
$45,000
$40,000
$35,000
$30,000
$25,000
$20,000
$15,000
$10,000
$5,000
$0
Hispanic
African
American
White
“Healthy People 2010”
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
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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 2Eliminate 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 Heal
Indicators to Measure Health Status

Physical Activity

Mental health
Injury and Violence
Environmental

Overweight/Obesity


Tobacco Use


Substance Abuse

Responsible Sexual  Immunization
Behavior
Quality

Access to health
Care
Health Disparities in Medicine




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)
Other Major Health Disparities
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
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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
Mental Health Disparities


Prevalence of Disorders
Diagnostic Bias
(Schizophrenia & African Americans)




Access to Services
Quality of Services
Cultural Competency
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)
10
Drugs
8
Alcohol
6
Mania
4
Dysthymia
2
Depression
0
USA
MEXICO
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
Use of Substances in Several Countries
(Medina-Mora et al, 2002)
USA
Canada
Mexico
South America
9
8
7
6
5
4
3
2
1
0
Marihuana
Cocaine
Asia
Hypertension in Mexican Americans
(NHHANES III-1988-1994)
40%
Men
Women
35%
30%
25%
20%
15%
10%
5%
0%
Mexicoborn
US-born
Spanish
US-bornEnglish
Mortality (Hazard Ratios) Latinos vs. Non
Latino Whites in the US (NLMS Data)
(Abraido-Lanza et al AJPH 1999)
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Males
Mexican
Central/South Amer.
Females
Puerto Rican
Non-Latino Whites
Cuban
PSYCHOTIC SYMPTOMS BY SEX
AND PLACE OF BIRTH (Vega et al, 2003)
Females/DISORDER
Males/Disorder
Females/ND
40
35
30
25
20
15
10
5
0
Immigrants;Less Immigrants>13 US-Born
than 13 Years
years
Males/ND
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)
Latinos
64%
62%
60%
58%
56%
54%
52%
Blacks
Whites
Basis 32 Baseline Scores
Latinos
Blacks
Whites
1.8
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
Total
Psychoticism
Percent With Serious Mental Illness
(Dementia, Schizophrenia, MDD, Bipolar)
Latinos
50
45
40
35
30
25
20
15
10
5
0
Blacks
Whites
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
Americans
Latinos
Other
Psychosis in African Americans
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The findings of a higher rate of
psychotic diagnoses in AfricanAmericans 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
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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.
Possible Explanations of
Diagnostic Disparities
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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
Disparities in
Treatment seem to be
improving
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
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)
Excellent/Very Good Poor
70%
60%
50%
40%
30%
20%
10%
0%
Self-English
MD-English Self-Spanish MD-Spanish
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
Immigrants
Long-term
Immigrants
US-BORN
Recommendations

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
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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).