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Health Disparities Among the
Mentally Ill
Prepared for Psychiatry Research Day
October 21, 2009
Rosalie A. Torres Stone
Assistant Professor of Psychiatry
Psychiatry Department
Center for Mental Health Services Research
Mortality and Morbidity and
Preventable Conditions
• Patients with severe mental illness (SMI) such as schizophrenia, die
25 years earlier than the general population. Suicide and injury
account for about 30-40% of excess mortality (NASMHPD Report 2006)
• In Massachusetts 1998 – 2000, among persons 25 to 44,
cardiovascular mortality was 6.6 times higher among DMH clients
than the general population (the deceased population was more
likely to be younger, less educated and African American) (NASMHPD
2006)
• Largely due to treatable medical conditions (cardiovascular,
metabolic disorders, diabetes and infectious diseases)
• Modifiable risk actors such as tobacco use (Vanable, Carey et. al. 2003; de Leon and Diaz,
2005), alcohol use and misuse, obesity, diabetes, (Goff, Cather et al. 2005), poor
nutrition, infrequent physical activity (Daumit, Goldberg et al., 2005), and in some
cases the medication itself
Other Factors associated with increased
risk of morbidity and mortality
• Higher rates of vulnerability factors:
homelessness, victimization/trauma,
unemployment, poverty, incarceration, social
isolation
• Lack of access to appropriate care and lack of
coordination between mental health and
general health care providers (patient,
provider, system level factors)
• However, co-occurrence of diabetes and depression disproportionately
affects low-income Hispanics served in primary care. Among Latinos, Type
2 diabetes is the 5th leading cause of death (CDC 2004)
• Puerto Ricans have the highest rates compared to other Latino subgroups
particularly those with less than high school education (Burrell et. al. 2009; Smith
and Barnett 2005)
• The increased prevalence is thought to be due to poorer control of blood
sugar levels, lower access and quality of diabetes care, cultural, social and
perhaps, inactivity and genetic factors (NASMHPD 2006)
IOM Report
• The IOM (2003) reported that minorities were less likely to
receive the health care they needed even after taking into
account health insurance coverage and other economic and
health factors.
• The findings indicated that health disparities goes beyond
“access” issues (Smedley 2008).
• What others factors contribute to racial and ethnic health
disparities? ….factors outside the health care arena
Patterns of Behavior Embedded in
a Social Context
• In a recent study, Cabassa et. al. (2008) examined the
explanatory models of depression, perceived relationships
between diabetes and depression, and depression treatment
experiences of low income, Spanish-speaking Hispanics with
diabetes and depression.
In this study:
• The respondents perceived depression as a serious condition
linked to the accumulation of social stressors.
• The respondents perceived a reciprocal relationship between
diabetes and depression.
• Depression interfered with self care behaviors and
management of diabetes.
Sociocultural Context
• In addition, the respondents feared the addictive and harmful
properties of antidepressants and worried about taking too
many pills and the stigmas attached to taking antipsychotic
medications. These concerns were prevalent in their
communities.
• This study highlighted the importance of understanding the
social dimensions surrounding the experience of depression
in developing treatments, engaging Hispanic patients and
improving treatment adherence.
Racial Inequality and
Community Level Factors
• Racial disparities in health should be understood not only in
individual characteristics but in patterned racial inequalities in
exposure to societal risks and resources (Williams and Jackson 2005)
• The residential concentration of African Americans is high and
distinctive
• The related inequities in neighborhood environments,
socioeconomic circumstances, and access to medical care are
all important factors in initiating and maintaining racial
disparities in health.
Social and Community Level
Considerations
• Perceptions of neighborhood safety is associated with
physical exercise, and this association is greater for minority
group members than whites.
• Access to recreational facilities, green space?
• Availability of cost of health products in grocery stores
• Tobacco and alcohol are heavily marketed in low income
areas.
Policy Recommendations
We need policies to address the social and community level determinants of
health disparities in underserved communities.
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Strategies to improve coordination of relevant state agencies (e.g., education,
housing, employment, and poverty)
State can create incentives for better food resources in underserved communities
Promote community level interventions for health-behavior promotion (e.g.,
smoking cessation and exercise)
Monitoring environmental degradation
Expand health care coverage
Improve the capacity and number of providers in underserved communities
Increase knowledge base on causes and interventions to reduce it (e.g., teach
disease prevention)
Provide training and reimbursement to community health educators
Conclusion
Health is shaped by many factors from the biological, the social
and political. Elimination health disparities is complex:
• Insurance coverage, access or quality of care
• Intertwined with race, social class and gender relations
• Providing equity involves health plan purchaser, payers, and
providers of care
What we know: Inequities result in loss of productivity, use of
services at a later stage of illness, and health care and social
costs to all.