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Office of the Surgeon General (US); Center for Mental Health Services (US); National Institute of Mental Health (US). Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2001 Aug.

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Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General.

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Appendix A Inclusion of Minorities in Controlled Clinical Trials Used to Develop Professional Treatment Guidelines for Major Mental Disorders

This appendix1 examined the inclusion of racial and ethnic minorities in randomized clinical trials used to develop professional guidelines for treatment of four specific mental disorders: bipolar disorder, major depression, schizophrenia, and attention-deficit/hyperactivity disorder.

The American Psychiatric Association (1994) developed practice guidelines for treatment of patients with bipolar disorder. Their guidelines were based on a review of all relevant studies, including randomized con-trolled clinical trials. This appendix considered the representation of minorities in all randomized trials conducted in the United States during the most recent 10-year period (1983-1994). Results are presented in Table A-1. Seventeen of these studies represented 16 separate patient populations. Two articles reported on the same subjects, but these subjects are only included once in this review. Of 825 participants, 29 were identified as non-white, and 32 were identified as black. No analyses were conducted to determine if these participants differed from white participants in outcomes. As a result, the treatment guidelines for patients with bipolar disorder developed by the APA do not offer any information on expected outcomes for minority persons.

The American Psychiatric Association (1997) conducted a similar review to develop guidelines for schizophrenia. Results are presented in Table A-2. Twenty-five randomized clinical trials that occurred in the United States between 1986 and 1997 were included in this analysis. A total of 2,865 participants were included in these 25 studies. Of those participants, 316 were identified as nonwhite, 376 as African American, 40 as Hispanic, and 3 as Asian American. Although several studies had a modest African American sample (39-74), none analyzed results separately for African Americans or presented outcomes specifically for them. As a result, the guidelines developed by the APA to guide treatments for those with schizophrenia do not provide information regarding potentially different outcomes for African Americans or any other ethnic minorities.

The American Psychiatric Association (2000) conducted a similar review to develop treatment guidelines for major depression. Randomized clinical trials conducted between 1986-1997 were evaluated, with 27 studies included. Results are presented in Table A-3. A total of 3,980 patients were involved. Amoung them, 241 were nonwhite, 150 were African American, and 2 were Asian American. None of the studies analyzed minority participants separately. The one study with a sizeable African American population (N=123) did find similar clinical outcomes as a result of depression care, although there were differences in functional outcomes.

To examine the inclusion of ethnic minority children in research, this appendix reviewed the randomized trials of interventions for attention-deficit/hyperactivity disorder (AD/HD) used by a multidisciplinary team assembled by the Agency for Healthcare Research and Quality (AHRQ). These trials were used to develop an evidence-based report on treatment (AHRQ, 1999). Thirty-two studies from 1988 to 1999 were eligible for review. Results are presented in Table 4. These studies evaluated 1,657 children with AD/HD. Of those children, 126 were African American, 55 Hispanic, 4 nonwhite, and 1 each Asian American, Pacific Islander, East Indian, and Asian Indian. With the exception of the recent multisite study sponsored by the National Institute of Mental Health, the largest inclusion of minorities in any study was 5. However, in the recent NIMH trial, 115 African Americans and 48 Latinos were included. Although not analyzed separately in this Supplement, further reports analyzing outcomes for the ethnic minorities could still be forthcoming.

The American Psychological Association recently reviewed empirically validated therapies, namely, those therapies judged by a panel of scientists to be effective, according to explicit criteria for empirical studies (Chambless et al., 1996). Their report states: Examining the citations for empirically validated therapies identified in the 1995 task force report, we find not a single study included tests of the efficacy of the treatment for ethnic minority populations. Most investigators did not specify ethnicity of subjects or used only white subects. Out of about 41 studies cited, only 6-7 made any reference to race or ethnicity of subjects. No one used ethnicity as a variable of interest.

Overall, minorities are not represented in studies that evaluate the impact of interventions for major mental disorders. Furthermore, when minorities are included, rarely are analyses conducted to determine whether the treatments are as effective for them as they are for white populations. Although a great deal is known about efficacy of a wide range of interventions for treating common mental disorders, specific information about the efficacy of these interventions for racial and ethnic minority populations is unavailable.

References

  1. Agency for Healthcare Research and Quality (1999). Treatment of Attention-Deficit/Hyperactivity Disorder: Summary, evidence report/technology assessment No. 11 (AHCPR Publication No. 99-E018), Rockville,, MD:. Author .
  2. American Psychiatric Association (1994). Practice guideline for treatment of patients with bipolar disorder American Journal of Psychiatry, 151 (12th suppl.) 1–36.
  3. American Psychiatric Association (1997). Practice guideline for treatment of patients with bipolar disorder American Journal of Psychiatry, 154 (4th suppl.) 1–63.
  4. American Psychiatric Association (2000). Practice guideline for treatment of patients with bipolar disorder American Journal of Psychiatry, 157 (4th suppl.) 1–45.
  5. Chambless, D. L., Sanderson, W. C., Shoham, V., Bennett Johnson, S., Pope, K. S., Crits-Christoph, P., Baker, M., Johnson, B., Woody, S. R., Sue, S., Beutler, L., Williams, D. A., & McCurry, S (1996). An update on empirically validated therapies The Clinical Psychologist, 49, 5–18.

Table A-1: Representation of Minorities in Randomized Controlled Trials for Treatment of Bipolar Disorder

Table A-1: Representation of Minorities in Randomized Controlled Trials for Treatment of Bipolar Disorder.

Table A-1: Representation of Minorities in Randomized Controlled Trials for Treatment of Bipolar Disorder.

Table

Table A-1: Representation of Minorities in Randomized Controlled Trials for Treatment of Bipolar Disorder.

References

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  15. (1991). Carbamazepine compared with lithium in the treatment of mania Archives of General Psychiatry, 48, 915–921. [PubMed: 1929761]

Table A-2: Representation of Minorities in Randomized Controlled Trials for Treatment of Schizophrenia

Table A-2: Representation of Minorities in Randomized Controlled Trials for Treatment of Schizophrenia.

Table A-2: Representation of Minorities in Randomized Controlled Trials for Treatment of Schizophrenia.

Table

Table A-2: Representation of Minorities in Randomized Controlled Trials for Treatment of Schizophrenia.

References

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Table A-3: Representation of Minorities in Randomized Controlled Trials for Treatment of Depression

Table A-3: Representation of Minorities in Randomized Controlled Trials for Treatment of Depression.

Table A-3: Representation of Minorities in Randomized Controlled Trials for Treatment of Depression.

Table

Table A-3: Representation of Minorities in Randomized Controlled Trials for Treatment of Depression.

References

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Table A-4: Representation of Minorities in Randomized Controlled Trials for Treatment of AD/HD

Table A-4: Representation of Minorities in Randomized Controlled Trials for Treatment of AD/HD.

Table A-4: Representation of Minorities in Randomized Controlled Trials for Treatment of AD/HD.

Table

Table A-4: Representation of Minorities in Randomized Controlled Trials for Treatment of AD/HD.

References

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This Appendix was prepared by the Senior Scientific Editor for this Supplement

Footnotes

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This Appendix was prepared by the Senior Scientific Editor for this Supplement

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