Jennifer Alvidrez

Ethnic Variations in Mental Health Attitudes and Service Use Among Low-Income African American, Latina, and European American Young Women

This study examines the predictors of mentalhealth service use among patients in an ethnicallydiverse public-care womens clinic. While waiting fortheir clinic appointments, 187 Latina, African American, and White women were interviewed about theirattitudes towards mental illness and mental healthservices. White women were much more likely to have madea mental health visit in the past than the ethnic minority women. Having a substance use problem,use of mental health services by family or friends, andbeliefs about causes of mental illness were allpredictors of making a mental health visit.

Distressed women's clinic patients: Preferences for mental health treatments and perceived obstacles.

Women seen in public gynecology settings are at very high risk of developing psychiatric disorders. Because low-income and ethnic minority women seen in such settings underutilize mental health services, it is important to better understand treatment preferences and obstacles among this high-risk patient population. Public womens clinic patients (N = 105) who reported psychological or emotional distress were asked about their interest in medication, psychotherapy, and psychoeducational classes, as well as perceived obstacles to using these services. The vast majority were interested in receiving some form of mental health treatment, with the most interest shown for individual therapy and general psychoeducational classes about health and stress. Less interest was expressed in group therapy and medication. Women anticipated more instrumental barriers to using services, such as lack of money, transportation, and childcare, than stigma-related barriers, such as fear of embarrassment or rejection. However, Latinas, women with less education, and those with a current mood or anxiety disorder were more likely to anticipate stigma-related barriers to treatment than other women. Implications of these findings for referral and treatment of mental health problems among public womens clinic patients are discussed.

The Experience of Stigma among Black Mental Health Consumers

Little is known about how stigma affects Black people receiving mental health treatment. For a project to develop a consumer-based stigma intervention, qualitative interviews were conducted with public-sector Black mental health consumers (N=34). Primary themes from the interviews regarding stigma concerns, experiences, and coping strategies were examined. Concerns about stigma prompted most consumers initially to avoid or delay treatment; once in treatment, consumers commonly faced stigmatizing reactions from others. Consumers identified numerous strategies to deal with stigma, including seeking support from accepting members of their existing social networks, and viewing their own health as more important than the reaction of others. These consumer perspectives may be valuable to Black individuals who are contemplating seeking mental health treatment.

Adherence to antidepressant medications in black and latino elderly patients

OBJECTIVE The purpose of this pilot study was to identify ethnic group differences in nonadherence and to determine predictors of nonadherence to antidepressant medications in older minority-group members. METHODS Participants were 49 black and 52 Latino subjects over the age of 55 who had been prescribed antidepressant medications within the past 12 months. RESULTS We found a distinction between intentional nonadherence (e.g., alteration of medication regimen to fit ones needs) and unintentional nonadherence (e.g., forgetfulness/difficulties keeping track of medication regimen). Results suggested that older Latino subjects reported significantly more unintentional nonadherence than older black subjects. However, once other predictors were entered into the model, ethnicity did not remain a significant predictor. No ethnic group differences in intentional nonadherence were suggested. After controlling for ethnicity and medication type, intentional nonadherence was associated with concerns about the side effects of antidepressant medications, the stigma associated with antidepressant medications, and the attribution of lesser importance to antidepressant medications than other medications. Unintentional nonadherence was associated with greater cognitive impairment. CONCLUSIONS Results suggest that the two ethnic minority groups face similar barriers to adherence to antidepressant medications. Interventions to increase adherence should target the specific type of nonadherence presented by the elderly patients. Some may benefit from memory aids and the assistance of family and friends, others from specific educational interventions about the nature of depression and antidepressant medications.

Gender and Ethnic Diversity in NIMH-funded Clinical Trials: Review of a Decade of Published Research

A total of 379 NIMH-funded clinical trials published between 1995 and 2004 in five major mental health journals were assessed on their inclusion of women and racial/ethnic groups in their study recruitment. Findings showed that whereas most of the studies reported gender information and gender representation was balanced across studies, less than half of the studies provided complete racial/ethnic information. All racial/ethnic groups except Whites and African Americans were underrepresented, a pattern that has not improved significantly over the last decade. Less than half of the studies had potential for subgroup analyses by gender and race/ethnicity.

The experience of Black consumers in the mental health system--identifying barriers to and facilitators of mental health treatment using the consumers' perspective.

Research has shown that relative to Whites, Blacks are less likely to seek outpatient mental health treatment and more likely to seek emergency services. Furthermore, Blacks often terminate treatment prematurely. The goal of the present study was to identify barriers to and facilitators of mental heath treatment among Blacks who have a documented need for mental health services. Thirty-four Black mental health consumers were interviewed for this purpose. Comments were categorized into four main categories: (a) barriers to treatment, (b) treatment facilitators, (c) recommendations for improvement of services, and (d) advice to potential consumers. The most common barriers were the importance of family privacy, lack of knowledge regarding available treatments, denial of mental health problems, and concerns about stigma, medications, and treatment. Participants also reported system barriers, such as not receiving appropriate information about services or receiving inadequate, dehumanizing services. Acknowledging the need for mental health services, having a supportive environment, and positive past treatment experiences were identified as treatment facilitators. Community outreach, adequate follow-up, and coordination of services also were important messages delivered by consumers. The results of this study indicate the importance of educating the general public, not just mental health consumers, about the nature of mental illness and available services.

Physician Willingness to Refer Older Depressed Patients for Psychotherapy

Objective: Psychotherapy for late-life depression is an efficacious treatment option for older primary care patients who do not wish to take or do not respond to antidepressant medication. However, rates of physician referral to psychotherapy to treat late-life depression tend to be low. The purpose of this study was to assess attitudes toward psychotherapy for late-life depression and to identify predictors of physician willingness to refer older patients to psychotherapy. Methods: Two hundred and five physicians identified from PPO directories of general internists in California and North Carolina completed a brief mailed survey about how they would treat a hypothetical older depressed patient and specific attitudes and practices regarding their own treatment of late-life depression. Results: Only 27 percent of physicians said they would refer a depressed older patient to psychotherapy. In a regression analysis, female gender, the belief that psychotherapy is effective for older adults, and physician use of psychosocial techniques were associated with increased willingness to refer to psychotherapy. Practicing in North Carolina, awareness of depression treatment guidelines, and the perception of patient willingness to attend psychoeducational classes on depression and medication management were associated with decreased willingness to refer. Conclusions: More efforts are needed to increase the use of referral to psychotherapy as a treatment option for older medical patients. Education about guideline-level treatment alone may not be sufficient. More specific education, including information about the efficacy of psychotherapy for older adults, as well as direct training in psychosocial techniques, may be helpful in promoting referral to psychotherapy.

Psychoeducation to Address Stigma in Black Adults Referred for Mental Health Treatment: A Randomized Pilot Study

Forty-two Black clients referred for outpatient treatment were randomly assigned to receive existing brochures about services or a psychoeducational booklet about stigma based on experiences of Black mental health consumers. At 3-month follow-up, clients reported that both types of information were helpful; there were no significant differences between the types of information on treatment attendance. However, individuals who reported higher perceived treatment need or greater uncertainty about treatment showed greater stigma reduction from the psychoeducation. Findings indicate the need to move beyond “customer satisfaction” to evaluate educational interventions, as well as for greater understanding of differential impact of stigma reduction interventions.

Overrepresentation of Black Americans in Psychiatric Inpatient Care

OBJECTIVE Numerous studies have documented overrepresentation of the black population in psychiatric inpatient settings, but none have included certain important covariates or examined heterogeneity within the black population. After controlling for key social, demographic, and clinical factors, the investigators sought to determine whether blacks are overrepresented in inpatient psychiatric settings; they examined differences within the black population by separately examining the prevalence of inpatient treatment of African Americans and U.S.- and foreign-born Caribbean blacks. METHODS Secondary analysis was performed on data from two population-based household surveys, the National Survey of American Life (NSAL) and the National Comorbidity Survey Replication (NCS-R), which provided a population-based sample of 9,371 community-dwelling adults, including 3,570 African Americans, 1,621 blacks of Caribbean descent, and 4,180 non-Hispanic whites. Using logistic regression, the investigators estimated self-reported lifetime psychiatric hospitalization as a function of racial-ethnic background after controlling for sociodemographic differences and differences in lifetime counseling or therapy and psychiatric diagnosis. RESULTS With controls for demographic and clinical factors, both African Americans (odds ratio [OR]=2.52, 95% confidence interval [CI]=1.91-3.33) and Caribbean blacks (OR=2.74, CI=1.98-3.82) had higher odds than whites of having a psychiatric hospitalization in their lifetime. U.S.-born Caribbean blacks had much higher odds of hospitalization (OR=5.47, CI=3.60-8.32) than whites, whereas the likelihood of hospitalization of foreign-born Caribbean blacks did not differ from that of whites (OR=.96, CI=.51-1.82). CONCLUSIONS Disparities between blacks and whites in the prevalence of psychiatric inpatient treatment appear to be persistent, but global comparisons mask important heterogeneity within the black population.

Potential ethnic modifiers in the assessment and treatment of Alzheimer's disease: challenges for the future

OBJECTIVE Despite numerous clinical trials, it is unknown whether ethnicity affects treatment response to cognitive enhancers in Alzheimers disease (AD). There is convincing evidence of ethnic and genetic variability in drug metabolism. This article reviews the available data on ethnicity in clinical trials for AD to answer two questions: (1) what are the challenges to diagnose and treat AD across different ethnic groups, and (2) are there differences in response to pharmacologic interventions for AD across these different ethnic groups? METHOD Available data from Alzheimers Disease Cooperative Study (ADCS) randomized controlled clinical trials and from randomized controlled industry-sponsored trials for four cognitive enhancers (donepezil, galantamine, rivastigmine and sabeluzole) were pooled to assess the numbers of non-Caucasian participants. RESULTS The participation of ethnic minority subjects in clinical trials for AD was dependent on the funding source, although Caucasian participants were over-represented and non-Caucasian participants were under-represented in the clinical trials. Because of the low participation rate of ethnic minorities, there were insufficient data to assess any differences in treatment outcome among different ethnic groups. Strategies to improve diversity in clinical trials are discussed. CONCLUSION Greater participation of ethnically diverse participants in clinical trials for AD would generate additional information on possible differences in metabolism, treatment response, adverse events to therapeutic agents, and could foster the investigation of genetic variability among ethnic groups.