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Previous studies have documented diagnostic bias and noted that its reduction could eliminate misdiagnosis and improve mental health service delivery. Few studies have investigated clinicians' methods of obtaining and using information during the initial clinical encounter. We describe a study examining contributions to clinician bias during diagnostic assessment of ethnic/racial minority patients. A total of 129 mental health intakes were videotaped, involving 47 mental health clinicians from 8 primarily safety-net clinics. Videos were coded by another clinician using an information checklist, blind to the diagnoses provided by the original clinician. We found high levels of concordance between clinicians for substance-related disorders, low levels for depressive disorders, and anxiety disorders except panic. Most clinicians rely on patients' mention of depression, anxiety, or substance use to identify disorders, without assessing specific criteria. With limited diagnostic information, clinicians can optimize the clinical intake time to establish rapport with patients. We found Latino ethnicity to be a modifying factor of the association between symptom reports and likelihood of a depression diagnosis. Differential discussion of symptom areas, depending on patient ethnicity, may lead to differential diagnosis and increased likelihood of diagnostic bias. [ABSTRACT FROM AUTHOR]

Background and Objectives: Refugees and asylum seekers are at risk of head trauma. They endure blows to the head due to exigent circumstances necessitating resettlement (e.g., torture, war, interpersonal violence) and during their dangerous journeys to refuge. Our objective was to assess the global prevalence of head trauma in refugees and asylum seekers and describe its clinical characteristics in this population., Methods: The protocol was registered in the PROSPERO International Prospective Register of Systematic Reviews (CRD42020173534). PubMed/MEDLINE, PsycInfo, Web of Science, Embase, and Google Scholar databases were searched for relevant studies. We included all studies in English that comprised refugees or asylum seekers of any age and examined the prevalence or characteristics of head trauma. We excluded studies that were not peer-reviewed original research. Information was recorded on the prevalence of head trauma, method of ascertaining head trauma, severity, mechanism of injury, other trauma exposures, and comorbidities. Descriptive analyses and narrative syntheses were performed., Results: A total of 22 studies were included, of which 13 with 6,038 refugees and asylum seekers reported head trauma prevalence. Prevalence estimates ranged from 9% to 78%. Heterogeneity among studies precluded meta-analysis. Most studies were US based (n = 9, 41%), followed by the Middle East (n = 5, 23%). Most refugees or asylum seekers were from the Middle East (n = 9, 41%), with those from Latin America least represented (n = 3, 14%). Studies disproportionately involved younger (pooled mean age = 29 years) adult samples composed of men. Recruitment settings were predominantly hospitals/clinics (n = 14, 64%), followed by refugee camps (n = 3, 14%). The most common mechanism of injury was direct impact through a beating or blow to the head. Studies varied greatly in how head trauma was defined and ascertained; no study used a validated traumatic brain injury (TBI)-specific screening tool. Similarly, TBI severity was not uniformly assessed, although hospital-based samples captured more moderate-to-severe head injuries. Mental health comorbidities were more frequently documented rather than physical health ones. Only 2 studies included a comparison with local populations., Discussion: Refugees and asylum seekers are vulnerable to head trauma, but studies using systematic approaches to screening are lacking. Increased attention to head trauma in displaced populations will allow for optimizing equitable care for this growing vulnerable population., (© 2023 American Academy of Neurology.)

Objective: The aim was to assess the magnitude of health care disparities in treatment for substance use disorder (SUD) and the role of health plan membership and place of residence in observed disparities in Medicaid Managed Care (MMC) plans in New York City (NYC)., Data Source: Medicaid claims and managed care plan enrollment files for 2015-2017 in NYC., Research Design: We studied Medicaid enrollees with a SUD diagnosis during their first 6 months of enrollment in a managed care plan in 2015-2017. A series of linear regression models quantified service disparities across race/ethnicity for 5 outcome indicators: treatment engagement, receipt of psychosocial treatment, follow-up after withdrawal, rapid readmission, and treatment continuation. We assessed the degree to which plan membership and place of residence contributed to observed disparities., Results: We found disparities in access to treatment but the magnitude of the disparities in most cases was small. Plan membership and geography of residence explained little of the observed disparities. One exception is geography of residence among Asian Americans, which appears to mediate disparities for 2 of our 5 outcome measures., Conclusions: Reallocating enrollees among MMC plans in NYC or evolving trends in group place of residence are unlikely to reduce disparities in treatment for SUD. System-wide reforms are needed to mitigate disparities., Competing Interests: T.L. reports grant funding from the Agency for Healthcare Research and Quality. J.W. reports a relationship to Medicaid Transformation and Financing at Aurrera Health Group. R.L.F. reports institutional support from the New York State Psychiatric Institute and the Office of Mental Health. The remaining authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Trauma and/or symptoms of posttraumatic stress disorder (PTSD) have been linked to the onset of cardiovascular disease (CVD), but the exact mechanism has not been determined. We examine whether the risk of CVD is different among those who have a history of trauma without PTSD symptoms, those who have experienced trauma and developed any symptoms of PTSD, and those with a PTSD diagnosis. Furthermore, we examine whether this association varies across ethnic/racial groups., Methods: We used two data sets that form part of the Collaborative Psychiatric Epidemiology Surveys - the National Latino and Asian American Study and the National Comorbidity Survey Replication., Results: We found an increased likelihood of cardiovascular events for those with a diagnosis of PTSD (odds ratio [OR] = 2.10, 95% CI = 1.32-3.33) when compared with those who had not experienced trauma. We did not find an increased risk for those who had experienced trauma without symptoms or with subclinical symptoms of PTSD. The higher likelihood of having a cardiovascular event in those with PTSD was significant for non-Latino whites (OR = 1.86, 95% CI = 1.08-3.11), Latinos (OR = 1.94, 95% CI = 1.04-3.62), and non-Latino blacks (OR = 3.73, 95% CI = 1.76-7.91), but not for Asian respondents., Conclusions: The constellation of symptoms defining PTSD diagnosis reflect adverse reactions to traumatic events and indicate that complex responses to traumatic events may be a risk factor for CVD.

Context: Latino immigrants constitute a large portion of the Spanish and US immigrant populations, yet a dearth of research exists regarding barriers to retention in behavioral health care., Objectives: To identify and compare perceived barriers related to behavioral health care among first- and second-generation Latinos in Boston, Madrid, and Barcelona, and evaluate whether the frequency of behavioral health care use in the last year was related to these barriers., Design, Setting, and Participants: Data were obtained from the International Latino Research Partnership project. First- or second-generation self-identified Latino immigrants aged 18 years and more who resided more than 1 year in the host country were recruited from community agencies and primary care, mental health, substance abuse, and HIV clinics., Main Outcome Measures: Eleven barriers were assessed and compared across sites. The relationship between barriers and behavioral services visits within the last year was evaluated, adjusting for sociodemographics, clinical measures, degree of health literacy, cultural, and social factors., Results: Wanting to handle the problem on one's own, thinking that treatment would not work, and being unsure of where to go or who to see were the most frequently reported barriers for Latino immigrants. Previous treatment failure, difficulties in transportation or scheduling, and linguistic barriers were more likely to be reported in Boston; trying to deal with mental health problems on one's own was more commonly reported in Barcelona and Madrid. Two barriers associated with the number of visits were concerns about the cost of services and uncertainty about where to go or who to see., Conclusions: After adjusting for sociodemographics, clinical measures, degree of health literacy, cultural, and social factors, barriers still differed significantly across sites. Efforts to improve behavioral health services must be tailored to immigrants' context, with attention to changing attitudes of self-reliance and outreach to improve access to and retention in care.

Background: Persistent disparities in access and quality of mental health care for Latinos indicate a need for evidence-based, culturally adapted, and outside-the-clinic-walls treatments., Objective: Evaluate treatment effectiveness of telephone (ECLA-T) or face-to-face (ECLA-F) delivery of a 6-8 session cognitive behavioral therapy and care management intervention for low-income Latinos, as compared to usual care for depression., Design: Multisite randomized controlled trial., Setting: Eight community health clinics in Boston, Massachusetts and San Juan, Puerto Rico., Participants: 257 Latino patients recruited from primary care between May 2011 and September 2012., Main Outcome Measures: The primary outcome was severity of depression, assessed with the Patient Health Questionnaire-9 and the Hopkins Symptom Checklist-20. The secondary outcome was functioning over the previous 30 days, measured using the World Health Organization Disability Assessment Schedule (WHO-DAS 2.0)., Results: Both telephone and face-to-face versions of the Engagement and Counseling for Latinos (ECLA) were more effective than usual care. The effect sizes of both intervention conditions on Patient Health Questionnaire-9 were moderate when combined data from both sites are analyzed (0.56 and 0.64 for face-to-face and telephone, respectively). Similarly, effect sizes of ECLA-F and ECLA-T on the Hopkins Symptom Checklist were quite large in the Boston site (0.64 and 0.73. respectively) but not in Puerto Rico (0.10 and 0.03)., Conclusions and Relevance: The intervention appears to help Latino patients reduce depressive symptoms and improve functioning. Of particular importance is the higher treatment initiation for the telephone versus face-to-face intervention (89.7% vs. 78.8%), which suggests that telephone-based care may improve access and quality of care.

Objectives: We assess whether posttraumatic stress disorder (PTSD) varies in prevalence, diagnostic criteria endorsement, and type and frequency of potentially traumatic events (PTEs) among a nationally representative US sample of 5071 non-Latino whites, 3264 Latinos, 2178 Asians, 4249 African Americans, and 1476 Afro-Caribbeans., Methods: PTSD and other psychiatric disorders were evaluated using the World Mental Health-Composite International Diagnostic Interview (WMH-CIDI) in a national household sample that oversampled ethnic/racial minorities (n=16,238) but was weighted to produce results representative of the general population., Results: Asians have lower prevalence rates of probable lifetime PTSD, whereas African Americans have higher rates as compared with non-Latino whites, even after adjusting for type and number of exposures to traumatic events, and for sociodemographic, clinical, and social support factors. Afro-Caribbeans and Latinos seem to demonstrate similar risk to non-Latino whites, adjusting for these same covariates. Higher rates of probable PTSD exhibited by African Americans and lower rates for Asians, as compared with non-Latino whites, do not appear related to differential symptom endorsement, differences in risk or protective factors, or differences in types and frequencies of PTEs across groups., Conclusions: There appears to be marked differences in conditional risk of probable PTSD across ethnic/racial groups. Questions remain about what explains risk of probable PTSD. Several factors that might account for these differences are discussed, as well as the clinical implications of our findings. Uncertainty of the PTSD diagnostic assessment for Latinos and Asians requires further evaluation.

Objective: Haitian-born persons have been historically stigmatized for introducing HIV to North America; however, no previous study has reported on the national HIV surveillance trends among this foreign-born group., Methods: Annual AIDS cases were estimated for adults and adolescents (aged >12 years) from all 50 US states and the District of Columbia who were diagnosed between 1985 and 2007, and who reported 'Haiti' as country of birth to the Centers for Disease Control and Prevention. HIV data (with or without AIDS) for Haitian-born adults and adolescents diagnosed between 2004 and 2007 were obtained from 34 US states. Denominators for AIDS rates by race/ethnicity are from postcensal estimates, the American Community Survey of the US Census Bureau and the Haitian Consulates., Results: In 2007, Haitian-born persons constituted 1.2% of US AIDS cases, yet accounted for 0.18% of the total US population based on the American Community Survey estimates, which suggests a seven-fold overrepresentation in the CDC AIDS surveillance data. However, when using population estimates from the Haitian Consulate, the overrepresentation ranges from three-to-four-fold, which is similar to the AIDS rate for blacks/African-Americans., Conclusion: The importance of having accurate denominators to estimate the AIDS rate for the Haitian population is paramount.

The objective of this paper is to estimate the impact of managed care on psychiatric hospitalizations and length of stay of medically indigent residents in Puerto Rico. A quasi-experimental design and three waves of data from a random community sample were used. Results indicate that, after 2 years, managed care had minimal impact on the number of psychiatric hospitalizations; while the mean length of hospitalization decreased after implementation of managed care, this change was not significant. Based on the data in this study, the managed care initiative developed as part of health reform in Puerto Rico did not appear to affect rates of psychiatric hospitalization and produced only a nonsignificant reduction in the average length of psychiatric hospital stays. Additional research is needed to determine trends in mental health care provision in Puerto Rico based on more recent data.

Background: Evidence suggests that minority populations have lower levels of attendance and retention in mental health care than non-Latino whites. Patient activation and empowerment interventions may be effective in increasing minority patients' attendance and retention., Objectives: This study developed and evaluated a patient self-reported activation and empowerment strategy in mental health care., Research Design: The Right Question Project-Mental Health (RQP-MH) trainings consisted of 3 individual sessions using a pre/post test comparison group design with patients from 2 community mental health clinics. The RQP-MH intervention taught participants to identify questions that would help them consider their role, process and reasons behind a decision; and empowerment strategies to better manage their care., Subjects: A total of 231 participated, completing at least the pretest interview (n = 141 intervention site, 90 comparison site)., Measures: Four main outcomes were linked to the intervention: changes in self-reported patient activation; changes in self-reported patient empowerment; treatment attendance; and retention in treatment., Results: Findings show that intervention participants were over twice as likely to be retained in treatment and over 3 times more likely than comparison participants to have scheduled at least 1 visit during the 6-month follow-up period. Similarly, intervention participants demonstrated 29% more attendance to scheduled visits than comparison patients. There was no evidence of an effect on self-reported patient empowerment, only on self-reported patient activation., Conclusions: Results demonstrate the intervention's potential to increase self-reported patient activation, retention, and attendance in mental health care for minority populations. By facilitating patient-provider communication, the RQP-MH intervention may help minorities effectively participate in mental health care.

Background: Latinos experience substantial barriers to primary care. Limited English language proficiency may be a mechanism for these deficiencies, even for Latinos with health coverage., Objective: To determine the relationship between English language proficiency and the experience of primary care reported by insured Latinos., Design, Setting, Participants: Analysis of the National Latino and Asian American Study, a nationally representative household survey, 2002-2003. This analysis was restricted to Latinos who reported current health insurance (n= 1792), and included information on ethnic subgroups., Main Outcome Measures: Four outcomes addressed different aspects of the quality of primary care: (1) not having a regular source of care or lacking continuity of care, (2) difficulty getting an appointment over the phone, (3) long waits in the waiting room, and (4) difficulty getting information or advice by phone., Results: English language proficiency was associated with the experience of primary care for 3 of the 4 outcomes. Insured Latinos with poor/fair English language proficiency were more likely than those with good/excellent proficiency to report not having a regular source of care or lacking continuity [odds ratio (OR) 2.20, 95% confidence interval (CI) 1.60-3.02], long waits (OR, 1.88; CI, 1.34-2.64), and difficulty getting information/advice by phone (OR, 1.76; 95% CI, 1.25-2.46)., Conclusions: Among insured Latinos, low English language proficiency is associated with worse reports of the quality of primary care. These results suggest that interventions to address limited English proficiency may be important to improving the quality of primary care for this rapidly growing population.

Objective: The objective of this study was to assess the change in system cost-effectiveness of depression treatment after the introduction of managed care., Data Sources/study Setting: The study population consisted of adults ages 18 to 69 living in low-income areas of Puerto Rico., Study Design: Using a random probability sample of the population, 2 waves (1992-1993, 1993-1994) of data were collected before implementation of managed care and one wave (1996-1998) after implementation. Composite International Diagnostic Interview (CIDI)-generated depression diagnoses and Centers for Epidemiologic Studies-Depression (CES-D) scale of depressive symptoms scales were used to assess depression., Data Collection/extraction Methods: Effectiveness of treatment was defined by guideline standards and experts' assessment of the probability of remission resulting from treatment. Costs were measured by assigning representative prices to each treatment modality. Difference-in-difference (D-in-D) estimators were used to assess the impact of managed care on the effectiveness and costs of treating depression at the system level for the entire population., Principal Findings: System cost-effectiveness improved slightly after the introduction of managed care, with diminished costs but no significant improvements in effectiveness., Conclusion: Cost-effectiveness can be measured at the population level to assess system changes. Additional incentives and system realignments beyond utilization review and diminished treatment costs are necessary to attain a more cost-effective system of care.

Background: Substance abuse is an escalating problem among poor urban Latina women; little is known about their access to drug treatment and to needed social and health services., Objective: Our objectives were to (1) examine the need and use of substance abuse treatment, health services, government entitlement programs, and social service programs among cocaine and heroin using Puerto Rican women and (2) identify whether service use predicts their prospective entry into drug treatment., Research Design: This was a 3-wave longitudinal study of community substance abusing women evaluated on substance abuse and dependence using diagnostic measures, and hair and urine toxicological screens. Information was collected on self-reported need and receipt of substance abuse treatment, social services, general health services, and government entitlement programs., Subjects: A community sample of cocaine-, crack-, and/or heroin-using women from copping areas in low-income urban centers of Puerto Rico were interviewed in 1997-1998 with 2 follow-up periods., Results: Drug treatment, health, and social service utilization were low relative to need for services throughout all data waves. Social service utilization predicted prospective entry into drug treatment but not contacts with general health services or government entitlement programs., Conclusion: Drug-abusing women in low-income urban areas in Puerto Rico have substantial unmet substance abuse treatment, health, and social service needs. Mandated treatment by social service agencies may explain their clients' higher likelihood of entering drug treatment. Building linkages between service sectors to augment entry into drug treatment is essential for meeting the complex needs of this underserved population.

Background: Latino children have persistent low rates of mental health service use. Understanding the factors that influence caregivers' decisions about whether to use mental health care for their children can help explain why., Objective: The objective of this study was to investigate the factors reported by the primary caregiver that could help classify Puerto Rican children into users versus nonusers of mental health services and mental health versus school sector care, among users., Subjects: Data were collected from a random Puerto Rican community sample of caregiver-child dyads., Measures: Version-IV of the Computerized Diagnostic Interview for Children (DISC) was used to assess psychiatric disorders in children. The Service Assessment for Children and Adolescents (SACA) was used to examine the types of services used for mental health problems., Statistical Methods: The Classification and Regression Tree (CART) approach was used to develop a simple model simulating caregivers' decision-making around taking children for mental health care and the setting for care., Results: The classification model of use versus no use of mental health service suggested 3 significant predictors: child's level of impairment, parental concern, and child's difficulty in performing schoolwork. The classification model of sector of care, mental health versus school setting, identified 1 significant predictor, any disruptive disorder diagnosis., Conclusion: : Assisting caregivers in linking a child's impairment with need for mental health care might be a mechanism to reduce children's unmet need. Approaches such as CART, used to identify factors predicting consumer choices in marketing, might be useful to select strategies for social campaigns targeted toward decreasing unmet need.

In this study, the contribution of four distinct domains of the Help Seeking-Decision Making model to predicting the use of mental health services is examined. Using a proposed methodology the authors assess the relevance of this model and its domains to mental services planning. The methodology combines logistic regression analysis and receiver operating characteristic (ROC) curves. Logistic regression analysis allows us to examine the individual variables of the model and generate predictions about use. ROC curves allow us to compare and interpret the relative contribution of a predisposing domain, a physical and mental health domain, an enabling-restrictive domain, and an organizational domain in correctly classifying users and nonusers of mental health services. The physical and mental health domain yielded a Somer's D-statistic of 0.7, which corresponds to an 85% correct classification of randomly selected pairs of users and nonusers. The study findings suggest that comparing ROC curves helps to describe and interpret the domains of the model that are relevant for making predictions about who will or will not use mental health services during a 1-year period.