Advanced Center Background
NIMH Advanced Center for Latino and Mental Health Systems Research
Background and Overview of the Advanced Disparities Center
There are pervasive ethnic and racial disparities in mental health service utilization and status, yet the underlying causes of these disparities are poorly understood. Obtaining a better understanding of the factors associated with ethnic/racial, cultural, and contextual differences in mental health status and service utilization is critical due to the rapid growth of minority populations in the United States. The mental health service needs of Latinos are particularly important, given the well documented pattern of mental health service utilization inequities among Latinos residing in the US.
In response, CMMHR established an Advanced Center for Mental Health Disparities to focus on understanding factors which affect mental health service disparities in Latinos and to generate knowledge of how best to eliminate them. The overall aim of the Advanced Center is to bring together a synergistic core of researchers to formulate, conduct and disseminate interdisciplinary mental health services disparity research program to reduce mental health service disparities among Latinos. This five-year project is structured around two large research projects and two pilot projects.
Goals of the Advanced Disparities Center
- To conduct significant service disparities research that generates information to improve the mental health service access, quality and outcomes of care for Latino populations and is of clinical or programmatic service utility;
- To support investigators in conducting and developing service disparities research by problem-solving not only methodological, analytical and data management issues but by advancing novel approaches to tackle service disparities questions and challenges;
- To use information derived from our research and pilot projects to develop grants, research projects and/or community collaborations that test strategies or interventions for reducing Latinos mental health service disparities;
- To use multiple methods of dissemination including publishing papers on our research efforts with an emphasis on developing knowledge that has clinical utility, policy implications and/or informs Latino communities about how to reduce service disparities.
- To mentor junior investigators to encourage the development of independent research projects and opportunities for professional development;
Projects and Pilots of the Advanced Disparities Center: Overview and Aims
Project 1: Improving Clinical Assessment of Diagnosis for Ethnic and Racial Minorities: The Patient-Provider Encounter Study (PPES)
The goal of this project is to develop and test a mixed methods approach to help clinicians in public psychiatric settings decrease clinical uncertainty, accurately diagnose patients with diverse cultural backgrounds and improve the ‘matching’ of clinical services to the treatment needs of Latinos. We focus on an important clinical decision point – the initial diagnostic interview. During a diagnostic interview, the clinician must determine which information will help identify whether a new patient has a serious mental health or substance abuse disorder. In doing so, the clinician uses a process that we refer to as the “cultural formulation” of diagnosis.
The PPES minority supplement mirrors the methods of the Diagnostic Project but focuses on a smaller sample of Black patients. We hope to reduce clinical uncertainty among clinicians treating Black patients by identifying symptoms, cultural and social factors, used to make determinations about major depression in Black adults.
- Identify information about symptoms, cultural and social factors that clinicians use to make determinations about three disorders: major depression, drug abuse, and alcohol abuse.
- Use data from an epidemiological survey to assess the sensitivity and specificity of clinician diagnoses. Given inherent limitations associated with the diagnostic interview (i.e. time, establishing rapport, gathering pertinent information), how well can clinicians identify the likelihood of major depression among Black, Latino and/or white populations? Further, we investigate whether decision rules that help clinicians determine who receives treatment should be different for patients from different population groups.
- Assess clinician and patient reactions to the recommended improvements to diagnostic assessments. Using focus groups, we prioritize the type of information to be collected to improve diagnostic assessments in safety net settings and to generate suggestions for interventions that might benefit patients and providers.
- Make concrete recommendations to improve the efficiency and fairness of diagnostic decisions for Latino and non-Latino white population groups. We evaluate how diagnostic decision-making can be made more efficient and fair by providing guidelines to ensure that Latino and Non-Latino white patients receive the best possible diagnosis.
To learn more about the methods, data collection, analysis and findings in the study see Dr. Alegria’s article: How Missing Information in Diagnosis Can Lead to Disparities in the Clinical Encounter.
Project 2: Identifying and Addressing Healthcare Disparities Among Severely Mentally Ill Latinos and Black persons
This research program aims to generate new evidence on service use and quality of care for housed or homeless severely mentally ill Latinos, and generate specific recommendations aimed at better meeting the treatment needs of Latinos. We will also evaluate disparities for severely mentally ill Black persons. We will conduct analyses of two data sets: data collected as part of the federally-funded Access to Community Care and Effective Services and Support (ACCESS) quasi-experimental program (R. Rosenheck, PI), and Florida Medicaid claims data for the period 1994-2006. Our analyses will attempt to isolate the contribution of factors such as socioeconomic status and geography that may mediate the observed service disparities and identify strategies with the potential to narrow observed disparities. This research will enable us to expand clinical and policy implications, with the goal of designing comprehensive strategies to address racial and ethnic disparities.
- To assess disparities in service utilization for Latino and Black relative to white severely mentally ill and homeless persons under conditions of usual care.
- To assess disparities in service utilization and outcomes for Latino and Black relative to white severely mentally ill and homeless persons enrolled in a case management-based intervention.
- To assess disparities in utilization and quality of mental health services for publicly insured Latino and Black relative to white persons diagnosed with schizophrenia, and whether these differences are dynamic over time.
- To evaluate differences in antipsychotic treatment continuation rates for Latino, Black, and white adults with schizophrenia over three 3-year periods.
Papers currently in press include: Horvitz-Lennon, M., Reynolds, S., Witheridge, T.F. The Role of Assertive Community Treatment in the Treatment of Persons with Borderline Personality Disorder. American Journal of Psychiatric Rehabilitation.
Pilot 1: Ethnic Differences in Perceived Impairment and Need for Care. This pilot aims to investigate parental and provider beliefs about what constitutes impaired behavior among children, the severity of such behavior, and the need for treatment in a sample of Latino US, island Puerto Rican and non-Latino white providers and parents. We will examine the ratings of providers and parents using case vignettes of children with different levels of impairment and internalizing and externalizing symptoms, while varying ethnicity and gender. The goal is to assess whether differential behaviors and severity thresholds relate to mental health service disparities for Latino youth.
Sixteen case vignettes were created to reflect different types of mental health problems and levels of impairment in children. The vignettes reflect different manifestations of need for service in diverse populations as a function of whether the child’s symptoms are predominantly externalizing behaviors (e.g., ADHD or Oppositional Defiant Disorder) or internalizing ones (e.g., Depression or Social Phobia) and based on the severity of these symptoms. Parents and providers were asked to rate the vignettes to assess impairment and need for service.
Pilot 1 Aims
- Develop case vignettes of children with various levels of impairment and internalizing and externalizing problems based on secondary qualitative analyses of two data sets of children from clinics in Puerto Rico and the US.
- Compare parents’ impairment ratings and perceptions of the need for service across parents from different ethnic groups, island Puerto Ricans, Latinos residing in the mainland US, and US non-Latino whites, using these case vignettes of children. Compare providers’ impairment ratings and perceptions of the need for services of the children depicted in the vignettes across providers from the same ethnic groups using the same methodology.
- Compare the parental and provider impairment ratings and perceptions of the need for service within and across each of the different ethnic groups.
Data analysis is underway; please check back for updates and published findings.
Pilot 2: Dialogue with the Latino Community and Healthcare System Stakeholders for Identifying Quality Improvements. The state of Massachusetts has implemented a health insurance reform that is significantly changing the way in which health care is delivered to individuals formerly funded through “free care” or the uncompensated care pool in safety net hospitals. This pilot focuses on understanding the impact of this policy change. We have completed a baseline survey of patients from mental health outpatient clinics who were formerly on free care, and two follow-up surveys in order to describe the effect of this policy change on the delivery of mental health care for this population. The qualitative data collected will be used to generate hypotheses about the impact of the reform.
We also conduct a small secondary data analysis of the patient encounter data at two safety net institutions, as well as meetings and focus groups with providers and administrators following data analysis, to generate ideas for a future systems intervention and grant proposal.
The goal of this pilot project is to identify quality improvements meaningful to Latinos by increasing the Latino community voice within a safety net mental health care system. The specific policy barrier that the project focuses on is the experience of health insurance reform in MA, and the impact these policy changes have had on ethnic and racial minorities receiving outpatient mental health care in safety net settings. Policy and financial constraints in safety net healthcare systems make the provision of quality mental health care to the uninsured a daunting challenge. Latinos disproportionately rely on safety net providers, making them especially vulnerable to the constraints on quality of care in safety net healthcare systems.
- Consult multiple stakeholders to identify community, client, administrative, provider and mental healthcare system barriers to access and quality mental health services for Latino patients.
- Selecting barriers identified in Aim 1, conduct policy implementation analyses that ground the participatory process in a clear, shared understanding of the legal, administrative and fiscal constraints on efforts aimed at quality improvements.
- Use the information generated in Aims 1 and 2 to launch a participatory process with multiple stakeholders to identify leverage points for mental health care system change. As part of this research, we will generate hypotheses to be tested in the context of community and/or systems interventions and their prospective evaluation in RO1 applications.
Data analysis is underway; please check back for updates and published findings.