12491 - OVERVIEW: DISPARITIES IN THE DIAGNOSIS AND...

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Unformatted text preview: OVERVIEW: DISPARITIES IN THE DIAGNOSIS AND TREATMENT OF MENTAL DISORDERS JAVIER I ESCOBAR MD UMDNJ-ROBERT WOOD JOHNSON MEDICAL SCHOOL Hispanic Population In the United States 1990: 249 million total population 22.4 million Hispanics 9% of total population 35.3 million Hispanics 12.5% of total population 13.0 million 58% increase since 1990 2000: 281 million total population 1990 to 2000 change: 2 Disparities Affecting Latino Populations in the United States Educational Attainment (US 1996) 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Hispanic African American White High School Diploma College Degree Median Family Income (US 1995) $45,000 $40,000 $35,000 $30,000 $25,000 $20,000 $15,000 $10,000 $5,000 $0 Hispanic African American White "Healthy People 2010" Released by DHHS in January 2000 Contains 467 Objectives grouped into 28 "focus areas" Major Goals are: 1- Enhance life expectancy/quality of life and 2Eliminate health disparities including those related to gender, race, ethnicity, education, income, disability, living in rural localities and sexual orientation Disparities: The Federal Agenda National Assessment Tool = 10 Leading Health Indicators to Measure Health Status Physical Activity Tobacco Use Substance Abuse Mental health Overweight/Obesity Injury and Violence Environmental Quality Responsible Sexual Immunization Behavior Access to health Care Health Disparities in Medicine INFANT MORTALITY IMMUNIZATION RATES BREAST EXAMINATIONS/ MAMMOGRAMS ACCESS TO PROCEDURES (e.g. bypass surgery) DIABETES (prevalence and outcomes -- e.g. amputations) HYPERTENSION AIDS OBESITY CHD prevalence and mortality STROKE (outcomes) Other Major Health Disparities Insufficient information on Health Indexes, Treatment Adequacy and Response, etc. Lack of Access to and poor Quality of Services Low number of Minority Physicians, Dentists, Nurses Low number of Minority Faculty in Medical Schools Low number of Minority Researchers Mental Health Disparities Prevalence of Disorders Diagnostic Bias (Schizophrenia & African Americans) Access to Services Quality of Services Cultural Competency Cultural Advantages (Latino immigrants) Paradoxical Findings: The Health Advantages of Latinos in the United States 12 Month Prevalence of Mood and Addictive Disorders in Males (Vega et al, 1997) 10 8 6 4 2 0 Drugs Alcohol Mania Dysthymia Depression USA MEXICO Prevalence of Mood Disorders in Primary Care (Waitzkin, Escobar et al, 1997) 30 25 Major Depr. 20 Melancholia Dysthymia 15 10 5 0 US Whites US-born Latnos Mexicans Use of Substances in Several Countries (Medina-Mora et al, 2002) USA 9 8 7 6 5 4 3 2 1 0 Canada Mexico South America Asia Marihuana Cocaine Hypertension in Mexican Americans (NHHANES III-1988-1994) Men Women 40% 35% 30% 25% 20% 15% 10% 5% 0% Mexicoborn US-born Spanish US-bornEnglish Mortality (Hazard Ratios) Latinos vs. Non Latino Whites in the US (NLMS Data) (Abraido-Lanza et al AJPH 1999) 1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 Males Mexican Central/South Amer. Females Puerto Rican Non-Latino Whites Cuban PSYCHOTIC SYMPTOMS BY SEX AND PLACE OF BIRTH (Vega et al, 2003) Females/DISORDER Males/Disorder Females/ND Males/ND 40 35 30 25 20 15 10 5 Immigrants;Less Immigrants>13 US-Born than 13 Years years 0 Study of a Large Mental Health System in New Jersey Minsky et al, Archives of General Psychiatry, 2003 Consumer Satisfaction in a Large Mental Health System in NJ (very good to excellen Latinos 64% 62% 60% 58% 56% 54% 52% Blacks Whites Basis 32 Baseline Scores Latinos 1.8 1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0 Blacks Whites Total Psychoticism Percent With Serious Mental Illness (Dementia, Schizophrenia, MDD, Bipolar) Latinos 50 45 40 35 30 25 20 15 10 5 0 Blacks Whites Clinical Diagnosis for Patients Using MH Services (N=19,213) (Minsky et al, 2002) Major Depression 25 20 15 10 5 0 African Americans Latinos Other Psychotic Disorders Psychosis in African Americans The findings of a higher rate of psychotic diagnoses in AfricanAmericans are supported by several other reports (Bell &Mehta 1980; Strakowski et al, 1993; Lawson 1994). "Research" and "Clinical" Diagnoses less likely to agree in AA compared to White patients Possible Explanations of Observed Diagnostic Disparities Self-Selection: Latinos more likely to seek help for symptoms of depression? Language: Issues of Translation and Interpretation? Cultural Repertoire: Variation in Symptom Expression? Format of the Interview ? Interviewer or Examiner's Bias? Diagnostic Bias: Systems like DSM may lead to rigid use of common symptom lists, or preferential scrutiny of certain symptoms with little or no regard to cultural considerations. Possible Explanations of Diagnostic Disparities African Americans more likely to present with psychotic symptoms? Selective emphasis on certain symptoms (Focus on psychotic rather than mood symptoms). Undue emphasis on Schneiderian Symptoms? African Americans more likely to present with Schneiderian Symptoms? (No!, according to Strakowsky's recent paper) Clinician's Bias? Need for new, systematic research Disparities in Treatment seem to be improving NAMCS and NHAMCS data on Atypical Antipsychotics Odd Ratios (Whites = 1.0) WHITES 1.2 1 0.8 0.6 0.4 0.2 0 BLACKS HISPANICS 1992-94 1995-97 1998-2000 Some examples on inconsistencies in this area of research that complicate interpretation of data H-HANES Self Reports versus Health Assessment in Puerto Ricans (Angel and Guarnaccia, 1989) Excellent/Very Good Poor 70% 60% 50% 40% 30% 20% 10% 0% Self-English MD-English Self-Spanish MD-Spanish Risk of Dying and Self Reported "Poor/Fair" Health 2.5 2 1.5 1 0.5 0 (NHIS Data --Finch et al, 2002) Recent Immigrants Long-term Immigrants US-BORN Recommendations Increase awareness on diagnostic disparities Use systematic, standardized inventories for making diagnoses (research diagnoses less biased than clinical diagnoses) Provide Culturally Congruent Services (e.g., bilingual, bicultural services for US Latinos) Audit/Monitor trends in clinical diagnoses vs. symptom self reports (Basis-32). ...
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