Nicholas Carson

Disparities in Treatment for Substance Use Disorders and Co-Occurring Disorders for Ethnic/Racial Minority Youth

OBJECTIVE To review the literature on racial and ethnic disparities in behavioral health services and present recent data, focusing on services for substance use disorders (SUD) and comorbid mental health disorders for children and adolescents. METHOD A literature review was conducted of behavioral health services for minority youth. Articles were included if specific comparisons in receipt of SUD services for youth were made by race or ethnicity. The review was organized according to a sociocultural framework. RESULTS Compared with non-Latino Whites with SUD, Black adolescents with SUD reported receiving less specialty and informal care, and Latinos with SUD reported less informal services. Potential mechanisms of racial and ethnic disparities were identified in federal and economic health care policies and regulations, the operation of the health care system and provider organization, provider level factors, the environmental context, the operation of the community system, and patient level factors. Significant disparity decreases could be achieved by adoption of certain state policies and regulations that increase eligibility in public insurance. There is also a need to study how the organization of treatment services might lead to service disparities, particularly problems in treatment completion. Institutional and family characteristics linked to better quality of care should be explored. Because treatments appear to work well independent of race/ethnicity, translational research to bring evidence-based care in diverse communities can bolster their effectiveness. CONCLUSIONS This review suggests promising venues to decrease ethnic and racial disparities in behavioral health services for ethnic and racial minority youth.

Social Determinants of Mental Health Treatment among Haitian, African American, and White Youth in Community Health Centers

We examine adequate mental health treatment, emergency room (ER) use, and early treatment dropout for Haitian, African American and White youth with a psychiatric diagnosis treated in community health centers in the United States. We present associations with possible socioeconomic determinants of care. Adequate treatment was less likely among Haitian youth from areas with greater poverty and among all youth from areas with more female-headed households. Medicaid-insured youth had more ER visits, especially African Americans. The relative impact of poverty on adequate care was higher for Haitians than Whites, and the relative impact of Medicaid coverage on ER use was higher for African Americans than for Whites. Early dropout was more likely among youth who were uninsured or from areas with more female-headed households. Socioeconomic factors and insurance status were significant determinants of care. Haitians living in poverty in the U.S. may face barriers to mental health services relative to other racial/ethnic groups.

Episodes of mental health treatment among a nationally representative sample of children and adolescents

Despite renewed national interest in mental health care reform, little is known about treatment patterns among youth in the general population. Using longitudinal data from the Medical Expenditure Panel Survey, we examined both initiation and continuity of mental health treatment among 2,576 youth aged 5 to 17 with possible mental health treatment need (defined as a high score on a parent-assessed psychological impairment scale, fair/poor mental health status, or perceived need for counseling). Over a 2-year period, fewer than half of sampled youth initiated new mental health treatment. Minority, female, uninsured, and lower-income youth were significantly less likely to initiate care. Only one third of treatment episodes met criteria for minimal adequacy (≥4 provider visits with psychotropic medication treatment or ≥8 visits without medication). Episodes were significantly shorter for Latino youth. Efforts to strengthen mental health treatment for youth should be broadly focused, emphasizing not only screening and access but also treatment continuity.

Assessing Racial/Ethnic Differences in the Social Consequences of Early-Onset Psychiatric Disorder

Individuals with early onset of psychiatric disorder have worse social outcomes than individuals with adult onset. It is unknown whether this association varies by racial/ ethnic group. Identifying groups at risk for poor social outcomes is important for improving clinical and policy interventions. We compared unemployment, high school dropout, arrest, and welfare participation by race/ethnicity and time of onset using a nationally representative sample of Whites, Blacks, Asians, and Latinos with lifetime psychiatric disorder. Early onset was associated with worse social outcomes than adult onset. Significant Black-White and Latino-White differences in social outcomes were identified. The association between early onset and negative social outcomes was similar across Whites, Latinos, and Blacks. For Asians, the association between unemployment and early onset was opposite that of Whites. Increasing early detection and treatment of psychiatric illness should be prioritized. Further study will clarify the association between onset and social outcomes among sub-ethnic populations.

Explaining Racial/Ethnic Differences in Adolescent Substance Abuse Treatment Completion in the United States: A Decomposition Analysis

PURPOSE To identify contributors to racial/ethnic differences in completion of alcohol and marijuana treatment among adolescents at publicly funded providers. METHODS The 2007 Treatment Episode Data Set provided substance use history, treatment setting, and treatment outcomes for youth aged 12-17 years from five racial/ethnic groups (N = 67,060). Individual-level records were linked to variables measuring the social context and service system characteristics of the metropolitan area. We implemented nonlinear regression decomposition to identify variables that explained minority-white differences. RESULTS Black and Hispanic youth were significantly less likely than whites to complete treatment for both alcohol and marijuana. Completion rates were similar for whites, Native Americans, and Asian-Americans, however. Differences in predictor variables explained 12.7% of the black-white alcohol treatment gap and 7.6% of the marijuana treatment gap. In contrast, predictors explained 57.4% of the Hispanic-white alcohol treatment gap and 19.8% of the marijuana treatment gap. While differences in the distribution of individual-level variables explained little of the completion gaps, metropolitan-level variables substantially contributed to Hispanic-white gaps. For example, racial/ethnic composition of the metropolitan area explained 41.0% of the Hispanic-white alcohol completion gap and 23.2% of the marijuana completion gap. Regional differences in addiction treatment financing (particularly use of Medicaid funding) explained 13.7% of the Hispanic-white alcohol completion gap and 9.8% of the Hispanic-white marijuana treatment completion gap. CONCLUSIONS Factors related to social context are likely to be important contributors to white-minority differences in addiction treatment completion, particularly for Hispanic youth. Increased Medicaid funding, coupled with culturally tailored services, could be particularly beneficial.

Quality of follow-up after hospitalization for mental illness among patients from racial-ethnic minority groups.

OBJECTIVE Outpatient follow-up after hospitalization for mental health reasons is an important indicator of quality of health systems. Differences among racial-ethnic minority groups in the quality of service use during this period are understudied. This study assessed the quality of outpatient treatment episodes following inpatient psychiatric treatment among blacks, whites, and Latinos in the United States. METHODS The Medical Expenditure Panel Survey (2004-2010) was used to identify adults with any inpatient psychiatric treatment (N=339). Logistic regression models were used to estimate predictors of any outpatient follow-up or the beginning of adequate outpatient follow-up within seven or 30 days following discharge. Predicted disparities were calculated after adjustment for clinical need variables but not for socioeconomic characteristics, consistent with the Institute of Medicine definition of health care disparities as differences that are unrelated to clinical appropriateness, need, or patient preference. RESULTS Rates of follow-up were generally low, particularly rates of adequate treatment (<26%). Outpatient treatment prior to inpatient care was a strong predictor of all measures of follow-up. After adjustment for need and socioeconomic status, the analyses showed that blacks were less likely than whites to receive any treatment or begin adequate follow-up within 30 days of discharge. CONCLUSIONS Poor integration of follow-up treatment in the continuum of psychiatric care leaves many individuals, particularly blacks, with poor-quality treatment. Culturally appropriate interventions that link individuals in inpatient settings to outpatient follow-up are needed to reduce racial-ethnic disparities in outpatient mental health treatment following acute treatment.

Adolescents and the Internet: What Mental Health Clinicians Need to Know

The Internet’s permeation into daily life has profoundly changed the practice of psychiatry with adolescents, who mobilize online social media and related technologies in their efforts to develop identity and “hang out” with peers. Technology offers both challenges and opportunities to mental health professionals working with teens. Practitioners will need a new skill-set, including keeping abreast of technological developments; professionally incorporating technology into clinical assessment and practice; identifying the negative impacts of technology on teens’ physical and mental health and the particular vulnerabilities of at-risk patients in a digital world; and guiding patients and parents about interventions. Particular patient factors related to race/ethnicity, gender and sexual orientation, mental health and trauma history, family culture, parenting style, and personality traits will need to be considered. This article provides an overview of the literature on adolescents and the Internet focusing on recent research on Internet and digital technologies used for social communication among youth.

Assessment of Physical Illness by Mental Health Clinicians During Intake Visits

OBJECTIVES This study explored how mental health clinicians assess and respond to physical illness among patients presenting for mental health intake evaluations. METHODS A total of 129 adults were seen for a mental health intake visit. The intake visits were videotaped and involved 47 mental health clinicians from eight clinics who provided outpatient mental health and substance abuse treatment. A total of 120 videos of patient-provider interactions were coded using an information checklist containing 21 physical illness items. Twenty-eight intake visits exemplifying in-depth physical illness assessments were selected and transcribed for qualitative analysis. RESULTS Physical health was discussed in most intake visits (87%). Clinicians elicited information on physical health in 79 visits (66%), and patients volunteered such information in 80 visits (67%). Frequency of assessment differed by clinician discipline (p<.05) and by patient ethnicity (p=.06). Qualitative analysis revealed characteristics of appropriate assessments, such as formulating the contribution of physical conditions in the psychiatric differential diagnosis, noting physical side effects of medications, adjusting treatment plans, encouraging patient contact with primary care providers, and promoting physical health care. CONCLUSIONS Assessment of physical illness is relatively common among mental health clinicians but was lacking in one-third of the cases in this study, until raised by patients. Because frequency of assessment differed by clinician discipline and patient ethnicity, innovations in patient assessment and clinician education are needed to address disparities in management of physical illness among individuals with mental illness.

Use and Quality of Mental Health Services for Haitian Youth

Objective. To describe the mental health service use of Haitian, African-American, and non-Latino White youth in a community mental health setting. Groups are compared on adherence to treatment guidelines for attention-deficit/hyperactivity disorder (ADHD) and depressive disorders. Design. Retrospective review of outpatient mental health charts (n=252) from five community sites in an urban area of the Northeastern United States. We recorded the total number and treatment type of sessions during the first six months of treatment. Guideline-adherent treatments were compared and predicted after controlling for clinical need. Results. Most Haitian and African-American youth stopped treatment by six months, with the majority attending less than eight sessions. One third of Haitian and African-American patients attended just one session. Haitian patients who presented with less severe symptoms and dysfunction were more likely to have single-session treatments. Guideline-adherent treatment for ADHD and depression was less likely for Haitians. Older patients were more likely to receive adequate depression treatment. Haitian youth were relatively underinsured, had more family separations documented, and received Adjustment Disorder diagnoses more often. Conclusions. Haitian youth use outpatient mental health services in similar proportion to African-American youth and at lower rates than White youth. Guideline-adherent treatment for ADHD and depression is limited by low retention in care for Black youth. Low insurance coverage is likely an important contributor to reduced use of services, especially for Haitians. These findings are discussed in the context of providing culturally sensitive mental health care to diverse communities.

Effectiveness of the DECIDE interventions on shared decision making and perceived quality of care in behavioral health with multicultural patients a randomized clinical trial

Importance Few randomized clinical trials have been conducted with ethnic/racial minorities to improve shared decision making (SDM) and quality of care. Objective To test the effectiveness of patient and clinician interventions to improve SDM and quality of care among an ethnically/racially diverse sample. Design, Setting, and Participants This cross-level 2 × 2 randomized clinical trial included clinicians at level 2 and patients (nested within clinicians) at level 1 from 13 Massachusetts behavioral health clinics. Clinicians and patients were randomly selected at each site in a 1:1 ratio for each 2-person block. Clinicians were recruited starting September 1, 2013; patients, starting November 3, 2013. Final data were collected on September 30, 2016. Data were analyzed based on intention to treat. Interventions The clinician intervention consisted of a workshop and as many as 6 coaching telephone calls to promote communication and therapeutic alliance to improve SDM. The 3-session patient intervention sought to improve SDM and quality of care. Main Outcomes and Measures The SDM was assessed by a blinded coder based on clinical recordings, patient perception of SDM and quality of care, and clinician perception of SDM. Results Of 312 randomized patients, 212 (67.9%) were female and 100 (32.1%) were male; mean (SD) age was 44.0 (15.0) years. Of 74 randomized clinicians, 56 (75.7%) were female and 18 (4.3%) were male; mean (SD) age was 39.8 (12.5) years. Patient-clinician pairs were assigned to 1 of the following 4 design arms: patient and clinician in the control condition (n = 72), patient in intervention and clinician in the control condition (n = 68), patient in the control condition and clinician in intervention (n = 83), or patient and clinician in intervention (n = 89). All pairs underwent analysis. The clinician intervention significantly increased SDM as rated by blinded coders using the 12-item Observing Patient Involvement in Shared Decision Making instrument (b = 4.52; SE = 2.17; P = .04; Cohen d = 0.29) but not as assessed by clinician or patient. More clinician coaching sessions (dosage) were significantly associated with increased SDM as rated by blinded coders (b = 12.01; SE = 3.72; P = .001; Cohen d = 0.78). The patient intervention significantly increased patient-perceived quality of care (b = 2.27; SE = 1.16; P = .05; Cohen d = 0.19). There was a significant interaction between patient and clinician dosage (b = 7.40; SE = 3.56; P = .04; Cohen d = 0.62), with the greatest benefit when both obtained the recommended dosage. Conclusions and Relevance The clinician intervention could improve SDM with minority populations, and the patient intervention could augment patient-reported quality of care. Trial Registration clinicaltrials.gov Identifier: NCT01947283