Robert Wood Johnson Foundation

Improving the Quality of Depression Treatment for Ethnic/Racial Minorities


Background: CMMHR received a two-year grant in December, 2006 to enable investigators to perform analyses that will provide mental health service providers findings relevant for assessing, treating, and retaining ethnic/racial minority patients in depression treatment. This study will be based on new data from the combined National Latino and Asian American Study (NLAAS) and the National Comorbidity Survey Replication (NCS-R)(pooled, N = 14,146), one of the most comprehensive national data sources available that can be used to study depression treatment for ethnic minorities. We also plan to utilize recently collected qualitative data obtained from interviews with providers and ethnic minority patients with depression.

AIMS:
Aim 1: To compare the quality of depression treatment that ethnic/racial minorities receive relative to what non-Latino whites receive
Aim 2: To explore whether geographic factors play a role in explaining receipt of quality depression treatment, and whether these effects vary by ethnicity/race
Aim 3: Using qualitative and quantitative data, to examine how depression treatment can be designed to be more responsive to ethnic/racial minority patient needs
Aim 4: To address the economic and social costs of depression in ethnic/racial minority populations by estimating the effects of depression on labor market outcomes and public assistance receipt.

The analyses will inform the field regarding the quality of depression services received at the clinical level (e.g., guideline concordant care), at the patient level (e.g. patient-centeredness), and at the community level (e.g. availability of medical resources in community). This information will help policymakers make multi-tiered recommendations to address gaps in service provision for depression for minorities, and to generate concrete solutions for improving quality of care.


Funding Acknowledgment:
Improving the Quality of Depression Treatment for Ethnic/Racial Minorities is funded by the Robert Wood Johnson Foundation: Grant Number: 5-8678

Publications:

The following represent a selection of work funded by the RWJ grant, which examined ways to improve the quality of depression treatment for racial/ethnic minorities.

Socioeconomic Status

This study examined whether there were associations between individual measures of socioeconomic status (SES) and the 12-month prevalence of major depressive disorder (MDD) in representative samples of African-Americans, Latinos, Asians, and non-Latino whites in the United States. Statistically significant associations were present between household income and educational attainment and MDD only among non-Latino whites. In contrast, household income and educational attainment were not significantly associated with a decreased risk of MDD among African-Americans, Latinos, and Asians. Among both non-Latino whites and Latinos, being out of the labor force was significantly associated with MDD, but not for the other groups. Possible explanations for these findings may include the fact that the consequences of MDD may be similar for those who suffer from MDD, irrespective of income level, and that years of education, a traditional measure of social stratification, may effectively parallel the association between SES and MDD among non-Latino whites. Conversely, education may not translate into economic opportunity for racial/ethnic minority groups. This suggests that, in this study, education as a measure of SES fails to capture the context in which SES may influence MDD. Our findings suggest that an increased risk of MDD was not observed among high compared to low SES individuals. Thus, despite the low prevalence of MDD among racial/ethnic minority groups, there is no empirical evidence to support that the association between racial-ethnic status and MDD varied by SES level. The findings suggest that the association between indicators of SES and 12-month MDD is complex, and requires additional study.

Reference: Gavin, A, Walton, E, Chae, D, Alegria, M, Jackson, J, & Takeuchi, D. (2010). The Associations between Socioeconomic Status and Major Depressive Disorder among Blacks, Latinos, Asians, and Non-Hispanic Whites: Findings from the Collaborative Psychiatric Epidemiology Studies. Psychological Medicine. 40, 51-61.

Cultural Issues

Accurate assessment of depression can be stymied by cultural issues affecting patients’ response to diagnostic questions. We evaluated the concordance between diagnoses made with the World Health Organization Composite International Diagnostic Interview (WMH-CIDI) and structured clinical diagnostic interviews made by bilingual/bicultural mental health providers of U.S. Latinos. The WMH-CIDI is administered by trained laymen, while the World Mental Health Structured Clinical Interview for DSM-IV (WMH-SCID 2000) is administered by professional clinicians and mental health providers. Our results suggest several methodological improvements to diagnostic assessments for Latino respondents suffering from depression. For example, loosening the criteria for depression to one less seems to improve the concordance of the WMH-CIDI with the SCID. Also, asking about lifetime depression, rather than current depression, to identify potential cases for continued monitoring of depression appears to be another improvement in the assessment of depressive disorders. Good concordance was found for major depressive episode; this may be due to the fact that major depressive episode is a familiar condition with symptoms that are easy to comprehend and describe. It is important to consider cultural factors that may contribute to Latinos answering differently than non-Latinos on the same items.

Reference: Alegria, M, Shrout, P, Torres, M, Lewis-Fernandez, R, Abelson, J, Powell, M, Lin, JY, Interian, A, Laderman, M & Canino, G. (2009). Lessons Learned from the Clinical Reappraisal of the Composite International Diagnostic Interview with Latinos. International Journal of Methods in Psychiatric Research, 18(2), 84-95.

Quality of Depression Treatment

One of our main goals was to compare the access to and quality of depression treatment that ethnic and racial minorities receive relative to what non-Latino whites receive. Findings from this analysis show that for those with current depressive disorder, 63.7% of Latinos, 68.7% of Asians and 58.8% of African Americans, vs. 40.2% of non-Latino whites, did not access any mental health treatment in the last year (p<0.001). Among non-Latino whites with depression, 32.5% are predicted to both access treatment and receive quality depression care, compared to only 18.1% of Latinos, 13.7% of Asians and 13.4% of African Americans. These findings shift the debate to developing policy, practice, and community solutions that can effectively address the barriers that generate these disparities. Simply relying on present systems without considering the unique barriers to quality care that apply for underserved ethnic and racial minorities is unlikely to affect the pattern of disparities we observed. One possible point of intervention is the use of quality improvement programs to increase quality of care among minorities. Policy changes might include increased resources for mental health services in safety net clinics; practice changes might include training nurses in motivational interviewing or routinely implementing evidence-based quality improvement programs for depression; community strategies might include home visits by peer counselors to engage patients in understanding the importance of treatment or to provide ancillary services (e.g. transportation, child care, patient advocacy) that facilitate access to care.

Reference: Alegria, M, Chatterji, P, Wells, K, Cao, Z, Chen, C, Takeuchi, D, Jackson, J and Meng, X-L. (2008). Disparity in Depression Treatment among Racial and Ethnic Minority Populations in the United States. Psychiatric Services, 59(11), 1264-1272.

Antidepressant Use

Since depression is generally treated with antidepressants, we examined psychiatric and non-psychiatric factors associated with 12-month antidepressant use in a nationally representative sample of community-dwelling Latinos. We found that, regardless of mental disorders, 11.5% of Latinos and non-Latino Whites used antidepressants in the past year. Lifetime depressive and anxiety disorders explained an additional 21% of past-year antidepressant use. Nevertheless, 12-month and lifetime depressive and anxiety disorders did not account for nearly one-third of all the antidepressants use in this national sample. All of the Latino groups used antidepressants less than non-Latino Whites, however, only Mexicans and the “other Latino” group had significantly lower odds of use. Among respondents meeting criteria for any depressive or anxiety disorder examined in this study, Latinos (20.8%) had significantly lower rates (p=0.01) of antidepressant use compared to non-Latino Whites (32.4%). Mexican Americans, who represent over two-thirds of Latinos in the United States, are also the most likely to encounter inequalities in antidepressant use. Our findings highlight the importance of disaggregating Latinos by ethnic subgroups for pinpointing where treatment inequalities exist within the diversity of Latinos in the US. Ignoring the different experiences of Latino subgroups with mental health care access masks important treatment inequalities between major Latino subgroups. This research suggests several directions for future research and policy to improve delivery of mental health care for all Americans, but especially the most underserved groups. First, increased availability and initiation of treatment with mental health needs will require new evidence-based outreach efforts. Second, continued attempts to lower cross-cultural communication barriers between patients and care-providers may improve diagnoses and ensure the delivery of appropriate treatments. Third, better interventions are required to ensure treatment to those most in need. Finally, new research is required that explores the potential value of antidepressant treatment in medical conditions other than depressive and anxiety disorders. Our results provide a baseline from which policy makers and researchers can further understand and track patterns of antidepressant use among Latinos and assess ways to improve the matching of need and antidepressant use.

Reference: Gonzalez, H., Tarraf, W., West, B., Croghan, T., Bown, M., Cao, Z. & Alegria, M. (2009). Antidepressant Use in a Nationally Representative Sample of Community-Dwelling U.S. Latinos With and Without Depressive and Anxiety Disorders. Depression and Anxiety, 0, 1-8.

Suicide

This paper compares the prevalence of lifetime suicide ideation and suicide attempts among major U.S. Latino ethnic subgroups and identifies psycho-sociocultural factors associated with suicidal behaviors. We found that, among Latinos, the lifetime prevalence of suicidal ideation was 10.2% and suicidal attempts 4.4%. Puerto Ricans were more likely to report ideation as compared to other Latino subgroups but this difference was eliminated after adjustments for psychiatric and sociocultural factors. Most lifetime suicidal attempts described by Latinos were reported as occurring when they were under the age of 18 years. Any lifetime DSM-IV diagnoses, including dual diagnoses, were associated with an increased risk of lifetime suicidal ideation and attempts among Latinos. In addition, female gender, acculturation (born in U.S. and English speaking) and high levels of family conflict were independently and positively correlated with suicide attempts among Latinos, even among those without any psychiatric disorder. Our results provide evidence that meeting criteria for any DSM-IV psychiatric disorder is highly correlated with suicide ideation and attempts among Latinos, even when adjusting for age, gender and language/nativity. Therefore, the appropriate identification and diagnosis of these conditions continues to be an important issue for Latinos in terms of suicide prevention. This is a serious challenge for a population which tends to have lower access to mental health services than the general population due to lack of insurance, a shortage of culturally and linguistically trained service providers and stigma. Social and cultural supports may be important factors influencing variations in suicide risk across Latino groups. Complete assessment and screening for suicidality should not be limited to depressive disorders but should be considered in the presence of dual diagnoses. Our results also point to the importance of using a complete bio-psychosocial-cultural model in treating and considering suicidal risks among diverse groups of Latinos. Our findings, regarding family conflict and the complexity of acculturation as a potentially dynamic and influential issue related to suicidal behaviors even in absence of full DSM-IV diagnoses, point to the importance of examining this area in clinical research and treatment with Latino subgroups.

Reference: Fortuna, L, Perez, D, Canino, G, Sribney, W, Alegría, M. (2007). Prevalence and Correlates of Lifetime Suicidal Ideation and Attempts among Latino Subgroups in the United States. Journal of Clinical Psychiatry, 68(4):572-581.

Immigration Status

Although widely reported among Latinos, contradictory evidence exists regarding the generalizability of the immigrant paradox; that foreign nativity is protective against psychiatric disorders. We examined whether this paradox applies to all Latino groups by contrasting estimates of lifetime depressive disorders among Latino immigrants, Latino U.S.-born, and non-Latino whites. Our results show that, in aggregate, Latinos are at lower risk of most psychiatric disorders compared to non-Latinos whites and, consistent with the immigrant paradox, U.S.-born Latinos report higher rates for most psychiatric disorders than Latino immigrants. U.S.-born Latinos are at significantly higher risk than immigrant Latinos for major depressive episode (18.6% vs. 13.4%), and any depressive disorder (19.8% vs. 14.8%). The immigrant paradox is only observed for Mexicans, but not for Cubans, Puerto Ricans or other Latinos. Aggregating Latinos into a single group masks great variability in lifetime risk for psychiatric disorders, with some subgroups, like Puerto Ricans, suffering from psychiatric disorders at rates comparable to non-Latino whites. Our findings thus suggest that the protective context in which immigrants lived in their country of origin possibly inoculated them against risk for depressive disorders, particularly if they immigrated as adults. Our results demonstrate that within the Latino population, some subgroups suffer from psychiatric disorders at rates comparable to non-Latino whites. We urge the exercise of caution in generalizing the immigrant paradox to all Latinos, since the protective effect of nativity varies by type of psychiatric disorder and sub-ethnicity.

Reference: Alegria, M, Canino, G, Shrout, P, Woo, M, Duan, N, Vila, D., Torres, M., Chen, C. & Meng, X-L. (2008). Prevalence of Mental Illness in Immigrant and Non-Immigrant U.S. Groups. American Journal of Psychiatry, 165(3), 359-69.

Our previous work with Asians has shown that immigration is associated with depression, but that the direction of the association is inconsistent. Some studies find that individuals born in a country other than the United States are more likely to be depressed, but other studies find the opposite pattern. The age at which Asians immigrate to the United States is also strongly associated with major depression. For example, Chinese immigrants who immigrate after age 20 are nearly 1.5 to 3 times more likely to experience major depression than are those who immigrate before age 20. English proficiency is another important immigration-related factor that may affect mental health. The ability to speak English proficiently is a key feature in the social integration and acculturation of immigrants in such areas as the entry into the US labor force. Also, the circumstances under which people migrate to the United States are associated with depression. Asian refugees are more likely to report depressive symptoms than are Asian immigrants who voluntarily come to the United States. Our results show that years in the United States did not show the predicted pattern for an increased risk for depressive disorder for Asians. Although some associations were evident, they were often in the opposite direction of the prediction that length of residency reduces the chance of psychiatric disorders. In order to guide effective and culturally-appropriate prevention and treatment efforts, it is critical to identify and understand specific components of various cultures that are protective against psychopathology, as well as those factors that increase risk of psychiatric morbidity.

Reference: Takeuchi D, Zane N, Hong S, Chae D, Gong F, Gee G, et al. (2007). Immigration-related factors and mental disorders among Asian Americans. American Journal of Public Health. 97(1).