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The authors aimed to uncover factors that affect engagement in substance use disorder treatment among Medicaid beneficiaries in New York State. The authors conducted 40 semistructured interviews with clients, plan administrators, health care providers, and policy leaders directly involved with substance use care in New York State. Data were analyzed with thematic analysis. Main themes resulting from analysis of the 40 interviews showed that most stakeholders agreed that a need exists to better integrate psychosocial services into behavioral health care systems; that systemic stigma, stigma from providers, and lack of cultural responsiveness in the substance use care system hinder engagement in and provision of high-quality care; and that rural health care networks with coordinated models benefit clients' engagement in care. Stakeholders involved in care for substance use disorder perceived a lack of integration of resources to meet clients' social needs, the presence of stigma, and low levels of cultural and linguistic capacity as key factors contributing to low engagement in and low quality of care for substance use disorder. Future interventions should address social needs within the therapeutic regimen and modify curricula in clinical training to reduce stigma and increase cultural competence. [ABSTRACT FROM AUTHOR]

The fields of psychiatry and mental health are increasingly recognizing the importance of social determinants of health (SDOH) and their impact on mental health outcomes. In this overview, the authors discuss the recent research, from the past 5 years, on advances made in SDOH work. SDOH frameworks and theories have expanded to include more social conditions, from traumas associated with immigration to psychosocial and community strengths, that impact mental health and well-being. Research has consistently shown the pervasive deleterious impacts of inequitable social conditions (e.g., food insecurity, housing instability) on minoritized populations' physical and mental health. Social systems of oppression (e.g., racism, minoritization) have also been shown to confer higher risk for psychiatric and mental disorders. The COVID-19 pandemic illuminated the inequitable impact of the social determinants of health outcomes. More efforts have been made in recent years to intervene on the social determinants through interventions at the individual, community, and policy levels, which have shown promise in improving mental health outcomes in marginalized populations. However, major gaps remain. Attention should be paid to developing guiding frameworks that incorporate equity and antiracism when designing SDOH interventions and improving methodological approaches for evaluating these interventions. In addition, structural-level and policy-level SDOH efforts are critical for making long-lasting and impactful advances toward mental health equity. [ABSTRACT FROM AUTHOR]

The Biden-Harris Administration's FY22 budget includes $1.6 billion for the Community Mental Health Services Block Grant program, more than double the FY21 allocation, given the rising mental health crises observed across the nation. This is timely since there have been two interrelated paradigm shifts: one giving attention to the role of the environmental context as central in mental health outcomes, the other moving upstream to earlier mental health interventions at the community level rather than only at the individual level. An opportunity to reimagine and redesign the agenda of mental health research and service delivery with marginalized communities opens the door to more community-based care interventions. This involves establishing multisector partnerships to address the social and psychological needs that can be addressed at the community level rather than the clinical level. This will require a shift in training, delivery systems, and reimbursement models. The authors describe the scientific evidence justifying these programs and elaborate on opportunities to target investments in community mental health that can reduce disparities and improve well-being for all. They select levers where there is some evidence that such approaches matter substantially, are modifiable, and advance the science and public policy practice. They conclude with specific recommendations and the logistical steps needed to support this transformational shift. [ABSTRACT FROM AUTHOR]

Objective: Patient activation involves patients' ability and motivation to communicate about their health and health care. Research has demonstrated that clinician or patient interventions may improve patient activation. This study explored the degree to which clinician and patient interventions affected both patient activation and symptoms of depression and anxiety in a racially and ethnically diverse clinical sample.Methods: Data were from a randomized clinical trial that included 312 patients and 74 clinicians from 13 Massachusetts community- and hospital-based outpatient behavioral health clinics. Patients completed measures of patient activation and depression and anxiety symptoms. Secondary data analyses were conducted to examine the effect of patient and clinician interventions (DECIDE-PA and DECIDE-PC, respectively) on depression and anxiety symptoms and patient activation. A multilevel, mixed-effects simultaneous-equation model was estimated to assess the relationship between the interventions, changes in patients' symptoms, and patient activation.Results: Clinicians' greater intervention dosage (i.e., more completed DECIDE-PC training sessions) was associated with patients' decreased anxiety symptoms, but associations with patient activation or depression symptoms were not significant. The effect of clinician training dosage on anxiety symptoms was stronger when patients and clinicians were not of the same race-ethnicity. The reduction in patients' anxiety symptoms appeared to increase patient activation.Conclusions: Clinician interventions designed to boost patient-clinician communication and the therapeutic alliance may serve to lessen patients' anxiety and may ultimately improve patient activation. [ABSTRACT FROM AUTHOR]

Objectives: This study examined the interaction of race-ethnicity and gender in depression screening, receipt of any mental health care, and receipt of adequate care. Methods: Data from electronic health records (2010-2012) of adult primary care patients from a New England urban health care system were used (N=65,079). Multivariate logit regression models were estimated to assess associations between race-ethnicity, gender, and other covariates and depression screening, any depression care among those with a positive screen, and adequate depression care. To measure disparities in utilization, we controlled for need variables but not for non-need variables, including insurance, marital status, and socioeconomic status. Results: Among males and females, blacks and Asians were less likely and Latinos were more likely to be screened for depression compared with whites. Among those with moderate or severe depression, black males and females, Latino males, and Asian males and females were less likely than whites to receive any mental health care. The disparity in screening between blacks and whites was greater among females compared with males. The disparity between Latinos and whites in receipt of any mental health care and of adequate care was greater among males than females. Conclusions: This approach underscored the importance of identifying disparities at each step of depression care by both race-ethnicity and gender. Targeting certain groups in specific stages of care, for example, screening of black females or providing any mental health care and adequate care for Latino males, would be more effective than a blanket approach to disparities reduction. [ABSTRACT FROM AUTHOR]

Objectives: Past literature documents many individual predictors of treatment engagement among mental health clients in community settings, but few studies have examined clinic characteristics that may be associated with treatment engagement. With data from a patient activation and self-management trial, this study examined the variation in demographic and clinic characteristics across community mental health clinics and whether this variation predicted differences in treatment engagement in mental health services. Methods: Chart reviews were conducted for 638 clients of 12 community mental health clinics. Client attendance records were collected for a one-year period to examine engagement (defined as the ratio of kept versus scheduled appointments). Adjusting for client variability, the investigators examined which clinic-level characteristics were associated with treatment engagement. Results: Clinics varied significantly in their clients. demographic characteristics and engagement in mental health care. Providing case management and offering transportation vouchers or free parking at the clinic were associated with lower engagement. However, offering outreach was associated with greater engagement. Conclusions: The results of this study suggest that certain clinic characteristics are associated with engagement in mental health services. These results demonstrate the difficulties faced by community mental health clinics in reducing no-show rates even in the face of strong efforts to improve engagement. [ABSTRACT FROM AUTHOR]

The article discusses the study which examines the efficacy of race-ethnicity on the effectiveness of clozapine among adult patients in maintenance antipsychotic treatment. The study used cox proportional hazard regression models to estimate associations between race-ethnicity and clozapine and their interaction. Results show that the superior effectiveness of clozapine has been confirmed and did not find evidence that race-ethnicity modified the effect.

Objective: Case management-based interventions aimed at improving quality of care have the potential to narrow racial and ethnic disparities among people with chronic illnesses. The aim of this study was to assess the equity effects of assertive community treatment (ACT), an evidence-based case management intervention, among homeless adults with severe mental illness.Methods: This study used baseline, three-, and 12-month data for 6,829 black, Latino, and white adults who received ACT services through the ACCESS study (Access to Community Care and Effective Services and Support). Zero-inflated Poisson random regression models were used to estimate the adjusted probability of use of outpatient psychiatric services and, among service users, the intensity of use. Odds ratios and rate ratios (RRs) were computed to assess disparities at baseline and over time.Results: No disparities were found in probability of use at baseline or over time. Compared with white users, baseline intensity of use was lower for black users (RR=.89; 95% confidence interval [CI]=.83-.96) and Latino users (RR=.65; CI=.52-.81]). Intensity did not change over time for whites, but it did for black and Latino users. Intensity increased for blacks between baseline and three months (RR=1.11, CI=1.06-1.17]) and baseline and 12 months (RR=1.17, CI=1.11-1.22]). Intensity of use dropped for Latinos between baseline and three months (RR=.83, CI=.70-.98).Conclusions: Receipt of ACT was associated with a reduction in service use disparities for blacks but not for Latinos. Findings suggest that ACT's equity effects differ depending on race-ethnicity. [ABSTRACT FROM AUTHOR]

Objective: This literature review examined the effects of patients' limited English proficiency and use of professional and ad hoc interpreters on the quality of psychiatric care. Methods: PubMed, PsycINFO, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) were systematically searched for English-language publications from inception of each database to April 2009. Reference lists were reviewed, and expert sources were consulted. Among the 321 articles identified, 26 met inclusion criteria: peer-reviewed articles reporting primary data on clinical care for psychiatric disorders among patients with limited proficiency in English or in the provider's language. Results: Evaluation in a patient's nonprimary language can lead to incomplete or distorted mental status assessment. Although both untrained and trained interpreters may make errors, untrained interpreters' errors may have greater clinical impact, compromising diagnostic accuracy and clinicians' detection of disordered thought or delusional content. Use of professional interpreters may improve disclosure in patient-provider communications, referral to specialty care, and patient satisfaction. Conclusions: Little systematic research has addressed the impact of language proficiency or interpreter use on the quality of psychiatric care in contemporary U.S. settings. Findings are insufficient to inform evidence-based guidelines for improving quality of care among patients with limited English proficiency. Clinicians should be aware of the ways in which quality of care can be compromised when they evaluate patients in a nonprimary language or use an interpreter. Given U.S. demographic trends, future research should help guide practice and policy by addressing deficits in the evidence base. [ABSTRACT FROM AUTHOR]

Objective: Few studies have compared treatment outcomes of African- American, Hispanic, and non-Hispanic white patients with bipolar disorder. The U.S. Systematic Treatment Enhancement Program for Bipolar Disorder compared one-year outcomes for bipolar I or II disorder from each of these racial-ethnic groups. Methods: African Americans (N=155) were retrospectively compared with a matched group of non-Hispanic whites (N=729), and Hispanics (N=152) were compared with a separate matched group of non-Hispanic whites (N=822). Response and recovery outcomes were examined. Survival analysis was used to compare time to treatment response for depression (Montgomery-Asberg Depression Rating Scale) and mania (Young Mania Rating Scale) as well as global assessment of functioning (Global Assessment of Functioning). Results: For manic and depressive symptoms, time to response and proportion of responders were similar across groups. Over the study year the proportion of days well was similar across groups. A smaller proportion of African Americans met criteria for improved global functioning. Depression response among African Americans with psychotic symptoms was slower than the response among African Americans without psychotic symptoms and among non-Hispanic whites with or without psychotic symptoms. No differences between Hispanics and non-Hispanic whites in response times and recovery were observed. Conclusions: Results are consistent with U.S. clinical trials for other psychiatric disorders, which have reported similar outcomes for ratings of primary symptoms. Baseline psychotic symptoms are likely a significant contributor when African Americans with bipolar disorder are slow to recover. These results may be less generalizable to uninsured patients. [ABSTRACT FROM AUTHOR]

Objectives: This study explored how mental health clinicians assess and respond to physical illness among patients presenting for mental health intake evaluations.Methods: A total of 129 adults were seen for a mental health intake visit. The intake visits were videotaped and involved 47 mental health clinicians from eight clinics who provided outpatient mental health and substance abuse treatment. A total of 120 videos of patient-provider interactions were coded using an information checklist containing 21 physical illness items. Twenty-eight intake visits exemplifying in-depth physical illness assessments were selected and transcribed for qualitative analysis.Results: Physical health was discussed in most intake visits (87%). Clinicians elicited information on physical health in 79 visits (66%), and patients volunteered such information in 80 visits (67%). Frequency of assessment differed by clinician discipline (p<.05) and by patient ethnicity (p=.06). Qualitative analysis revealed characteristics of appropriate assessments, such as formulating the contribution of physical conditions in the psychiatric differential diagnosis, noting physical side effects of medications, adjusting treatment plans, encouraging patient contact with primary care providers, and promoting physical health care.Conclusions: Assessment of physical illness is relatively common among mental health clinicians but was lacking in one-third of the cases in this study, until raised by patients. Because frequency of assessment differed by clinician discipline and patient ethnicity, innovations in patient assessment and clinician education are needed to address disparities in management of physical illness among individuals with mental illness. [ABSTRACT FROM AUTHOR]

Objective: This study examined whether there are service disparities among homeless adults with severe mental illnesses, a vulnerable population with a high level of unmet need. Methods: Data were collected at baseline for 6,829 black, Latino, and non-Latino white participants in the Access to Community Care and Effective Services and Support study. Outcome variables were measures of utilization of psychiatric outpatient, housing, and case management services in the previous 60 days. The sample was divided into white-black and white-Latino horts. Within each cohort, participants were stratified into comparable groups by propensity scores that estimated log-odds of being black or Latino as a function of several confounding variables. White-black and white-Latino differences in mean number of visits (a measure of intensity) and in the mean probability of at least one visit (a measure of access) were subsequently estimated for each of the three services. Results: The composition of the sample was 50% black, 6% Latino, and 44% white. Service utilization was low for the three services regardless of race-ethnicity. On multivariate analyses of service utilization in the previous 60 days, blacks made fewer psychiatric outpatient visits than whites (mean difference=.46, 95% confidence interval [CI]=.10 to .81]), yet Latinos had more case management visits than whites (mean difference=-.51, CI=-1.03 to -.05]). Analyses of access did not reveal racial-ethnic disparities. Conclusions: Whereas blacks used psychiatric outpatient services less frequently than whites, hence experiencing a service disparity, Latinos used case management services more than whites did. Possible contributors and clinical and methodological implications of these results are discussed. [ABSTRACT FROM AUTHOR]

Objective: Prior research on racial and ethnic disparities in depression treatment has been limited by the scarcity of national samples that include an array of diagnostic and quality indicators and substantial numbers of non-English-speaking individuals from minority groups. Using nationally representative data for 8,762 persons, the authors evaluated differences in access to and quality of depression treatments between patients in racial-ethnic minority groups and non-Latino white patients.Methods: Access to mental health care was assessed by past-year receipt of any mental health treatment. Adequate treatment for acute depression was defined as four or more specialty or general health provider visits in the past year plus antidepressant use for 30 days or more or eight or more specialty mental health provider visits lasting at least 30 minutes, with no antidepressant use.Results: For persons with past-year depressive disorder, 63.7% of Latinos, 68.7% of Asians, and 58.8% of African Americans, compared with 40.2% of non-Latino whites, did not access any past-year mental health treatment (significantly different at p<.001). Disparities in the likelihood of both having access to and receiving adequate care for depression were significantly different for Asians and African Americans in contrast to non-Latino whites.Conclusions: Simply relying on present health care systems without consideration of the unique barriers to quality care that ethnic and racial minority populations face is unlikely to affect the pattern of disparities observed. Populations reluctant to visit a clinic for depression care may have correctly anticipated the limited quality of usual care. [ABSTRACT FROM AUTHOR]

Objective: Although widely reported among Latino populations, contradictory evidence exists regarding the generaliz-ability of the immigrant paradox, i.e., that foreign nativity protects against psychiatric disorders. The authors examined whether this paradox applies to all Latino groups by comparing estimates of lifetime psychiatric disorders among immigrant Latino subjects, U.S-born Latino subjects, and non-Latino white subjects. Method: The authors combined and examined data from the National Latino and Asian American Study and the National Comorbidity Survey Replication, two of the largest nationally representative samples of psychiatric information. Results: In the aggregate, risk of most psychiatric disorders was lower for Latino subjects than for non-Latino white subjects. Consistent with the immigrant paradox, U.S.-born Latino subjects reported higher rates for most psychiatric disorders than Latino immigrants. However, rates varied when data were stratified by nativity and disorder and adjusted for demographic and socioeconomic differences across groups. The immigrant paradox consistently held for Mexican subjects across mood, anxiety, and substance disorders, while it was only evident among Cuban and other Latino subjects for substance disorders. No differences were found in lifetime prevalence rates between migrant and U.S.-born Puerto Rican subjects. Conclusions: Caution should be exercised in generalizing the immigrant paradox to all Latino groups and for all psychiatric disorders. Aggregating Latino subjects into a single group masks significant variability in lifetime risk of psychiatric disorders, with some subgroups, such as Puerto Rican subjects, suffering from psychiatric disorders at rates comparable to non-Latino white subjects. Our findings thus suggest that immigrants benefit from a protective context in their country of origin, possibly inoculating them against risk for substance disorders, particularly if they emigrated to the United States as adults. [ABSTRACT FROM AUTHOR]

Objective: The authors investigated whether there are disparities in the rates of specialty mental health care for Latinos and African Americans compared with non-Latino whites in the United States. Methods: Data were analyzed from the 1990-1992 National Comorbidity Survey, which surveyed a probability sample of 8,098 English-speaking respondents aged 15 to 54 years. Respondents self-identified their race or ethnicity, yielding a sample of 695 Latinos, 987 African Americans, and 6,026 non- Latino whites. Data on demographic characteristics, insurance status, psychiatric morbidity, whether the respondent lived in an urban or a rural area, geographic location, income, and use of mental health services were determined for each ethnic or racial group. Logistic regression analyses were used to examine the associations between ethnic or racial group and use of specialty services, with relevant covariates adjusted for. Results: Significant differences between ethnic groups were found in demographic characteristics, geographic location, zone of residence, insurance status, income, wealth, and use of mental health services. The results indicated that poor Latinos (family income of less than $15,000) have lower access to specialty care than poor non-Latino whites. African Americans who were not classified as poor were less likely to receive specialty care than their white counterparts, even after adjustment for demographic characteristics, insurance status, and psychiatric morbidity. Conclusions: To understand ethnic or racial disparities in specialty care, the effects of ethnicity or race should be analyzed in combination with variables related to poverty status and environmental context. Further research needs to address the complex construct of social position in order to bridge the gap in unmet need in specialty care. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Disparity in Depression Treatment Among Racial and Ethnic Minority Populations in the United States," by M Alegría and colleagues in the November 2008 issue.