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Psychiatric Illnesses and Ethnic
Minorities
Jeanne Miranda, Ph.D.
UCLA Neuropsychiatric
Institute
Foster Care Assessment Program,
University of Washington, School of
Social Work
January 28, 2009
Disclosure

At this time, I have no actual or potential
conflict of interest in relation to this
program.
We will cover:





Minorities in the U.S.
Rates of mental disorders of minorities
Disparities in mental health care of minorities
Response to evidence-based care
Bringing care to ethnic minority communities
Minorities in the U.S.



1924 Immigration Act - national origins
system - 2% of foreign-born in 1890.
Until 1960, majority of all legal immigrants
were from Europe and Canada.
1965 Immigration Act - 20,000 from each
country in Eastern Hemisphere.
Minorities in U.S.

14% Hispanic American

13% African American

5% Asian American

1.5% American Indian/Alaskan Native
Minorities in the U.S.

30% of population.

In 50 years - 57% of under 18.

Immigration now worldwide.

Growing percentage of population and
growing more diverse
Minorities in the U.S.
• Racism and Race
 Indirect
effects through stress,
segregation, poorer education.
 Direct
effects through inequitable
distribution of medical resources
Minorities in the U.S.


Historical perspective essential
Legally sanctioned discrimination and
exclusion of ethnic minorities is the rule,
rather than the exception, for much of the
history of this country.
Minorities in the U.S.
POVERTY
 8.7% of White Americans
 9.8% of Asian/Pacific Islanders
 21.9% of Hispanic Americans
 24.5% of Am Indians/Alaskans
 24.7% of African Americans
Rates of Mental Disorders

Income is not monotonically related to mental
disorders.
– more common among the impoverished.
– serious and persistent disorders frequently
result in poverty.

Symptoms are monotonically related to SES.
Rates
of
Mental
Disorders
Lifetime
Past Year
Latino American
%
%
Puerto Rican
38.98
22.88
Cuban
28.38
15.91
Mexican
28.42
14.48
Other Latino
27.29
14.42
Asian American
%
%
Chinese
18.00
10.00
Filipino
16.74
8.99
Vietnamese
13.95
6.69
Other Asian
18.29
9.55
Black American
%
%
African
American
30.54
14.79
Caribbean Black
27.87
16.38
37.37
19.00
White American
Rates of Mental Disorders

Disorders are not higher in minorities.
–
Rates of disorders


–
Rates of depression*





25% of Mexican immigrants
48% of U.S.- born Mexicans
U.S.-born black women – 10.5
African-born black women – 3.9
Caribbean-born black women – 4.8
Symptoms are higher in minorities
Minorities recover less
Rates of Mental Disorders

Some evidence African Americans have
increased rates of schizophrenia.

American Indians have higher rates of PTSD
and alcoholism and lower rates of
depression.

Southeast Asian refugees have extremely
high rates of PTSD and depression
Disparities do exist in care

Minorities in need of care are less likely to
get care than are white Americans.

Minorities getting care are less likely to get
quality care than are white Americans.
Any depression treatment
Psychiatric Visits
Psychiatry Visits
100%
92.9%
92.5%
90%
85.0%
87.8%
91.5%
86.4%
80%
70%
91.4%
91.1%
91.1%
83.8%
69.5%
Percent
66.0%
60%
50%
40%
30%
20%
White
Black
Hispanic
10%
0%
1995 - 1996
1997 - 1999
2000 - 2002
Time period
2003 - 2005
Any depression treatment
Primary Care Visits
Primary Care Visits
20%
18%
16%
Percent
14%
12.4%
12%
8%
6%
10.8%
10.4%
9.5%
10%
7.6%
6.6%
6.1%
8.5%
7.7%
9.8%
9.0%
7.1%
White
Black
4%
Hispanic
2%
0%
1995 - 1996
1997 - 1999
2000 - 2002
Time Period
2003 - 2005
Disparities in Mental Health Care
Logistic barriers
–
–
–


Insurance
Providers who speak language
Child care/work/life demands
Stigma
Somatization
U.S. Department of Health and Human Services. (2001). Mental Health: Culture, Race, and Ethnicity—A Supplement to Mental Health: A
Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Office of the
Surgeon General.
People without Health Insurance Coverage
by Race using 3-yr Average: 2003 to 2005
White
Asian
Black
American Indian
Hispanic
11.2%
17.7%
19.5%
29.9%
32.6%
Source: U.S Census Bureau, Central Population Report, Income,
Poverty, and Health Insurance Coverage in the United States: 2005
Race
U.S. Physician
2005 2005
White
67%
77%
81%
93%
92%
Hispanic
14%
4%
5%
3%
3%
Black
13%
5%
3%
2%
4%
Asian
5%
14%
11%
2%
1%
1.5%
0.1%
0.1%
0.3%
0.2%
Amer.Ind
Psychiatrist Psychologist SWorker
2002
2004
2004
Stigma Concerns
Nationally representative insured HCC sample
Friends
Employers
Insurers
n=5,930
N=5,589
N=5,589
Little/no
concern
72%
26%
25%
Some/a lot
of concern
28%
73%
76%
Response to Evidence-based Care

Culturally competent care
–
Evidence being culturally competent doesn’t
improve outcomes
–
Definitely not memorizing facts about culture,
which continually shifts, but awareness of
important issues
–
Being sensitive to historical perspectives and
power differences
–
Being aware of the context of an individual’s life
Response to Evidence-based Care

African Americans and Latinos appear to
respond similarly or better than do white
Americans.

The few trials of Asians are promising.

American Indians/Alaskan Natives haven’t been
studied.
Promise of Quality Improvement

Partner’s in Care – QI Study – 46 practices
across U.S.*

Randomized resources to improve medication
management or psychotherapy for depression

Latinos and African Americans
–
Less quality care at baseline
Miranda J, Duan N, Sherbourne C, Schoenbaum M, Lagomasino I,Jackson-Triche M, Wells KB. Can Quality Improvement
Interventions Improve Care and Outcomes for Depressed Minorities? Results of a Randomized Controlled Trial. Health Services
Research, 38(2):613-630. 2003.
Clinics Were Randomized
Usual Care
(UC)
QI-THERAPY
QI-MEDS
support for
psychotherapy
support for
medication
management
Interventions
•
“Depression nurse” supported patient
education, assessment, and getting
started on treatment
•
Primary care clinicians were taught about
depression
•
Patients and doctors could choose any
treatment, or no treatment
•
Provider networks were taught CBT
Interventions Increased Appropriate
Care for All
QI programs
Usual care
African
American
Latino
White
0
10
20
30
40
50
% receiving appropriate care at 1 year
60
70
80
Percentage with Probable Depression
6 Mo. Response to QI Resources
70
60
% Depressed
50
40
QI
30
Control
20
10
0
Latina
Black
White
Implications

How we manage depressed patients for even
one episode (information and treatment) can
have long-term consequences over many years
–

Patients may not need prolonged management by
providers to reap some long-term gains
The most vulnerable depressed populations
may have the most to gain from efforts to
improve care
Similar Interventions Help:
Youth Partners in Care

QI intervention for depressed youth in
primary care increased rates of specialty
care and counseling, improved
depressive symptoms at 6 month followup - similar to PIC

Minorities benefited more than did white
youth
WE Care for Impoverished Women

Randomized trial of 267 women screened in county
entitlement clinics
–
–
–



CBT
Guideline concordant medication (Paroxetine)
Referral to community care
9-11 telephone outreach calls necessary to engage
women in care
Flexibility of care
Babysitting and transportation provided
Miranda J, Chung JY, Green BL, Krupnick J, Siddique J, Revicki DA, Belin T. Treating Depression in Predominantly
Low-Income Young Minority Women: A Randomized Controlled Trial. JAMA, 290(1):57-65. 2003.
Treatment Received

88 medication
–

90 CBT
–

67 (76%) received appropriate care
32 (35.5%) received appropriate care
89 referred
–
–
15 (16.9%) received at least one session
74 (83.1) did not attend care
Response to Care

6-month outcomes – asymptomatic
–
44.4% medication
–
32.2% CBT
–
28.1% referred
Response to Care

12-month outcomes – asymptomatic
–
–
–

41.6% medication
48.9% CBT
30.3% referred
Cost-effectiveness ratios similar to those in
advantaged populations
Public Sector Challenges for Young
Mothers
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Mental health departments prioritize severe mental
illness
Primary care has limited resources
“Depression is everyone’s problem…but nobody’s
business”
Lack of insurance is a huge barrier to care
Public sector services may not be places of trust
Conclusions



Understanding context of minorities lives are
important to treatment.
For the most part, minorities do not have higher
rates of disorders.
For the most part, evidence-based care works
for African Americans and Hispanics and is
promising for minorities.
Conclusions

Minorities with disorders are particularly
unlikely to get care.
–
–
–
–
–
Treating minorities in settings the trust and
frequent.
Engaging in outreach to minorities.
Improving overall quality of care
Overcoming barriers, such as transportation,
babysitting, time of care, etc.
Increasing rates of minority providers.