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To investigate how the COVID-19 pandemic impacted low-income individuals with substance use disorder (SUD) in New York City (NYC) during the beginning of the pandemic, using a structural competency and structural vulnerability theoretical framework and a qualitative research approach.Primary qualitative data were collected from racial/ethnic minority adults enrolled in Medicaid receiving outpatient substance use treatment (e.g., medication, counseling) in NYC.Semi-structured in-depth qualitative interviews (N = 20) were conducted during "stay-at-home" orders in NYC, the first epicenter of the COVID-19 pandemic in the United States. Interviews were conducted over the phone during the earlier stages of the pandemic, between April 2020 and June 2020.Semi-structured in-depth interviews were conducted and audio recorded, transcribed, and analyzed using a thematic analysis approach.Three themes were yielded from our thematic analysis: (1) COVID-19 heightened food insecurity and housing conditions increased risks of infection; (2) stay-at-home orders limited access to resources but had positive impacts in strengthening social relationships and reducing substance use triggers; and (3) although COVID-19 created challenges for treatment, most described that SUD care improved during the pandemic.While COVID-19 exacerbated numerous structural vulnerabilities among low-income individuals with SUD, programmatic adaptations to COVID-19 SUD care, including telehealth and loosening restrictions around medications for opioid use disorders mitigated past difficulties that patients had faced. Reducing structural vulnerabilities for Medicaid patients will require continuation of telehealth treatment delivery, retaining flexible medication regulations, and mobilizing community resources to mitigate economic disparities.

POLICY POINTS: In low‐income communities in the South Bronx and Puerto Rico, Puerto Rican youth are exposed to many of the same risk and protective factors for developing depression, anxiety, or psychological distress; yet it is unclear how the ethnic minority context of the South Bronx and ethnic majority context of Puerto Rico influence risk. Results from our quasi‐experimental, longitudinal study demonstrate the importance of addressing social factors (parent‐child relationships, youth peer relationships) for youth living in the majority context, and neighborhood and cultural factors (residential mobility, perceived discrimination, perceived social position in the neighborhood) for youth living in the minority context. Our findings support the need for tailoring programs specific to the needs of youth who reside in an ethnic majority or a minority context, since some of the risk factors might operate differently depending on context. Housing and neighborhood environment policies that address discrimination and eliminate structural inequities for ethnic minority groups may protect against the harm of minoritization on young people's mental health. CONTEXT: Puerto Rican youth growing up in low‐income communities in the South Bronx and Puerto Rico are exposed to many of the same risk factors for major depressive disorder, generalized anxiety disorder, and psychological distress. One potentially powerful factor differs: Puerto Ricans have been socially marginalized as an ethnic minority group in the South Bronx, but are the ethnic majority of the population in Puerto Rico. A growing body of literature demonstrates the influence of neighborhood, cultural, and social factors and parental psychopathology in the development of mental health problems. An important unanswered question is whether these risk and protective factors have the same impact for youth raised as members of an ethnic majority versus minority group. METHODS: Using a population‐based cohort study, with four waves of assessment from early childhood into young adulthood, we investigated whether ethnic minority context alters risk and protective factors for depression, anxiety, and psychological distress. Our longitudinal data set includes 2,491 young children at baseline (82.8% retained at wave 4). Using a quasi‐experimental design, we examine how ethnic minority context can alter the development of mental health disorders as Latinx children transition to late adolescence and young adulthood. FINDINGS: Some risk and protective factors operated differently across minority and majority contexts. Higher discrimination and social position were more powerful risk and protective factors, respectively, in the minority context, whereas positive peer relationships mattered more in the majority context. Children of mothers with depression were significantly more likely to develop anxiety in late adolescence and young adulthood in the majority context (60.0%) compared to the minority context (4.5%). CONCLUSIONS: Preventing depression and anxiety disorders in Latinx young adults may require targeting different childhood factors depending on whether they reside within the ethnic majority or minority context. People in the ethnic minority context may benefit more from policies aimed at reducing discrimination and improving economic opportunity, while people in the majority context may benefit more from opportunities for strengthening family and peer relationships.

Delirium is a debilitating medical condition that disproportionately affects hospitalized older adults(1) and is associated with adverse health outcomes, increased mortality, and high medical costs.(2) Efforts to understand delirium risk in hospitalized older adults have focused on examining medical comorbidities, pre-existing cognitive deficits, and other clinical and demographic factors present in the period proximate to the hospitalization.(3,4) The contribution of social determinants of health (SDOH), including social circumstances, environmental characteristics, and early-life exposures, referred as the social exposome,(5) to delirium risk are poorly understood. Increased knowledge about the influence of SDOH will offer a more comprehensive understanding of factors that may increase vulnerability to delirium and poor outcomes. Clinically, these efforts can guide the development and implementation of holistic preventive strategies to improve clinical outcomes. We propose a social determinants of health (SDOH) framework for delirium tailored to older adults. We provide the definition, description, and rationale for the domains and variables in our proposed model.

Although research suggests neighborhood-level factors influence youth well-being, few studies include youth when creating interventions to address these factors. We describe our three-step process of collaborating with youth in low-income communities to develop an intervention focused on civic engagement as a means to address neighborhood-level problems impacting their well-being. In the first step, we analyzed qualitative interviews from a project in which youth shared perceptions about their neighborhoods (e.g., interpersonal relations with neighbors and institutions). Three major themes were identified: pride in youth's communities, desire for change, and perceptions of power and responsibility. Based on these themes, we completed the second step: developing a civic engagement and leadership program, called LEAP, aimed at helping youth take an active role in addressing neighborhood problems. In the third step, we collaborated with youth who completed a pilot version of the civic program and provided feedback to finalize it for large-scale testing. While discussing our process, we highlight the importance of including youth voices when developing programs that affect them. Furthermore, we note the need for more research exploring whether civic engagement serves as a mechanism for encouraging youth involvement in addressing neighborhood-level health disparities and identifying potential psychological costs of such involvement.

Despite current interest in collaborative practices, few investigations document the ways practitioners can facilitate collaboration during in-session interactions. This investigation explores verbatim psychotherapy transcripts to describe and illustrate therapist's communications that facilitate or hinder centering client's voice in work with socioeconomically disadvantaged populations. Four exemplar cases were selected from a large intervention trial aimed at improving shared decision making (SDM) skills of psychotherapists working with low-income clients. The exemplar cases were selected because they showed therapist's different degrees of success in facilitating SDM. Therapist's verbalizations were grouped into five distinct communicative practices that centered or de-centered the voice of clients. Communication practices were examined through the lens of collaborative approaches in family therapy. The analysis suggests that cross-fertilization between SDM and family-oriented collaborative and critical approaches shows promise to illuminate and enhance the challenging road from clinician-led to client-led interactions. This paper also stresses the importance of incorporating relational intersectionality with individuals and families who may not feel entitled to express their expectations or raise questions when interacting with authority figures.A pesar del interés actual en las prácticas colaborativas, pocas investigaciones documentan las maneras en las que los profesionales pueden facilitar la colaboración durante las interacciones dentro de las sesiones. Esta investigación analiza transcripciones textuales de la psicoterapia para describir e ilustrar las comunicaciones de los terapeutas que facilitan u obstaculizan la centralización de la voz del paciente en el trabajo con poblaciones desfavorecidas socioeconómicamente. Se eligieron cuatro casos ejemplares de un ensayo grande de intervención orientado a mejorar las habilidades para la toma de decisiones compartidas de psicoterapeutas que trabajan con pacientes de bajos recursos. Los casos ejemplares se eligieron porque demostraban los diferentes grados de éxito de los terapeutas a la hora de facilitar la toma de decisiones compartidas. Las verbalizaciones del terapeuta se agruparon en cinco prácticas comunicativas diferentes que centralizaban o descentralizaban la voz de los pacientes. Se examinaron las prácticas de comunicación desde la perspectiva de los enfoques colaborativos en la terapia familiar. El análisis sugiere que la fertilización entre el esquema de decisiones compartidas y los enfoques teóricos críticos y colaborativos orientados a la familia promete iluminar y mejorar el difícil camino desde las interacciones dirigidas por el clínico a las dirigidas por los clientes. Este artículo también acentúa la importancia de incorporar la interseccionalidad relacional con personas y familias que posiblemente no se sientan con derecho a expresar sus expectativas o a hacer preguntas cuando interactúan con figuras de autoridad.尽管目前人们对实际治疗中的医患合作很感兴趣，但很少有研究记录执业治疗师在谈话互动时具体用到的促进这种合作关系的方式方法。本文研究了详细的心理治疗过程的笔录，旨在描述和说明治疗师的沟通如何促进或如何阻碍了把来访者的声音放在中心位置的做法，这些来访者属于社会经济弱势群体成员。我们从一项大型干预试验中选取了4个典型案例，目的是提高为低收入来访者服务的心理治疗师的共同决策(SDM)技能。之所以选择这些典型案例，是因为它们显示了治疗师在促进SDM方面的不同程度的成功。治疗师的语言被分为五种以来访者的声音为中心的或不重视来访者声音的交流方式。我们通过对家庭治疗过程中的医患协作方面的考察对实际的话语交流进行了研究。分析表明，SDM和以家庭为导向的协作和关键方法之间的交叉混合，有希望照亮和增强从临床主导到以来访者主导的互动这条具有挑战性的路径。本文还强调了融合某些个人和家庭的交叉性关系的重要性，这些人的特点是他们可能觉得在与权威人士互动时，没有权利表达他们的期望或提出问题。.

Background and aims The focus of this paper is on the improvement of substance use disorder (SUD) screening and measurement. Using a multi-dimensional item response theory model, the bifactor model, we provide a psychometric harmonization between SUD, depression, anxiety, trauma, social isolation, functional impairment and risk-taking behavior symptom domains, providing a more balanced view of SUD. The aims are to (1) develop the item-bank, (2) calibrate the item-bank using a bifactor model that includes a primary dimension and symptom-specific subdomains, (3) administer using computerized adaptive testing (CAT) and (4) validate the CAT-SUD in Spanish and English in the United States and Spain. Design Item bank construction, item calibration phase, CAT-SUD validation phase. Setting Primary care, community clinics, emergency departments and patient-to-patient referrals in Spain (Barcelona and Madrid) and the United States (Boston and Los Angeles). Participants/cases Calibration phase: the CAT-SUD was developed via simulation from complete item responses in 513 participants. Validation phase: 297 participants received the Composite International Diagnostic Interview (CIDI) and the CAT-SUD. Measurements A total of 252 items from five subdomains: (1) SUD, (2) psychological disorders, (3) risky behavior, (4) functional impairment and (5) social support. CAT-SUD scale scores and CIDI SUD diagnosis. Findings Calibration: the bifactor model provided excellent fit to the multi-dimensional item bank; 168 items had high loadings (> 0.4 with the majority > 0.6) on the primary SUD dimension. Using an average of 11 items (four to 26), which represents a 94% reduction in respondent burden (average administration time of approximately 2 minutes), we found a correlation of 0.91 with the 168-item scale (precision of 5 points on a 100-point scale). Validation strong agreement was found between the primary CAT-SUD dimension estimate and the results of a structured clinical interview. There was a 20-fold increase in the likelihood of a CIDI SUD diagnosis across the range of the CAT-SUD (AUC = 0.85). Conclusions We have developed a new approach for the screening and measurement of SUD and related severity based on multi-dimensional item response theory. The bifactor model harmonized information from mental health, trauma, social support and traditional SUD items to provide a more complete characterization of SUD. The CAT-SUD is highly predictive of a current SUD diagnosis based on a structured clinical interview, and may be predictive of the development of SUD in the future.

Few longitudinal studies have explored to date whether minority status in disadvantaged neighborhoods conveys risk for negative mental health outcomes, and the mechanisms possibly leading to such risk. We investigated how minority status influences four developmental mental health outcomes in an ethnically homogeneous sample of Puerto Rican youth. We tested models of risk for major depressive disorder (MDD) and generalized anxiety disorder (GAD), depressive and anxiety symptoms (DAS), and psychological distress, as Puerto Rican youth (aged 5-13 years) transitioned to early adulthood (15-29 years) in two sites, one where they grew up as a majority (the island of Puerto Rico), and another where they were part of a minority group (South Bronx, New York). At baseline, a stratified sample of 2,491 Puerto Rican youth participated from the two sites. After baseline assessment (Wave 1), each youth participant and one caregiver were assessed annually for two years, for a total of three time points (Waves 1-3). From April 2013 to August 2017, participants were contacted for a Wave 4 interview, and a total of 2,004 young people aged 15 to 29 years participated in the assessment (response rate adjusted for eligibility = 82.8%). Using a quasi-experimental design, we assessed impacts of minority status on MDD, GAD, DAS and psychological distress. Via mediation analyses, we explored potential mechanisms underlying the observed relationships. Data from 1,863 Puerto Rican youth (after exclusion of those with MDD or GAD during Waves 1-3) indicated links between minority status and higher rates of lifetime and past-year GAD, DAS and past 30-day psychological distress at Wave 4, and a marginal trend for MDD, even after adjustments. Childhood social support and peer relationships partially explained the differences, as did intercultural conflict, neighborhood discrimination, and unfair treatment in young adulthood. The experience of growing up as a minority, as defined by context, seemingly elevates psychiatric risks, with differences in social relationships and increased social stress as mediators of this relationship. Our findings suggest that interventions at the neighborhood context rather than at the individual level might be important levers to reduce risks for the development of mood disorders in minority youth.

Latina immigrant women are vulnerable to traumatic stress and sexual health disparities. Without autonomy over their reproductive health and related decision-making, reproductive justice is elusive. We analyzed behavioral health data from 175 Latina immigrant participants (M age = 35; range = 18-64) of the International Latino Research Partnership (ILRP) study. We used descriptive and inferential statistics to compare immigrant mothers of minor children to those without, regarding their psychological and reproductive health, and correlates of past exposure to sexual trauma. Over one third (38%) of ILRP participants had minor children, and 58% had citizenship in their host country. The rate for sexual assault was 30 and 61%, respectively, for physical assault; these rates were similarly high for women with and without minor children. Women who reported sexual assault scored significantly higher for depression, posttraumatic stress disorder, and substance-abuse screens. Odds of experiencing sexual assault was highest for women who experienced physical assault (odds ratio = 10.74), and for those from the Northern Triangle (odds ratio = 8.41). Subgroups of Latina migrant mothers are vulnerable to traumatic stress and related sexual and mental health risks. Given these findings, we frame the implications in a reproductive justice framework and consider consequences for caregiver-child well-being.Trasfondo: Las mujeres latinas inmigrantes son vulnerables al estrés traumático y a las disparidades de salud sexual. Sin autonomía sobre su salud reproductiva y las decisiones que se deben tomar al respecto, la justicia reproductiva es difícil de alcanzar. Métodos: Analizamos información sobre las actitudes con respecto a la salud de parte de 175 inmigrantes latinas participantes (edad promedio 35; entre 18 y 64) del estudio de Investigación Conjunta Internacional de Asuntos Latinos (ILRP). Usamos estadísticas descriptivas y deductivas para comparar las madres inmigrantes de niños menores con aquellas sin ellos, sin tomar en cuenta su salud sicológica y reproductiva, y correlacionar el haber estado expuestas a trauma sexual en el pasado. Resultados: Más de un tercio (38%) de las participantes del grupo de ILRP tenían niños menores, y 58% tenían ciudadanía en el país donde residían. El promedio en cuanto a la agresión sexual fue de 30% y 61% en el caso de agresión física; estos promedios fueron similarmente altos tanto para mujeres con niños pequeños como mujeres sin niños pequeños. Las mujeres que reportaron agresión sexual tuvieron puntajes significativamente más altos en el caso de depresión, trastorno por estrés postraumático (PTSD) y exámenes de detección de abuso de sustancias. Las posibilidades de experimentar agresión sexual fue lo más alto para mujeres que experimentaron agresión física (OR = 10.74), y para aquellas del Triángulo del Norte (OR = 8.41). Conclusiones: Los subgrupos de madres latinas inmigrantes son vulnerables al estrés traumático y los relacionados riesgos de salud sexual y mental. Dados estos resultados, colocamos las implicaciones dentro de un marco de trabajo de justicia reproductiva y consideramos las consecuencias para el bienestar de quien le presta cuidados al niño.Contexte Les femmes immigrées latinas sont vulnérables au stress traumatique et aux disparités de santé sexuelle. Sans autonomie quant à leur santé reproductive et les décisions qui y sont liées, leur justice reproductive est insaisissable. Méthodes Nous avons analysé des données de santé comportementale de 175 participantes immigrées (moyenne d’âge 35 ans; éventail de 18 à 64 ans) de l’étude du partenariat de recherche international International Latino Research Partnership (ILRP). Nous avons utilisé des statistiques descriptives et déductives pour comparer les mères immigrées d'enfants mineurs à celles sans enfants, pour ce qui concerne leur santé psychologique et reproductive, ainsi que les corrélats d'exposition à un trauma sexuel dans le passé. Résultats Plus d'un tiers (38%) des participantes ILRP avaient des enfants mineurs et 58% détenaient la citoyenneté dans leur pays d'accueil. Le taux de violences sexuelles était de 30% et de 61% pour les aggressions physiques. Ces taux étaient aussi élevés chez les femmes avec ou sans enfants mineurs. Les femmes ayant déclaré des violences sexuelles ont fait état de scores bien plus élevés pour la dépression, le TSPT et la toxicomanie. Les probabilités de faire face à des violences sexuelles étaient les plus élevées chez les femmes ayant vécu une aggression physique (OR = 10,74), et pour celles du Triangle du Nord de l'Amérique centrale (OR = 8,41). Conclusions Des sous-groupes de mères migrantes latinas sont vulnérables au stress traumatique et à des risques de santé mentale qui y sont liés. Au vu de ces résultats, nous encadrons les implications dans une structure de justice de reproduction et considérons les conséquences pour le bien-être mère-enfant.Hintergrund: Lateinamerikanische Immigrantinnen sind vulnerabel für traumatischen Stress und Ungleichheiten in der sexuellen Gesundheit. Ohne Autonomie über ihre reproduktive Gesundheit und die damit verbundenen Entscheidungen ist reproduktive Gerechtigkeit schwer erreichbar. Methoden: Wir analysierten verhaltensbezogene Gesundheitsdaten von 175 lateinamerikanischen Immigrantinnen (Durchschnittsalter 35 Jahre; Range: 18-64 Jahre) aus der Studie der „International Latino Research Partnership“ (ILRP). Wir verwendeten deskriptive und inferentielle Statistiken, um immigrierte Mütter von minderjährigen Kindern mit solchen ohne minderjährige Kinder in Bezug auf ihre psychologische und reproduktive Gesundheit und hinsichtlich Korrelaten mit einer früheren Exposition gegenüber sexuellen Traumata zu vergleichen. Ergebnisse: Über ein Drittel (38%) der ILRP-Teilnehmerinnen hatte minderjährige Kinder, und 58% hatten die Staatsbürgerschaft in ihrem Gastland. Die Rate für sexuelle Übergriffe betrug 30% und für körperliche Übergriffe 61%; diese Raten waren für Frauen mit und ohne minderjährige Kinder ähnlich hoch. Frauen, die über sexuelle Übergriffe berichteten, erzielten signifikant höhere Ergebnisse in Bezug auf Depression, PTBS und Drogenmissbrauch. Die Wahrscheinlichkeit, sexuelle Gewalt zu erfahren, war bei Frauen, die körperlichen Übergriffen ausgesetzt waren (OR = 10.74) und bei Frauen aus dem nördlichen Dreieck (OR = 8.41) am höchsten. Schlussfolgerungen: Subgruppen von immigrierten, lateinamerikanischen Müttern sind vulnerabel für traumatischen Stress und damit verbundene Risiken für die sexuelle und psychische Gesundheit. Vor dem Hintergrund dieser Ergebnisse setzen wir die Implikationen in den Rahmen der reproduktiven Gerechtigkeit und betrachten die Folgen für das Wohlbefinden der Bezugsperson und des Kindes.ラテン系女性のトラウマ、移民、性の健康: 母子福祉と生殖の公平性の意味 背景 ラテン系移民女性は、外傷性ストレスや性の健康の相違に対して脆弱である。彼らの生殖の健康やそれに関連する意思決定についての自由がなくては、 生殖の公平性は、達成困難である。方法 我々は、「国際ラテン系研究パートナーシップ」 (ILRP) の研究における 175 人のラテン系移民の参加者(平均年齢 35 歳、範囲 18 歳～ 64歳)の行動に現れる精神保健のデータを分析した。我々は、未成年の子どもをもつ母親移民と未成年の子どもをもたない母親移民とを、心理的及び生殖の健康において、また、過去に晒された性的なトラウマとの関係にあるものについて比較するために、事実による統計と推定による統計を使用した。結果 ILRP 参加者の 3 分の 1 以上 (38％) は未成年の子どもがいて、 58％ は受け入れ国において市民権があった。性的暴行の割合は 30％で、身体的暴力は 61％ であった。これらの割合は、未成年の子どもがいようがいなかろうが、どちらの女性とも同様に高かった。性的暴行を報告した女性は、鬱病、 PTSD、物質乱用の評価が著しく高かった。性的暴行を体験した確率は、身体的暴力を体験した女性に最も高く(OR = 10.74)、そして、グアテマラ、ホンジュラス、エルサルバドルからの女性が最も高かった (OR = 8.41)。結論 小集団のラテン系の移民女性は、外傷性ストレスやそれに関連した性的な健康や精神保健のリスクに対して脆弱である。これらの調査結果より、我々は、生殖の公平性の枠組みにおける繋がりを形作り、養育者−子どもの福祉に関する結果を考察する。.拉丁裔婦女的創傷丶移民和性健康:對母嬰健康和生殖公義的意義 背景拉丁裔移民婦女容易受到創傷性壓力和性健康差異的影響。如果沒有生殖健康和相關決策的自主權, 生殖公義就難以實現。方法我們分析國際拉丁裔研究夥伴 (ILRP) 的 175 名拉丁裔移民參與者 (平均年齡 35 歲;範圍 18-64 歲) 的行為健康數據。我們使用描述性和推論性統計數據, 來比較未成年子女的移民母親與沒有子女的移民母親, 在心理和生殖健康, 以及過往性創傷的相關因素。結果超過三分之一 (38％) 的 ILRP 參與者有未成年子女, 58％ 的人在其所在國家擁有公民身份。性侵犯和身體侵犯的百分率分別為 30％和 61％; 對於有和沒有未成年子女的婦女, 這些比率同樣很高。報告性侵犯的女性在抑鬱丶創傷後應激障礙和藥物濫用篩查方面得分顯著較高。被侵犯身體的女性 (OR = 10.74) 和來自北三角的女性 (OR = 8.41) 經歷性侵犯的機率最高。結論一些拉丁裔移民母親易受創傷性壓力和相關的性和心理健康風險。我們在生殖公義框架中討論這些發現的含義, 並考慮其對照顧者 - 兒童福祉的影響。.الصدمة والهجرة والصحة الجنسية بين سيدات اللاتينو: تطبيقات رفاهية الأمهات والأطفال والعدالة الإنجابية نساء اللاتينو المهاجرات معرضات للإجهاد العصبي الناتج عن الصدمة النفسية وتفاوتات في الصحة الجنسية. فبدون سيطرتهم الكاملة على صحتهم الإنجابية واتخاذ القرارات ذات الصلة، تصبح العدالة الإنجابية غير متحققة بشكل واضح. الدراسة: قمنا بتحليل البيانات الصحية السلوكية من 175 مشاركا من المهاجرين اللاتينو (متوسط العمر 35 سنة؛ متراوحا بين 18-64) من ضمن بيانات دراسة الشراكة الدولية للبحوث اللاتينية (ILRP). واستخدمنا إحصاءات وصفية واستنتاجية لمقارنة الأمهات المهاجرات من الأطفال القصر بغيرهن، فيما يتعلق بصحتهن النفسية والإنجابية، ومعاملات ارتباط تعرضهن في الماضي للصدمات الجنسية. النتائج: أكثر من الثلث (38%) من المشاركين في دراسة “ILRP” كان لديهم أطفال قصر، وكان 58 في المائة منهم حاصلين على الجنسية في البلد التي هاجروا إليها. وكان معدل الاعتداء الجنسي 30 في المائة و 61 في المائة بالنسبة للاعتداء البدني؛ وكانت هذه المعدلات مرتفعة بالمثل بالنسبة للنساء سواء كان عندهن أطفال قصر أو لا . وسجلت النساء اللاتي أبلغن عن اعتداء جنسي معدلات أعلى بكثير من حالات الاكتئاب واضطراب ما بعد الصدمة واختبارات إساءة استعمال المخدرات. وكانت احتمالات التعرض للاعتداء الجنسي هي الأعلى بالنسبة للنساء اللاتي تعرضن للاعتداء البدني (معامل احتمال = 10.74)، وبالنسبة للنساء من المثلث الشمالي (معامل احتمال = 8.41). الاستنتاجات: مجموعات فرعية من أمهات اللاتينو المهاجرات عرضة للإجهاد العصبي وما يتصل بذلك من مخاطر الصحة الجنسية والنفسية. وفي ضوء هذه النتائج، نصوغ التطبيقات في إطار العدالة الإنجابية وننظر في العواقب على رفاهية مقدمي الرعاية والطفل.

Population projections predict that the number of older adults with mental illness will climb in the next 20 years. It is estimated that by 2030, 1 in 5 older adults – over 15 million persons – will have a mood, anxiety, or psychiatric disorder.1,2 Despite this demographic trend, the stigma of having a mental illness appears to be getting worse, not better.3 In particular older adults are more likely than younger adults to experience mental illness as stigmatizing, presenting an important barrier to accessing care.4,5 Older adult mental health consumers from racial/ethnic minorities have reported experiencing a “triple stigma” consisting of being old, mentally ill, and from an ethnic minority.5 However, little is known about racial/ethnic differences in stigma associated with mental illness among older adults. Since attitudes have shown to be a critical determinant of actual help-seeking behaviors,6,7 research on stigmatizing attitudes may provide valuable information concerning how to design and implement effective interventions to reduce disparities in mental health care. Most of the previous research regarding racial/ethnic minority adults’ attitudes towards mental illness has focused on young adults with no history of mental illness, and the results have been inconsistent. Some studies suggest that African-Americans, Latinos and Asian-Americans tend to hold more stigmatizing perceptions of mentally ill individuals than non-Latino Whites.8–11 Other studies have found no differences or more positive attitudes.8,12–15 Ethnic/racial group sampling differences (i.e., foreign versus U.S. born, college students vs. U.S. population) may account for these inconsistencies. Recent work by Conner et al.16 has sought to compare stigmatizing attitudes held by older African-Americans with depression with those of depressed non-Latino White older adults. In this study, the authors found that older African-Americans were more likely to experience stigma about mental illness than their White counterparts.16 To our knowledge, no similar studies have been conducted that include older mentally ill Asians or older mentally ill Latinos. The purpose of this study is to compare stigmatizing beliefs about mental illness among non-Latino Whites, African-Americans, Asian-Americans, and Latinos who are seeking treatment for a mental illness.

Objectives: To apply the Institute of Medicine definition of healthcare disparities, to measure disparities in different aspects of episodes of mental health care and to identify disparities in types of mental health services used. Design: Four 2-year longitudinal datasets from Panels 9 to 13 (2004�2009) of the Medical Expenditure Panel Surveys were combined. Setting: Large-scale surveys of families and individuals and their medical providers across the United States. Participants: One thousand six hundred fifty-eight participants (981 white, 303 black, and 374 Latino) aged 60 and older with probable mental healthcare needs. Measurements: Mental healthcare need was defined as a Kessler-6 Scale score >12 and a Patient Health Questionnaire-2 score >2. Five aspects of mental healthcare episodes were analyzed: treatment initiation, adequacy of care, duration of care, number of visits, and expenditures. Whether episodes of care included only prescription drug fills, only outpatient visits, or both was assessed. Results: Treatment initiation and adequacy were lower for blacks and Latinos than whites. Latinos experienced episodes of longer duration, more visits, and higher expenditures. Blacks and Latinos had significantly lower rates of episodes that consisted of only medication refills. Blacks had significantly greater rates of episodes with only outpatient care visits. Latinos had significantly higher rates of medication plus outpatient visits. Conclusion: Low mental health treatment initiation and poor adequacy suggest the need for culturally appropriate interventions to engage older blacks and Latinos in mental health care. The surprising findings in blacks (higher rates of outpatient care visits) and Latinos (higher rates of medication plus outpatient visits) highlight the complexities of the older adult population and suggest new avenues for disparities research.

We examine differential validity of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnoses assessed by the fully-structured Composite International Diagnostic Interview Version 3.0 (CIDI) among Latino, non-Latino Black, and non-Latino White adolescents in comparison to gold standard diagnoses derived from the Schedule for Affective Disorders and Schizophrenia for School-age Children (K-SADS). Results are based on the National Comorbidity Survey Replication Adolescent Supplement, a national US survey of adolescent mental health. Clinicians re-interviewed 347 adolescent/parent dyads with the K-SADS. Sensitivity and/or specificity of CIDI diagnoses varied significantly by ethnicity/race for four of ten disorders. Modifications to algorithms sometimes reduced bias in prevalence estimates, but at the cost of reducing individual-level concordance. These findings document the importance of assessing fully-structured diagnostic instruments for differential accuracy in ethnic/racial subgroups. Language: en

The effect of childhood trauma, psychiatric diagnoses, and mental health services on school dropout among U.S.-born and immigrant youth is examined using data from the Collaborative Psychiatric Epidemiology Surveys, a nationally representative probability sample of African Americans, Afro-Caribbeans, Asians, Latinos, and non-Latino Whites, including 2,532 young adults, aged 21-29. The dropout prevalence rate was 16% overall, with variation by childhood trauma, childhood psychiatric diagnosis, race/ethnicity, and nativity. Childhood substance and conduct disorders mediated the relation between trauma and school dropout. Likelihood of dropout was decreased for Asians, and increased for African Americans and Latinos, compared to non-Latino Whites as a function of psychiatric disorders and trauma. Timing of U.S. immigration during adolescence increased risk of dropout.

OBJECTIVES: To compare lifetime and 12-month prevalence of psychiatric disorders in a nationally representative sample of older Latino, Asian, African-American, and Afro-Caribbean adults with that of older non-Latino white adults. DESIGN: Cross-sectional study conducted in 2001 through 2004. SETTING: Urban and rural households in the contiguous United States. PARTICIPANTS: Two thousand three hundred seventy-five community-dwelling residents aged 60 and older living in noninstitutional settings. Data are from the National Institutes of Mental Health Collaborative Psychiatric Epidemiological Studies. METHODS: The World Mental Health Composite International Diagnostic Interview assessed lifetime and 12-month psychiatric disorders. Bayesian estimates compared psychiatric disorder prevalence rates of ethnic and racial groups. RESULTS: Older non-Latino whites exhibited a greater prevalence on several lifetime diagnoses than older Asian, African-American, and Afro-Caribbean respondents. Older Latinos did not differ from older non-Latino whites on any lifetime diagnosis and had higher 12-month rates of any depressive disorder. No differences were observed in the 12-month diagnoses between older non-Latino whites and the other racial and ethnic minority groups. Older immigrant Latinos had higher lifetime rates of dysthymia and generalized anxiety disorder (GAD) than U.S.-born Latinos. Older immigrant Asians had higher lifetime rates of GAD than U.S.-born Asians. Older immigrant Latinos had higher 12-month rates of dysthymia than older U.S.-born Latinos. CONCLUSION: Caution should be taken when generalizing the protective effects of ethnicity into old age. Older Asians and African-Americans exhibited lower prevalence rates of some psychiatric disorders, whereas older Latinos exhibited rates equal to those of older non-Latino whites. Also, the protective effect of nativity seems to vary according to age, psychiatric disorder, and ethnicity.

Schizophrenia affects only 0.7 percent of the U.S. population (2 million adults) (Saha et al. 2005), yet because of its early age of onset, chronicity, significant disability, and premature mortality, this severe mental illness is responsible for 5 percent of all burden of disease (Murray and Lopez 1996). Although U.S. community-based prevalence studies have generated little evidence on comparative rates for Latinos and non-Latino whites (Karno et al. 1987; Dassori, Miller, and Saldana 1995;), they suggest that blacks have a higher prevalence of schizophrenia than whites (Robins and Regier 1991; Kendler et al. 1996;). A recent California cohort study conducted in an insured population showed that the incidence of schizophrenia is three times higher among blacks than whites, the association partly mediated by socioeconomic status (Bresnahan et al. 2007). Although these studies employed standardized diagnostic methods, a previously documented tendency to overdiagnose schizophrenia in black adults may have played a role in these epidemiological findings (Williams and Earl 2007). The armamentarium of effective treatments for adults with schizophrenia has grown substantially in the past several decades. Even so, the quality of care typically received by people diagnosed with this severe psychiatric illness in the United States falls short of optimal (Lehman 1999). Moreover, quality of schizophrenia care varies depending on the race and ethnicity of patients. Relative to whites, blacks are more likely to use inpatient and emergency services (Snowden and Holschuh 1992) and less likely to receive outpatient care and a variety of recommended interventions (Wang, Demler, and Kessler 2002; Barrio et al. 2003;). Further, during a period when prevailing norms of good care favored atypical (over conventional) and oral (over long-acting injectable) antipsychotic medications, blacks had lower use rates of atypical antipsychotics and higher use rates of injectable antipsychotics than whites (Kuno and Rothbard 2002; Kreyenbuhl et al. 2003;). The evidence is substantially sparser and less consistent for Latinos (Vega et al. 2007). Despite rising awareness of the significance of disparities, some efforts to eradicate them, and isolated reports of improvements (Trivedi et al. 2005), disparities in health care for blacks and Latinos persist (Brady et al. 2007). For mental health care overall, studies have found either no change (Stockdale et al. 2008) or worsening health care disparities over time (Zuvekas 2005; Cook, McGuire, and Miranda 2007;). However, little is known about the care of minorities with schizophrenia. Daumit et al. (2003) used data on physician office and hospital outpatient department visits from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey to assess use of atypical antipsychotics by race/ethnicity during the period 1992–2000. Among subjects with psychotic disorders, the minority-white disparities in atypical antipsychotic use narrowed during the period 1992–2000, closing for Latinos yet persisting for blacks (Daumit et al. 2003). In sum, previous research on disparities in schizophrenia care has focused on specific levels of care or specific interventions and little is known about broader patterns of care. Further, little is known about the health care experience of Latinos, or about temporal trends in disparities within the evolving treatment patterns for schizophrenia. The overall purpose of this study was to study disparities among Medicaid recipients with schizophrenia receiving health care in Florida. We focused on Medicaid because most people in the United States with schizophrenia rely on Medicaid (Frank and Glied 2006), and we chose Florida because of its size and racially and ethnically diverse population. Further, availability of 12 years of data enabled us to evaluate trends in health care disparities. Consistent with the definition proposed by the Institute of Medicine, we define disparities as differences in care not explained by differences in health status or need for services (Smedley, Stith, and Nelson 2003). On the basis of past research, we expected to find racial/ethnic disparities. We hypothesized that because minorities are less likely to receive regular care and atypical antipsychotics, their spending on psychotropic drugs would be lower than that of whites. We further hypothesized that as a result of poorer access to high-quality care, minorities would have a higher likelihood of using psychiatric inpatient services, and as a result of nonclinical considerations, minorities would have higher psychiatric inpatient spending with respect to whites. Since these use patterns work in opposing directions we had no expectation on how total mental health and total health spending might differ among groups. Lastly, on the basis of limited research to date, we hypothesized that observed disparities would diminish over time.

The founders of AcademyHealth played a decisive role in advancing the health services field. Some, like Dr. Barbara McNeil, accomplished it through education and training of generations of health services researchers. Others, like Dr. Ron Andersen, achieved it through the development of theoretical models that resulted in a paradigm shift in how we conceptualize health services utilization. Still others, like Dr. Sam Shapiro, transformed the substantive nature of what we call health services research by linking structure and process to outcomes and asking questions such as, “What effect does being in a high performing organization have on the outcomes of care?”

In this study, the authors identify three guiding principles or relational strategies for developing successful community partnerships and building an alliance for systemic change. These principles were derived from their work over 4 years with an urban public school system, which was focused on generating a series of interventions for improving the behavioral and academic functioning of immigrant students. In their process, they developed an analysis and monitoring system of students’ progress, which allowed for earlier targeted effective support.

To test the effect of survey conditioning (whether observed survey responses are affected by previous experience in the same survey or similar surveys) in a survey instrument used to assess mental health service use.Primary data collected in the National Latino and Asian American Study, a cross-sectional household survey of Latinos and Asian Americans residing in the United States.Study participants are randomly assigned to a Traditional Instrument with an interleafed format placing service use questions after detailed questions on disorders, or a Modified Instrument with an ensemble format screening for service use near the beginning of the survey. We hypothesize the ensemble format to be less susceptible to survey conditioning than the interleafed format. We compare self-reported mental health services use measures (overall, aggregate categories, and specific categories) between recipients of the two instruments, using 2x2 chi(2) tests and logistic regressions that control for key covariates.In-person computer-assisted interviews, conducted in respondent's preferred language (English, Spanish, Mandarin Chinese, Tagalog, or Vietnamese).Higher service use rates are reported with the Modified Instrument than with the Traditional Instrument for all service use measures; odds ratios range from 1.41 to 3.10, all p-values.001. Results are similar across ethnic groups and insensitive to model specification.Survey conditioning biases downward reported mental health service use when the instrument follows an interleafed format. An ensemble format should be used when it is feasible for measures that are susceptible to survey conditioning.

Objective—To present national estimates and correlates of lifetime and 12-month DSM-IV eating disorders for Latinos. Method—Data come from the National Latino and Asian American Study (NLAAS), a national epidemiological household survey of Latinos in the Unied States. Results—Latinos have elevated rates of any binge eating and binge eating disorder but low prevalence of anorexia nervosa and bulimia nervosa. The US born and those living a greater percentage of their lifetime in the US evidenced higher risk for certain eating disorders while severe obesity and low levels of education were significant correlates. Rates of treatment utilization were exceedingly low. Conclusion—Standard eating disorder criteria may not be appropriate for understanding psychological morbidity of eating disorders for Latinos, particularly less acculturated Latinos, due to cultural differences in the presentation of eating disorder symptoms. Criteria for disturbed eating patterns that are more reflective of the illness experience of Latinos should be developed.

We examined correlates of lifetime parent-tochild aggression in a representative sample of 1,293 Asian American parents. Correlates examined included nativity, indicators of acculturation, socioeconomic status, family climate, and stressors associated with minority status. Results revealed that Asian Americans of Chinese descent and those who immigrated as youth were more likely to report minor parentalaggression; ethnicity and nativity were not associated with severe aggression. Indices of acculturation did not predict risk, but minority status stressors (perceived discrimination, low social standing) predicted risk of both minor and severe aggression. Affective climate differed markedly in families with minor versus severe aggression. Parental aggression in Asian American families may not be cultural per se, but stress associated with immigrant family context may heighten vulnerability. It is widely accepted that child physical abuse poses a major threat to public health. The psychological sequelae of physical abuse are widely recognized with elevated risk for mental health problems (for review see Kolko, 2002). Beyond

In a recent report, the Institute of Medicine (IOM) defines a health service disparity between population groups to be the difference in treatment or access not justified by the differences in health status or preferences of the groups. This paper proposes an implementation of this definition, and applies it to disparities in outpatient mental health care.Health Care for Communities (HCC) reinterviewed 9,585 respondents from the Community Tracking Study in 1997-1998, oversampling individuals with psychological distress, alcohol abuse, drug abuse, or mental health treatment. The HCC is designed to make national estimates of service use.Expenditures are modeled using generalized linear models with a log link for quantity and a probit model for any utilization. We adjust for group differences in health status by transforming the entire distribution of health status for minority populations to approximate the white distribution. We compare disparities according to the IOM definition to other methods commonly used to assess health services disparities.Our method finds significant service disparities between whites and both blacks and Latinos. Estimated disparities from this method exceed those for competing approaches, because of the inclusion of effects of mediating factors (such as income) in the IOM approach.A rigorous definition of disparities is needed to monitor progress against disparities and to compare their magnitude across studies. With such a definition, disparities can be estimated by adjusting for group differences in models for expenditures and access to mental health services.

This article investigates attitudes toward seeking mental health treatment in a national epidemiological sample. Young adults reported the most negative attitudes, as compared to older adults. Males reported more negative attitudes, as compared to females, a consistent finding in young adults. The gender difference was not consistent in Latinos and African Americans. Although African Americans reported more positive attitudes than Anglos, this effect was not observed in young adults. Latinos reported similar attitudes toward mental health treatment, as compared to Anglos, a consistent finding in young adults. Results show that attitudes toward mental health treatment in young adult males are the most negative of all groups. Latinos and African Americans do not necessarily demonstrate more negative attitudes toward mental health treatment than Anglos. Within-group differences in ethnic/racial minority groups may not be similar to differences seen in Anglo populations. © 2005 Wiley Periodicals, Inc. J Comm Psychol 33: 611–629, 2005.