This study examined ethnic differences in accessing treatment for depression and substance use disorders (SUDs) among men and women in a large integrated health plan and explored factors potentially contributing to health care disparities.
Methods:
Participants were 22,543 members ages 20 to 65 who responded to health surveys in 2002 and 2005. Survey questions were linked to provider-assigned diagnoses, electronic medication, psychiatry, and chemical dependency program records.
Results:
Among women diagnosed with depression, Latinas (p < .01) and Asian-Americans (p < .001) were less likely than Whites to fill an antidepressant prescription. Among men diagnosed with depression, African Americans (p < .01) were less likely than Whites to do so. Among women diagnosed with an SUD, African Americans (p < .05) were less likely than Whites to have one or more chemical dependency program visits.
Conclusions:
Results demonstrated ethnic differences in accessing depression and SUD treatment among patients diagnosed with these disorders, which persisted after controlling for education, income, having a regular health care provider and length of health plan enrollment. Findings highlight potential gender differences in ethnic disparities, lower antidepressant utilization among Asian Americans, and the effects of co-occurring disorders in accessing behavioral health care.
McGuireTGAlegriaMCookBLWellsKBZaslavskyAM. Implementing the Institute of Medicine definition of disparities: An application to mental health care. Health Services Research2006; 41: 1979–2005.
2.
DasAKOlfsonMMcCurtisHLWeissmanMM. Depression in African Americans: Breaking barriers to detection and treatment. Journal of Family Practice2006; 55: 30–39.
3.
SimpsonSMKrishnanLLKunikMERuizP. Racial disparities in diagnosis and treatment of depression: A literature review. The Psychiatric Quarterly2007; 78: 3–14.
4.
HarmanJSEdlundMJFortneyJC. Disparities in the adequacy of depression treatment in the United States. Psychiatric Services2004; 55: 1379–1385.
5.
MirandaJCooperLA. Disparities in care for depression among primary care patients. Journal of General Internal Medicine2004; 19: 120–126.
6.
CooperLAGonzalesJJGalloJJRostKMMeredithLSRubensteinLVWangNYFordDE. The acceptability of treatment for depression among African-American, Hispanic, and white primary care patients. Medical Care2003; 41: 479–489.
7.
HanELiuGG. Racial disparities in prescription drug use for mental illness among population in US. Journal of Mental Health Policy and Economics2005; 8: 131–143.
8.
TaVMJuonHSGielenACSteinwachsDDugganA. Disparities in use of mental health and substance abuse services by Asian and Native Hawaiian/other Pacific Islander women. Journal of Behavioral Health Services & Research2008; 35: 20–36.
9.
ComptonWMThomasYFStinsonFSGrantBF. Prevalence, correlates, disability, and comorbidity of DSM-IV drug abuse and dependence in the United States: Results from the national epidemiologic survey on alcohol and related conditions. Archives of General Psychiatry2007; 64: 566–576.
10.
CaetanoR. Alcohol-related health disparities and treatment-related epidemiological findings among whites, blacks, and Hispanics in the United States. Alcoholism: Clinical and Experimental Research2003; 27: 1337–1339.
11.
WeisnerCMatzgerHTamTSchmidtL. Who goes to alcohol and drug treatment? Understanding utilization within the context of insurance. Journal of Studies on Alcohol2002; 63: 673–682.
12.
KaskutasLAWeisnerCCaetanoR. Predictors of help seeking among a longitudinal sample of the general population, 1984–1992. Journal of Studies on Alcohol1997; 58: 155–161.
13.
DaleyMC. Race, managed care, and the quality of substance abuse treatment. Administration and Policy in Mental Health2005; 32: 457–476.
14.
National Institute on Drug Abuse.Highlights From the 1989 National Drug and Alcoholism Treatment Unit Survey (NDATUS). Rockville, MD: Department of Health and Human Services, 1990.
15.
JacobsonJORobinsonPLBluthenthalRN. Racial disparities in completion rates from publicly funded alcohol treatment: Economic resources explain more than demographics and addiction severity. Health Services Research2007; 42: 773–794.
16.
AlegriaMCaninoGRiosRVeraMCalderonJRuschDOrtegaAN. Inequalities in use of specialty mental health services among Latinos, African Americans, and non-Latino whites. Psychiatric Services2002; 53: 1547–1555.
17.
PadgettDKPatrickCBurnsBJSchlesingerHJ. Ethnicity and the use of outpatient mental health services in a national insured population. American Journal of Public Health1994; 84: 222–226.
18.
SchneiderECZaslavskyAMEpsteinAM. Racial disparities in the quality of care for enrollees in medicare managed care. Journal of American Medical Association2002; 287: 1288–1294.
19.
KesslerRC. Epidemiology of women and depression. Journal of Affective Disorders2003; 74: 5–13.
20.
HintonLZweifachMOishiSTangLUnutzerJ. Gender disparities in the treatment of late-life depression: Qualitative and quantitative findings from the IMPACT trial. American Journal of Geriatric Psychiatry2006; 14: 884–892.
21.
WilliamsJBSpitzerRLLinzerMKroenkeKHahnSRdeGruyFVLazevA. Gender differences in depression in primary care. American Journal of Obstetrics and Gynecology1995; 173: 654–659.
22.
GreenCA. Gender and use of substance abuse treatment services. Alcohol Research and Health2006; 29: 55–62.
23.
Dwight-JohnsonMSherbourneCDLiaoDWellsKB. Treatment preferences among depressed primary care patients. Journal of General Internal Medicine2000; 15: 527–534.
24.
GumAMAreanPAHunkelerETangLKatonWHitchcockPSteffensDCDickensJUnutzerJ. Depression treatment preferences in older primary care patients. Gerontologist2006; 46: 14–22.
25.
HeflingerCAChatmanJSaundersRC. Racial and gender differences in utilization of Medicaid substance abuse services among adolescents. Psychiatric Services2006; 57: 504–511.
26.
MertensJRWeisnerCM. Predictors of substance abuse treatment retention among women and men in an HMO. Alcoholism: Clinical and Experimental Research2000; 24: 1525–1533.
27.
GreenCAPolenMRDickinsonDMLynchFLBennettMD. Gender differences in predictors of initiation, retention, and completion in an HMO-based substance abuse treatment program. Journal of Substance Abuse Treatment2002; 23: 285–295.
28.
AndersenRNewmanJP. Societal and individual determinants of medical utilization in the United States. Milbank Memorial Fund Quarterly1973; 51: 95–124.
29.
LagomasinoITDwight-JohnsonMMirandaJZhangLLiaoDDuanNWellsKB. Disparities in depression treatment for Latinos and site of care. Psychiatric Services2005; 56: 1517–1523.
30.
ZivinKPfeifferPNMcCammonRJKavanaghJSWaltersHWelshDEDifrancoDJBrownMMValensteinM. “No-shows”: Who fails to follow up with initial behavioral health treatment?American Journal of Managed Care2009; 15: 105–112.
31.
SatreDDKnightBGDickson-FuhrmannEJarvikLF. Substance abuse treatment initiation among older adults in the GET SMART program: Effects of depression and cognitive status. Aging & Mental Health2004; 8: 346–354.
32.
CrystalSSambamoorthiUWalkupJTAkincigilA. Diagnosis and treatment of depression in the elderly medicare population: Predictors, disparities, and trends. Journal of the American Geriatrics Society2003; 51: 1718–1728.
33.
MiechRAEatonWWBrennanK. Mental health disparities across education and sex: A prospective analysis examining how they persist over the life course. The Journals of Gerontology Series B, Psychological Sciences and Social Sciences2005; 60Spec No 2: 93–98.
34.
Institute of Medicine.Improving the quality of health care for mental and substance-use conditions: Quality Chasm Series. Washington, DC: National Academies Press, 2006.
35.
WellsKKlapRKoikeASherbourneC. Ethnic disparities in unmet need for alcoholism, drug abuse, and mental health care. American Journal of Psychiatry2001; 158: 2027–2032.
36.
MaysVMPonceNAWashingtonDLCochranSD. Classification of race and ethnicity: Implications for public health. Annual Review of Public Health2003; 24: 83–110.
37.
Lewis-FernandezRDasAKAlfonsoCWeissmanMMOlfsonM. Depression in US Hispanics: Diagnostic and management considerations in family practice. Journal of the American Board of Family Practice2005; 18: 282–296.
38.
HunkelerEMMeresmanJFHargreavesWAFiremanBBermanWHKirschAJGroebeJHurtSWBradenPGetzellMFeigenbaumPAPengTSalzerM. Efficacy of nurse telehealth care and peer support in augmenting treatment of depression in primary care. Archives of Family Medicine2000; 9: 700–708.
39.
SelbyJVSmithDHJohnsonESRaebelMAFriedmanGDMcFarlandBH. Kaiser Permanente Medical Care Program. In StromBL (ed.), Pharmacoepidemiology (4th ed.). New York: Wiley, 2005: 241–259.
40.
BiermanASBubolzTAFisherESWassonJH. How well does a single question about health predict the financial health of Medicare managed care plans?Effective Clinical Practice1999; 2: 56–62.
41.
HavilandMGMoralesLSDialTHPincusHA. Race/ethnicity, socioeconomic status, and satisfaction with health care. American Journal of Medical Quality2005; 20: 195–203.
42.
FloresGBauchnerHFeinsteinARNguyenUS. The impact of ethnicity, family income, and parental education on children's health and use of health services. American Journal of Public Health1999; 89: 1066–1071.
43.
MirandaJMcGuireTGWilliamsDRWangP. Mental health in the context of health disparities. American Journal of Psychiatry2008; 165: 1102–1108.
44.
SnowdenLR. Bias in mental health assessment and intervention: Theory and evidence. American Journal of Public Health2003; 93: 239–243.
45.
GrellaCEKarnoMPWardaUSNivNMooreAA. Gender and comorbidity among individuals with opioid use disorders in the NESARC study. Addictive Behaviors2009; 34: 498–504.
46.
HannaEZFadenVBDufourMC. The effects of substance use during gestation on birth outcome, infant and maternal health. Journal of Substance Abuse1997; 9: 111–125.
47.
AlegriaMPerezDJWilliamsS. The role of public policies in reducing mental health status disparities for people of color. Health Affairs (Millwood)2003; 22: 51–64.
48.
ChowJCJaffeeKSnowdenL. Racial/ethnic disparities in the use of mental health services in poverty areas. American Journal of Public Health2003; 93: 792–797.
49.
KilbourneAMSwitzerGHymanKCrowley-MatokaMFineMJ. Advancing health disparities research within the health care system: A conceptual framework. American Journal of Public Health2006; 96: 2113–2121.
50.
KalesHCMellowAM. Race and depression: Does race affect the diagnosis and treatment of late-life depression?Geriatrics2006; 61: 18–21.
51.
LuFGPrimmA. Mental health disparities, diversity, and cultural competence in medical student education: How psychiatry can play a role. Academic Psychiatry2006; 30: 9–15.
52.
Aguilar-GaxiolaSAZeleznyLGarciaBEdmondsonCAlejo-GarciaCVegaWA. Translating research into action: Reducing disparities in mental health care for Mexican Americans. Psychiatric Services2002; 53: 1563–1568.
53.
MoffetHHAdlerNSchillingerDAhmedATLaraiaBSelbyJVNeugebauerRLiuJYParkerMMWartonMKarterAJ. Cohort profile: The Diabetes Study of Northern California (DISTANCE)—Objectives and design of a survey follow-up study of social health disparities in a managed care population. International Journal of Epidemiology2008; 38: 38–47.
54.
SelbyJVSwainBEGerzoffRBKarterAJWaitzfelderBEBrownAFAckermannRTDuruOKFerraraAHermanWMarreroDGCaputoDNarayanKM. Understanding the gap between good processes of diabetes care and poor intermediate outcomes: Translating Research into Action for Diabetes (TRIAD). Medical Care2007; 45: 1144–1153.
55.
VirnigBHuangZLurieNMusgraveDMcBeanAMDowdB. Does Medicare managed care provide equal treatment for mental illness across races?Archives of General Psychiatry2004; 61: 201–205.
56.
CampbellCIWeisnerCSterlingS. Adolescents entering chemical dependency treatment in private managed care: Ethnic differences in treatment initiation and retention. Journal of Adolescent Health2006; 38: 343–350.
57.
TrivediANZaslavskyAMSchneiderECAyanianJZ. Trends in the quality of care and racial disparities in Medicare managed care. New England Journal of Medicine2005; 353: 692–700.
58.
CookBLMcGuireTMirandaJ. Measuring trends in mental health care disparities, 2000–2004. Psychiatric Services2007; 58: 1533–1540.
59.
TiwariSKWangJ. Ethnic differences in mental health service use among White, Chinese, South Asian and South East Asian populations living in Canada. Social Psychiatry and Psychiatric Epidemiology2008; 43: 866–871.
60.
WoodEMontanerJSLiKBarneyLTyndallMWKerrT. Rate of methadone use among Aboriginal opioid injection drug users. Canadian Medical Association Journal2007; 177: 37–40.
61.
AliSDaviesMJTaubNAStoneMAKhuntiK. Prevalence of diagnosed depression in South Asian and white European people with type 1and type 2 diabetes mellitus in a UK secondary care population. Postgraduate Medical Journal2009; 85: 238–243.
62.
WaltersPAshworthMTyleeA. Ethnic density, physical illness, social deprivation and antidepressant prescribing in primary care: Ecological study. British Journal of Psychiatry2008; 193: 235–239.
63.
YoungJLGriffithEEWilliamsDR. The integral role of pastoral counseling by African-American clergy in community mental health. Psychiatric Services2003; 54: 688–692.
64.
KoenigHGMcCulloughMELarsonDB. Handbook of religion and health. New York: Oxford University Press, 2001.
65.
KuykenWByfordSTaylorRSWatkinsEHoldenEWhiteKBarrettBByngREvansAMullanETeasdaleJD. Mindfulness-based cognitive therapy to prevent relapse in recurrent depression. Journal of Consulting and Clinical Psychology2008; 76: 966–978.
66.
BowenSWitkiewitzKDillworthTMChawlaNSimpsonTLOstafinBDLarimerMEBlumeAWParksGAMarlattGA. Mindfulness meditation and substance use in an incarcerated population. Psychology of Addictive Behaviors2006; 20: 343–347.
67.
KarnoMHoughRLBurnamMAEscobarJITimbersDMSantanaFBoydJH. Lifetime prevalence of specific psychiatric disorders among Mexican Americans and non-Hispanic whites in Los Angeles. Archives of General Psychiatry1987; 44: 695–701.
68.
ChandraAMinkovitzCS. Stigma starts early: Gender differences in teen willingness to use mental health services. Journal of Adolescent Health2006; 38: 754e751–758.
69.
California Health Interview Survey.Making California's Voices Heard on Health. Los Angeles, CA: The Regents of the University of California; 2007. [cited August 28, 2008]. Available at: http://www.chis.ucla.edu/.
70.
GordonNP. Surveillance of health, functional status, and satisfaction of health plan members by mailed survey: Potential sources of bias. 123rd annual meeting of the American Public Health Association. San Diego, CA, 1995.
