Mental Health Disparities: More Questions than Answers

Karen D. LincolnAssociate Professor

Associate Director, Roybal Institute on AgingUniversity of Southern California

Presentation prepared for the 8th Annual SIRC Research Conference “Health Disparities: A Global Challenge, a Local Response” April 23, 2010, Phoenix, AZ.

• “Mental health is not just the absence of mental disorder. It is defined as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.”

World Health Organization.

Racial Disparities in Mental Health

Health Disparities

• The unequal distribution of disease

• Health disparities are differences in the incidence, prevalence, mortality, burden of diseases and other adverse health conditions or outcomes that exist among specific population groups in the United States.

Mental Disorders are Common in the U.S.

• 1 in 2 Americans has a diagnosable mental disorder each year, including 44 million adults 13.7 million children.

• Mental disorders are as disabling as cancer or heart disease in terms of premature death and lost productivity .

• 80 to 90 percent of mental disorders are treatable using medication and other therapies.

• Of those with a diagnosable mental disorder fewer than half of adults get help. Only one-third of children get help.

Suicide

• Suicide is the 8th leading cause of death in the U.S. 81 Americans die by suicide each day.

• Since 1980, suicide has more than doubled among young Black males in America.

• 80 to 90 percent of people who die by suicide are suffering from a diagnosable mental illness.

0

1

2

3

4

5

6

7

Suicide Attempts by Students in Grades

9-12, by Gender and Race/EthnicityPercent

0

Note: Black and White exclude Hispanic. Hispanic may be any race.

SOURCE: Youth Risk Behavior Surveillance System (YRBSS), NCCDPHP, CDC.

2010 Target

1991 1993 1995 1997 1999 2001

Hispanic Females

Black MalesBlack Females

White Females

Hispanic Males

White Males

Nock, M. K. et al. Epidemiol Rev 2008 30:133-154; doi:10.1093/epirev/mxn002

Numbers of suicide deaths in the United States, by race/ethnicity, sex, and age group, 2005

2003 US Suicide Rates per 100,000Race or

Hispanic Origin

Male1 Female1 Additional Information

Whites 21.0 5.0 Suicide remains the 10th leading cause of death in the

US for whites1

African

Americans

9.2 1.9 Suicide rate among African Americans ages 10–14

increased 233%, vs 120% among non-Hispanic

whites of the same ages, between 1980–19952

Asian Americans/

Pacific Islanders

8.5* 3.1* Older Asian American women have the highest

suicide rate of all women over age 65 in the US2

Latinos/ Hispanic

Americans

9.7 1.7 Hispanic adolescents report more suicidal ideation

and attempts than non-Hispanic whites and African

Americans2

Native American

Indians/ Alaskan

Natives (AI/AN)

16.6* 3.5* Males ages 15–24 account for two-thirds of all AI/AN

suicides2

National Center for Health Statistics. Health, United States, 2005.US DHHS. Mental Health: Culture, Race, and Ethnicity: Fact Sheets. 2001.

Lower prevalence rates for some mental health disorders

Higher persistence rate and greater disability

This is the paradox!

Prevalence and persistence of DSM-IV/CIDI-defined major depressive disorder in the NSAL sample by race

Participants, % (SE)

Prevalence African American Caribbean Black White F

Lifetime 10.4 (0.5) 12.9 (2.1) 17.9 (1.5) 30.2*

12 mo before the interview 5.9 (0.4) 7.2 (1.2) 6.9 (0.7) 1.3

30 d 2.2 (0.3) 2.2 (0.9) 3.1 (0.8) 0.9

Persistence

12 mo within lifetime 56.5 (3.0) 56.0 (5.3) 38.6 (5.4) 9.4*

30 d within 12 mo 38.2 (4.6) 31.2 (12.1) 44.1 (8.2) 0.4

30 d within lifetime 21.6 (3.2) 17.5 (7.4) 17.0 (4.3) 0.5

Severity of role impairment in 12-month DSM/CIDI-defined MDD cases in the NSAL by race

Severity of Role Impairment

Domain None/Mild/ Moderate Severe/Very Severe F Statistic (P value)

Home

Black 61.9 (4.3) 38.1 (4.3) 0.22 (.64)

White 56.8 (10.2) 43.2 (10.2)

Work

Black 62.8 (4.2) 37.2 (4.2) 0.91 (.34)

White 71.1 (7.4) 28.9 (7.4)

Relationship

Black 56.8 (4.0) 43.2 (4.0) 1.09 (.30)

White 69.1 (10.1) 30.9 (10.1)

Social

Black 44.6 (3.4) 55.4 (3.4) 9.51 (.003)

White 65.8 (5.3) 34.2 (5.3)

Overall

Black 25.6 (3.3) 74.4 (3.3) 0.91 (.35)

White 36.4 (11.7) 63.6 (11.7)

• Racial and ethnic minorities bear a greater burden from unmet mental health needs and thus suffer a greater loss to their overall health and productivity.

Severity of role impairment using the SDS in 12-month DSM/CIDI-defined MDD cases in the NSAL by race

Days out of role among 12-month MDD cases

No. of days out of role due to depression in the past 365 d, mean

None/Mild/ Moderate

Severe/Very Severe F Statistic (P value)

Black 25.5 (11.1) 70.8 (10.8) 8.89 (.005)

White 0.7 (0.4) 62.9 (18.3) 10.92 (.002)

F-statistic (P value) 4.9 (0.4) 0.3 (.61) 10.92 (.002)

Disparities arising within the clinical encounter may be more important in

mental health care than in health care

Mental Health Providers

• Physicians tend to hold a prior belief about the likelihood of a patient having a condition and update this belief according to the strength of information received in the clinical encounter.

• Because the prevalence of mental disorders may be slightly lower in minorities, underlying assumptions about the distribution of disease or communication problems between the physician and patient can lead to discrimination.

• Provider discrimination has been documented in two studies of mental health care, in which clinicians respondedwith less alacrity to variation in severity of depression among minority patients than white patients.

Balsa AI, McGuire TG, Meredith LS: Testing for statistical discrimination in health care. Health Serv Res 2005; 40:227–252.McGuire TG, Ayanian JZ, Ford DE, Henke RE, Rost KM, Zaslavsky AM: Testing for statistical discrimination by race/ethnicity in panel data for depression treatment in primary care. Health Serv Res 2008; 43:531–551.

Mental Health Workforce

• Low treatment rates in minority populations are likely related to poor minority representation in the health care workforce.

• Ethnic minorities are even more poorly represented in mental health care than in health care in general.

• Because of the greater need for cultural sensitivity in dealing with mental health issues, extensive issues of trust, and the increasing language barrier between provider and patients, disparities in the workforce may account for more disparities in mental health than general health care.

• Disparities in mental health professionals also likely contributes to the inadequate representation of minorities in research, including in important clinical trials.

Mental Health Workforce

Health and Mental Health

Comorbidity

Recently Funded Translational Research (NIH)

• Depression-Diabetes Mechanisms: Urban African Americans

• Risk of Major Depression Among Breast Cancer Patients

• Preventing Comorbid Mental and Physical Health Disability

• Anxiety and Recurrent Abdominal Pain in Children

Causes of Morbidity and Mortality in People with Serious Mental Illness

• While suicide and injury account for about 30-40% of excess mortality, about 60% of premature deaths in persons with schizophrenia are due to “natural causes”

– Cardiovascular disease

– Diabetes

– Respiratory diseases

– Infectious diseases

Cardiovascular Disease (CVD) Risk Factors

Modifiable Risk

Factors

Estimated Prevalence and Relative Risk

Schizophrenia Bipolar Disorder

Obesity 45–55%, 1.5-2X 26%

Smoking 50–80%, 2-3X 55%

Diabetes 10–14%, 2X 10%

Hypertension ≥18% 15%

Dyslipidemia Up to 5X

1. Davidson S, et al. Aust N Z J Psychiatry. 2001;35:196-202. 2. Allison DB, et al. J Clin Psychiatry. 1999; 60:215-220. 3. Dixon L, et al. J Nerv Ment Dis. 1999;187:496-502. 4. Herran A, et al. Schizophr Res. 2000;41:373-381. 5. MeElroy SL, et al. J Clin Psychiatry. 2002;63:207-213. 6. Ucok A, et al. Psychiatry Clin Neurosci. 2004;58:434-437. 7. Cassidy F, et al. Am J Psychiatry. 1999;156:1417-1420. 8.

Allebeck. Schizophr Bull. 1999;15(1)81-89.

Depressive Disorders and Comorbid Diseases

• Patients with several medical complaints have an increased probability of a coexisting depressive or anxiety disorder

• Patients with depression often have histories of chronic medical conditions such as:

– Cardiovascular disease

– Diabetes mellitus

– Arthritis

– Stroke

– Cancer

Kroenke K. Primary Care Comp J Clin Psych. 2003;5(suppl7):11.

Aina Y. J Am Osteopath Assoc. 2006;106(5 suppl 2):S9.Chapman DP. Prev Chronic Dis. 2005;2(1):A14.

Racial Disparities in Health

100

200

300

400

500

600

700

1950 1960 1970 1980 1990 2000

Dea

th R

ate

s p

er 1

00,0

00 P

op

ula

tion

YEAR

Age-Adjusted Heart Disease Death Rates

for Blacks and Whites, 1950-2000

White

Black

Diabetes Death Rates 1955-1995

12.610.4

8.6

11.7

17.0

24.3 24.4

46.4

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

50.0

1955 1975 1985 1995

Am

In

d/W

Ra

tio

Dea

ths

per

10

0,0

00

Pop

ula

tio

n

Year

White

Am Ind

Am Ind/W Ratio

Source: Indian Health Service; Trends in Indian Health 1998-99

Age-Adjusted Percentage of Civilian, Noninstitutionalized Population with Diagnosed

Diabetes, by Race and Sex, United States, 1980–2007

100

150

200

250

300

1950 1960 1970 1980 1990 2000

Dea

th R

ate

s p

er 1

00,0

00 P

op

ula

tion

YEAR

Age-Adjusted Cancer Death Rates for

Blacks and Whites, 1950-2000

White

Black

Heart Disease, Cancer, & StrokeAge-Adjusted Death Rates per 100,000 Persons by Race & Hispanic Origin: U.S.,

2005

211.1 207.8

271.3

141.8

113.3

157.3

183.8 182.6

222.7

123.2110.5

122.8

46.6 44.7

65.2

34.8 38.6 35.7

0

50

100

150

200

250

300

All Races White African American American Indian/Alaska

Native

Asian/Pacific Islander

Hispanic

Ag

e-A

dju

sted

Death

Rate

per

100,0

00

Pers

on

s

Heart Disease

Cancer

Stroke

Moving Forward

Consider the heterogeneity within and between groups

Ten Leading Countries of Birth for African-Born U.S. Blacks, 2005

African country of birth Thousands Percent

All Countries 871 100

Nigeria 160 18

Ethiopia 105 12

Ghana 75 9

Liberia 61 7

Somalia 57 7

Kenya 53 6

Sudan 29 3

Sierra Leone 29 3

Cameroon 27 3

Eritrea 18 2

Guinea 10 1

Other countries 245 28

Ten Leading Countries of Birth for Caribbean and Latin American-Born US Blacks, 2005

Caribbean/Latin Americancountry of birth

Thousands Percent

All Countries 1,876 100

Jamaica 568 30

Haiti 478 25

Trinidad and Tobago 167 9

Guyana 128 7

Dominican Republic 73 4

Barbados 49 3

Panama 45 2

Mexico 40 2

Bahamas 28 2

Belize 27 1

Other countries 274 15

1

1.25

1.5

1.75

2

2.25

1986 1989 1994 2002

Nu

mb

er o

f D

ep

ress

ive

Sym

pto

ms

Waves

Four-class Model

Increasers (N=260)

Decreasers (N=584)

High symptoms (N=187)

Low symptoms (N=2,462)

Lincoln, K. D. & Takeuchi, D.T. (in press). Social Biology

37.447.3*

40.328.8

62.652.7

59.771.2

0

10

20

30

40

50

60

70

80

90

100

Increasers Decreasers High Symptoms

Low Symptoms

Latent Class by Race

White

African American

10.71 47.3*9.64

11.96

10.7 10.9*

9.6*

12.0

0

5

10

15

20

Increasers Decreasers High Symptoms Low Symptoms

Latent Class by Socioeconomic Status

Income

Education

Segregation and Disparities

Segregation: Distinctive for Blacks

• Blacks are more segregated than any other racial or ethnic group in the U.S.

• Segregation varies by income for Latinos and Asians, but is high at all levels of income for Blacks.

• Wealthiest Blacks (>$50K) are more segregated than the poorest Latinos and Asians (<$15,000).

• Middle class Blacks live in poorer areas than Whites of similar SES and poor Whites live in better areas than poor Blacks.

• Blacks show a higher preference for residing in integrated areas than any other group.

Source: Massey 2004

The Cumulative Impacts of Spatial, Racial and Opportunity Segregation

Neighborhood

Segregation

School Segregation

Racial stigma, other

psychological impacts

Job segregation

Impacts on community power

and individual assets

Impacts on Educational Achievement

Exposure to crime; arrest

Transportation limitations and

other inequitable public services

Adapted from figure by Barbara Reskin at: http://faculty.washington.edu/reskin/

Neighborhood Segregation impacts a number of life-opportunities

Impacts on Health

Proportion of Black & Latino Children in Poorer Neighborhoods Compared to Worst Off White Children

76%

86%

57%

69.074.0

44.0

0

10

20

30

40

50

60

7080

90

100

All Metro Areas 5 Metro Areas High Segr. 5 Metro Areas Low Segr.

Per

cen

tage

Neighborhood

Black

Latino

Policy Implications

• Geographic location determines exposure to risk factors and resources that affect health.

• Where we live, learn, work, play and worship determine our opportunities and chances for being healthy.

Redefining Health PolicyHealth Policies should include all sectors of society

that influence mental health, including:

• Housing Policy

• Employment Policies

• Community Development Policies

• Income Support Policies

• Transportation Policies

• Environmental Policies

Neighborhood Renewal and Health

• A 10-year follow-up study of residents in 5 neighborhood types in Norway found that changes in neighborhood quality were associated with improved health.

• The neighborhood improvements: a new public school, playground extensions, a new shopping center with restaurants and a cinema, a subway line extension into the neighborhood, a new sports arena & park, and organized sports activities for adolescents.

• Residents of the area that had experienced these dramatic improvements in its social environment reported improved mental health 10 years later

• This effect was not explained by selective migration

Dalgard and Tambs 1997

Neighborhood Renewal and Health

• Neighborhood improvement in a poorly functioning area in England was linked to improved health and social interaction.

• Improvements: housing was refurbished (made safe & sheltered from strangers), traffic regulations improved, improved lighting & strengthening of windows, enclosed gardens for apartments, closed alleyways, and landscaping. Residents involved in planning process.

• One year later:

– Levels of optimism, belief in the future, identification with their neighborhood, trust in other neighbors, and contactbetween the neighbors had all increased.

– Symptoms of anxiety and depression had declined.

Halpern, 1995

Neighborhood Change and Health

• The Moving to Opportunity Program randomized families with children in high poverty neighborhoods to move to less poor neighborhoods.

• It found, three years later, that there were improvements in the mental health of both parents and sons who moved to the low-poverty neighborhoods.

Leventhal and Brooks-Gunn, 2003

Income Change and Mental Health

• A natural experiment assessed the impact of an income supplement on the mental health of American Indian children.

• It found that increased family income (because of the opening of a casino) was associated with declining rates of deviant and aggressive behavior.

Costello et al. 2003

Social Context

• Neighborhood

• Built environment

• Physical structures

• Material resources

• Shapes and reflect relationships among individual inhabitants, social groups and social structures and institutions.

Place harbors the dynamics of power, varies by culture, and

changes over time.

Take Home Points

• Research matters!

• Providers matters!

• Health matters!

• Place matters!