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Evans TS, Berkman N, Brown C, et al. Disparities Within Serious Mental Illness [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2016 May. (Technical Briefs, No. 25.)
In this section, we first summarize key themes and findings across serious mental illness (SMI) diagnoses, disparity groups, and intervention types to answer Guiding Questions (GQs) 1 and 2. We then look at very broad characteristics of the interventions we reviewed, including the intervention's general goals, components, settings, and needed resources. We also include the context our Key Informants (KIs) provided.
In the GQ 3 findings section, we provide a more detailed summary of the 26 studies (reported in 37 publications) we identified that met our inclusion criteria of having evaluated the effectiveness or comparative effectiveness of interventions to improve outcomes in patients with SMI in one or more of the specified disparity groups. In this section, we summarize these studies in the context of the disparity group that they targeted.
As previously noted, although many groups of adults with SMI of various types may experience disparities in health care and outcomes, specifically selected patient populations are the focus of this Technical Brief. Therefore, we present the findings about interventions focusing on these commonly identified disparity groups, as available in the literature and suggested by the topic nominator. The groups are categorized based on the following characteristics:
- race or ethnicity (or both);
- gender;
- lower socioeconomic status (SES);
- homelessness;
- age, specifically being elderly;
- geographic location (e.g., geographic isolation from needed treatment because of rural residence);
- identifying as lesbian, gay, bisexual, and/or transgender (LGBT); and
- having difficulty communicating in English (when the person has a different primary language and for whom English is a second language).
Some studies include participants who could be categorized in more than one group. In reporting results in response to GQ 3, we assigned studies to one group largely according to the description of the main target or intent of the intervention as described by the investigators and mapped to the groups of specific interest for this Technical Brief. For example, if an intervention primarily sought to assess the efficacy of an intervention in an elderly population but was limited to individuals of low socioeconomic status (SES) or to certain racial/ethnic minority groups, or compared results across these groups, we categorized the study in the elderly disparity group because the authors focused on this as the intervention's primary population of concern.
Figure 1 illustrates the yield of our literature search at the various review stages. We identified and reviewed 1,906 titles and abstracts and, of these, 263 full-text articles. Based on this process, we identified 26 distinct studies in 37 articles from which we extracted data for GQ 3 that met our inclusion criteria and addressed the effectiveness of interventions to reduce disparities among SMI groups. Because the searches for GQs 1, 2, and 4 were broader than for GQ 3, also including studies describing interventions, contextual considerations, and research gaps and directions, we included 42 additional articles for GQs 1, 2, and 4 that are appropriate for these GQs but not for GQ 3. These articles are described and cited at the discretion of the authors where appropriate.
Figure 1
Flow chart of search yield and GQ 3 included studies. GQ = Guiding Question; SMI = serious mental illness.
Figures 2 through 5 describe the number of studies for each disparity group by type of intervention, within one of the four diagnosis categories: (1) major depressive disorder (MDD), (2) schizophrenia or schizoaffective disorder, (3) posttraumatic stress disorder (PTSD), and (4) a combination of diagnoses or the specific SMI diagnosis of the population not specified in the study. These figures are limited to the interventions included in the GQ 3 literature. For patients with MDD or dysthymia, the most prevalent intervention type was some form of psychological or behavioral therapy (includes group, family, individual, cognitive behavioral therapy [CBT]) and the least common was pharmacotherapy. The racial or ethnic minority group was the most studied disparity group under this diagnosis. For those with a schizophrenia diagnosis, varying modalities of care management was the most commonly included intervention type. Similar to the MDD or dysthymia diagnosis, racial or ethnic minority groups were the most often studied under this diagnosis. Studies of interventions for the homeless included, more commonly than for other groups, participant populations with a combination of diagnoses—or, the studies did not report the specific SMI and included the greatest diversity of intervention types being tested.
Table 2 displays intervention types by diagnoses, disparity groups, and position along the health care continuum. The table highlights that improving the quality of health care services was the focus of most interventions across diagnoses. The largest number of interventions was provided to individuals in racial or ethnic minority disparity groups, followed by the number focusing on the homeless and then the low SES disparity group. Individuals identifying as LGBT and those who have difficulty communicating in English (because it is a second language) were the least studied disparity groups across all intervention types and diagnoses. We provide additional detail about the interventions and the disparity groups they focus on later in the Guiding Question 3 section.
Table 2
Summary of interventions by diagnosis and disparity group.
We list and briefly describe below some of the more noteworthy interventions we identified within and across the disparity groups, but more detail on these and other interventions can be found in the Guiding Question 3 section later in the report.
- Critical Time Intervention (CTI) provides an array of services to patients recently discharged from inpatient psychiatric hospitalizations.
- Choices is an intensive case management and support program of outreach and engagement to foster relationship with staff.
- The Assertive Community Treatment (ACT) program was an evidence-based multidisciplinary intensive community treatment program for individuals with SMI and comorbid homelessness, frequent hospitalization, substance abuse, and criminal justice involvement.
- The ACCESS Program aimed to improve outcomes through enhancing system integration.
- Primary Care Access, Referral, and Evaluation (PCARE) includes manualized care management provided by nurses to address patient, system, and provider barriers to primary care.
- Blacks Receiving Interventions for Depression and Gaining Empowerment includes a patient-centered, culturally tailored collaborative care strategy delivered by primary care providers.
- Motivational Enhancement Therapy for Antidepressants (META) included individual sessions to improve medication adherence in addition to usual care.
Guiding Question 1. Description of Interventions to Reduce Disparities Among SMI Groups
Key Findings
This section answers GQ 1, describing and summarizing the goals, components, outcomes, advantages, and disadvantages of interventions to reduce disparities. The goals of specific interventions were related to the specific diagnosis and disparity group that the intervention was targeting. Commonly, interventions included multiprovider service components or enhanced service delivery modalities. Increased service use and treatment adherence were the most common intervention outcomes. For interventions targeting the homeless, increased housing stability was an important outcome.
Intervention Goals, Components, and Outcomes
Intervention Goals and Outcomes
The goals of most study interventions included improving access to mental health services, reducing depressive symptoms, increasing treatment adherence, and improving quality of life.27-29,32,43-46,48,50,57,59-64 A specific goal of all the interventions for the homeless population was increasing housing stability. We identified four telepsychiatry studies.24,32,49,57 In one study, investigators found that collaborative care through a telemedicine service was acceptable to the low SES and Hispanic disparity groups, although within the study, they were not able to conclusively demonstrate the intervention's feasibility and effectiveness.24
Outcomes for interventions included improving the trends in service utilization patterns (e.g., decreased visits to emergency departments, increased access to outpatient services) and enhancing housing stability (e.g., decreased number of days on the street or in a shelter).31,34,39,40,48,54,65,66 Intervention outcomes also included the reduction in depression severity, increase in quality of life, and enhanced access and delivery of psychiatric services.
Intervention Components
Researchers tailored intervention designs to meet the unique needs of the disparity group. Intervention components for homeless populations included integration of services, multicare team structures, and street outreach and followup.42,48,50,63,67-69 The predominance of multicare teams as an intervention focus reflected a need for a breadth of skills and associated qualifications among staff. Staff types included outreach workers, clinical case managers, psychiatrists, primary care providers, and psychiatric nurses; the outreach worker was consistently reported across studies as a required staffing component for the program to reach the homeless population effectively.31,34,48,52
KIs highlighted other alternative service delivery options as components of the interventions that could improve effectiveness across various disparity groups. These approaches included (1) enhancing service integration such as using virtual health homes in conjunction with a health outreach worker doing illness self-management training and support or (2) using virtual health homes plus automatic teller assistance (using technology to create a kind of robotic in-home support). One KI noted that a team at Dartmouth is working on mobile health technology for measuring the mental health of patients called “Common Ground,” a Web-based computer program based on self-management that features video testimonials, and allows the patient to select a testimonial from someone they can identify with on the basis of ethnicity or some other characteristic.
We also identified appropriate staff qualifications as another component in the various studies, especially interventions targeting racial and ethnic minority disparity groups. Staff qualifications required for case management and integrated service interventions targeting racial and ethnic populations included primary care providers, psychiatric nurses, psychiatrists, and lay health workers who were familiar to and trusted by the study population, including those who spoke the patient's primary language.
Other important intervention components included algorithm-based recommendations to physicians and case managers to improve the quality of care60 and prepsychoeducational sessions before the delivery of services.61 Similar to interventions for the homeless population, the components of interventions for the elderly also included integrative service teams and resources (primary care, case management, monitoring and tracking systems) to address the multifaceted needs of this population.25,70
Interventions studied involved a variety of service delivery options. These included use of offsite mental health professionals to provide on-site primary health care providers with decision support for medication or psychotherapy (or both) or patient therapy through a “tele-psychologist”49; the latter can support on-site mental health services or provide individual or group-based psychotherapy through a telemedicine link.57
KIs noted that rural residents with SMI are a rapidly growing disparity population. They expressed that using technology to provide services for this population has great potential, especially telemedicine or telepsychiatry. Additionally, technology based on machines that learn by collecting information from patients and incorporating responses into decisionmaking offer considerable promise. Mobile health technology is another key area that is now increasingly being tapped as a way to better assess and monitor patients in real time.
Disparity Groups
Interventions targeting racial and ethnic minority groups were most prevalent, followed by those targeting low SES including homelessness. Interventions for the elderly appeared primarily in studies of racial and ethnic groups. We did not identify any studies that focused on interventions targeting individuals identifying as LGBT or American Indian/Alaska Natives (race or ethnicity) disparity groups.
We found that researchers included patients who are members of multiple disparity group categories within individual interventions. For example, the geographic disparities group, which focused on rural populations in our studies, was captured primarily in discussions of other disparity groups, because of the overlap with other characteristics. For example, one study examined collaborative care intervention across the elderly, racial or ethnic, and low SES disparity groups.25,26
Two studies,57,71 however, looked at geographic location independent of any other group characteristics; both found that telemedicine approaches were acceptable to the targeted populations. KIs reinforced the importance of interventions focused on increasing access to accurate diagnoses in rural areas given the dearth of psychiatrists and behavioral health professionals in those regions.
Potential Advantages and Disadvantages
We found that interventions described in the available literature or by KIs have two main advantages: (1) they address the unique needs of the disparity group by integrating specifically identified services, clinical care models, or resources and (2) they seek to build on existing treatment modalities. KIs believed that collaborative care is the only intervention for which more than minimum evidence exists for reducing disparities and improving engagement. This view aligns with positive research findings on this intervention.72 We found that many of the interventions had a collaborative care base,25-27,58,59 with components modified to be specific to the disparity population of interest.
We did not identify any studies that addressed either potential disadvantages of any of the interventions or issues of safety or harm. KIs did not directly address this issue.
Guiding Question 2. Context of Interventions to Reduce Disparities Among SMI Groups
Key Findings
This section describes contextual issues associated with these interventions; of specific interest were intervention settings, organization and staff characteristics, and resources and other requirements for successful implementation. Most evidence was identified in the existing literature; we indicate where KIs specifically noted relevant issues.
The homeless population and racial and ethnic minorities have been the targets of most of this research. Settings involved primarily mental health specialists being colocated in nonpsychiatric locations. These settings were usually primary care, but sometimes they were obstetrics-gynecology clinics and perinatal health care settings; settings also included community mental health entities, although other community-based settings or in-home locations were described.
Use of, and thus research on, mobile health and Internet technology are increasing (for all populations and health care purposes). Many of the interventions for disparity groups (e.g., ACT teams and CTI for the homeless, colocation of mental health specialists for minorities or the elderly, telemedicine for rural areas) require giving additional responsibilities to existing health care clinicians and adding new personnel and new resources (e.g., mobile health technology). Homeless populations, racial and ethnic minorities, the elderly, and rural populations have all been included in this research, but what is needed for successful implementation across groups remains unclear.
Intervention Settings
Interventions to reduce the various disparities of the groups of interest were set in multiple locations, each of which increased the likelihood of capturing patients. The settings included public agencies in urban areas that involved contract service delivery programs43 and, specific to the homeless disparity group, community mental health clinics that provided both in-home service and services for the homeless through ACT teams,48 homeless shelters,42 or institutions.35,39
Other settings included community mental health clinics;24,44,47,56 primary care clinics with no integration of mental health specialists,32 some integration of mental health specialists,27,59-61,73 and primary care clinics with some description of this integration occurring within a patient-centered medical home;68 obstetric-gynecologic clinics;33,74 and family planning or pediatric-related services.31
Some interventions to reduce disparities among patients with SMI focused on enhancements in primary care settings. These studies illustrate situations in which mental health specialists have been colocated through collaborative care interventions. This approach can offer an infrastructure to support ongoing monitoring and management of medication or psychotherapy treatment.25,26 Interventions in primary care can also provide peer-led collaborative activation programs to improve “patient activation” and person-centered care of older adults with SMI and cardiovascular risk.70
In looking at the intervention settings for the homeless population, researchers focused primarily on patients with psychotic disorders. The aim was to help create a bridge to follow up with community mental health providers by, for instance, providing a CTI program for SMI populations or directly observed pharmacotherapy (DOT) in HIV clinics trying to improve depression care.34 Each of the interventions was an outreach from community mental health clinics, although the DOT in HIV clinics was delivered at a specific research site (not a formal clinic).
Interventions to reduce disparities in rural populations address the difficulties created by patients living in areas with limited access to specialty mental health providers (if not even basic primary or specialty medical care professionals). Settings studied included community-based outpatient clinics of the Department of Veterans Affairs.49,57,71 One limited research demonstration was conducted in an in-home treatment setting.75
KIs were generally in agreement that the settings described in the literature, which were primarily public-sector mental health settings, were the correct ones to target. They also indicated that the criminal justice setting, whether by diversion of homeless patients or because released mentally ill inmates are at increased risk of becoming homeless, can be important for better reaching SMI patients who are (or may become) homeless. Programs such as the Consensus Project (http://csgjusticecenter.org/mental-health-projects/report-of-the-consensus-project) can provide information on the implementation of practical, flexible mental health strategies in criminal justice environments such as on-site technical assistance and dissemination of information about programs, research, and policy developments in the field.
Additional Responsibilities of Health Professionals for Medical and Mental Health Care
By Intervention Type
Additional responsibilities for health professionals to enhance care vary by intervention type. Some add no clear burden to health professionals by virtue of their emphasis on public service agencies, whereas others put increasing degrees of burden on health care providers. All require additional resources, primarily an additional case manager or clinical personnel and effort.
The Los Angeles Homeless Opportunity Providing Employment (LA's HOPE), for example, placed various responsibilities on public health agencies and their contract service delivery programs.43 Some intervention models, such as the ACCESS Program,62,76 gave more responsibilities to case managers who provide intensive case management with outreach in an attempt to more efficiently integrate various delivery systems (e.g., medical, mental health, public services) to reduce disparities and improve quality of care. The ACT program, combining intensive case management services with more clinical intervention and outreach, can add substantial responsibilities, including in-home care delivery, to health care professionals' activities.48,54
CTI programs expanded responsibilities of health professionals by requiring participation in initial treatment planning to identify potential areas of intervention, such as adhering to medication regimens, managing money, making followup appointments, or dealing with conflict with caregivers. These added responsibilities occur often at a time of transition from an institution to the community, when discontinuity in care might lead to homelessness; it also entails providing ongoing supervision of CTI workers by mental health professionals.39,40 DOT therapy required receipt of fluoxetine to be directly observed by a care provider (not a psychiatrist) with a weekly meeting with the psychiatrist for 1 month, followed by a meeting every 2 weeks for the second month, and then monthly thereafter.34
KIs did not directly address the question of placing additional responsibilities on health care providers, but they did place it in a useful context. They noted that the nation lacks enough behavioral health professionals (including a dearth of psychiatrists) to address the mental health needs of those with SMI, in general. KIs also emphasized that, as an extension and intensification of this general problem, not enough psychiatrists are available to work with SMI patients who are homeless.
By Intervention Setting
The burden of additional responsibilities and need for resources also varied by setting. For example, in community mental health settings, some interventions had psychiatrists performing what they usually did to monitor medications, but needed telepsychiatry resources were added through a virtual clinical interaction.24 Others provided enhanced case management with bilingual workers; weekly or biweekly followup by psychiatrists; a behavioral intervention package47 or a psychoeducational package44 targeting the family; a culturally tailored psychoeducational intervention;46 and motivational interviewing to improve treatment adherence.28,29 The interventions similarly required cooperation and integration with community-based psychiatric and medical clinics.49,57,71
For interventions in primary care settings, mental health care was often integrated with standard medical care. Systematic support of diagnosis and management was provided by culturally tailored collaborative care interventions; these could involve medication or psychotherapy (or both) services and enhanced provider training in cultural competence to better align services and patients' needs.27,44,45,56,59-61,73,77 Two examples involved telepsychiatry with no additional mental health integration into primary care, one involving a psychiatrist32 and the other a telephone depression care manager.78
In primary care clinics, this additional effort involved patient-centered assessment of barriers to access, better understanding of social stressors that disproportionately affected the particular minority group, and more culturally targeted materials to address barriers to treatment.27 Interventions in obstetric-gynecologic clinics required additional personnel to provide CBT and active outreach, services that had not previously been provided.33,74 Studies in family planning or pediatric clinics looked at adding a nurse practitioner under supervision from a psychiatrist to better manage patients with MDD.31
All interventions also required increased cooperation and integration with other service providers. Most frequently this involved mental health providers colocating with nonpsychiatric medical providers.27,31,33,59-61,73,74 “Peer services” in this group have also been considered as an additional type of provider. The goal is to help individuals with SMI better navigate the process of obtaining and maintaining better health care, which can improve both physical and psychiatric outcomes.79,80
Colocation of a mental health specialist with the primary care clinic, and the requisite cooperation between mental health and primary care providers, is a part of this collaborative model. It involves provider education, patient activation, systematic treatment monitoring, mobilization of community resources, and ready access to mental health services.25 81,26 Such a model requires a substantial degree of cooperation and integration. For example, the peer-led collaborative activation training (CAT) requires patient training, which consists of nine group-based 90-minute sessions delivered weekly over 2 months.70
One potential cause of reduced care in elderly patients with SMI is that primary care providers may not know the preferences for decisionmaking among their patients with SMI or how to communicate clearly and effectively with them. A collaborative care approach that addresses this gap provided a skills training intervention consisting of CAT for SMI patients and their primary care providers (CAT-PC); its goal was to improve patient activation skills and provider communication in the primary care medical encounter.70
Resources Needed to Provide the Intervention
Successful implementation of any of the interventions requires greater cooperation and integration with other service providers, primarily between case managers,39,40,48,54,55 mental health providers,39,40,48,54,55,60,61,74 and (in one instance) HIV providers.34 Additional vocational assistance (with job training and placement assistance) and psychosocial rehabilitation services (including links to peer support and daily living skills training) appear to be key components.65 In addition, dissemination strategies and challenges, including successful integration into large urban systems, have been described.66,81
Three important organizational issues must be addressed to allow successful implementation of these types of interventions for the homeless. The first is the need to allow staff to divide their time effectively between institution-based and community-based assignments. A second important change is to allow workers to focus their efforts on particular areas that can result in the greatest opportunity for successful transition to or maintenance in a community (in contrast with being required to provide comprehensive services to all clients). Third is the need to overcome barriers among different organizations that can prevent collaboration (e.g., the need for client consent to exchange information).66
As indicated above, additional resources vary by setting and include the addition of bilingual case managers, more frequent followup by psychiatrists, or more comprehensive behavioral packages targeted at families. All of these added resources required a substantial addition of personnel resources (in community mental health settings),28,29,44-47,56 and demanded increased effort of particular personnel such as a care manager, a health care manager, a nurse practitioner, a psychotherapist, or a supervising psychiatrist (in primary care clinics).27,31,33,46,56,59-61,73,74,77 One study described a telepsychiatry intervention that would require additional personnel (a psychiatrist off-site) and an Internet/Webcam connection,32 while the other required an off-site depression care manager and a telephone connection.78
The collaborative care intervention addressed in studies requires additional personnel and effort; these additional components can include a depression clinical specialist (often a nurse or psychologist) with increased followup and closer monitoring. The peer-led collaborative activation training required a 45-minute video training of primary care providers.70 The addition of telepsychiatry required resources to provide and maintain the video-conferencing link. Other research examined involved providing ACT interventions to veterans by adding personnel, such as small specialized intensive case management teams.71
Guiding Question 3. Current Evidence About the Effectiveness (or Comparative Effectiveness) of Interventions
We identified 26 studies (reported in 37 publications) that evaluated the effectiveness or comparative effectiveness of interventions to improve access to mental health treatment, quality of care, and outcomes among disparity groups of individuals with SMI. To promote a parsimonious presentation of the included studies, we describe each of the 26 studies only once, even if it cuts across disparity, diagnostic, or outcome categories. We grouped studies into the following categories:
For each included study, Table 3 documents the intervention being evaluated, the participants' SMI diagnoses, and the disparity group membership(s) of the participants. We found no studies of interventions for individuals identifying as LGBT and no studies specifically of individuals with difficulty communicating in English. However, as discussed below, several studies provided written materials or direct services through individuals who spoke the participant's primary language (when other than English) as a component of an intervention that was striving to provide culturally competent care. In relation to the primary concerns that the interventions were seeking to address, we found no studies addressing accurate diagnosis of an SMI or access to health insurance. All studies were conducted in the United States.
Table 3
Studies with evidence for GQ 3: Study citation, disparity group(s), SMI diagnosis, and type of intervention.
In the tables below, we present summary information regarding the patient population, the design of the study including the treatment intervention and comparison, and the key findings. Evidence tables include more detailed data for each study (Appendix F).
Interventions for the Homeless
Overview
Eight studies examined seven interventions for homeless individuals with SMI (Table 4). Seven of the studies included services to address homelessness and considered improving housing stability to be a key intervention activity and outcome goal. The interventions addressing homelessness generally focused on individuals with psychotic or affective disorders. The two largest studies were implemented in multiple cities: the McKinney research demonstration projects54 and ACCESS.50-53 Three randomized controlled trials (RCTs) were conducted in New York City, New York; two evaluated CTI, an intervention providing services to homeless men recently discharged from inpatient psychiatric hospitalizations39-42; and the third was Choices, a program of intensive case management and support.55 An RCT evaluating the ACT program conducted in Baltimore, Maryland, evaluated outcomes after adding intensive case management to an array of services offered to program participants.48 The last two included studies were LA's HOPE, a program focusing on housing and employment support,43 and an RCT of DOT for depression; the DOT trial did not provide services to ease homelessness.34
Table 4
Characteristics of studies of interventions to address disparities based on homelessness among individuals with SMI.
Among the seven programs whose goals were to improve housing outcomes, as well as health and other outcomes, each provided an array of some or all of the following services: enhanced outreach, intensive case management, life skills, opportunities for socializing, other supports, and linkages to needed services. Across programs, participants tended to see improvements in housing, health care service use, and quality of life. Outcomes were not superior to comparison interventions in all cases, but some of the comparison programs used alternative approaches to providing many of the same services so that improvements were seen in both groups. One RCT of DOT to promote antidepressant medication adherence resulted in improved depression outcomes.
Detailed Program Descriptions and Outcomes
The McKinney research demonstration project was conducted across sites in four cities; all included assertive outreach and intensive case management teams.54 Usual care comparisons differed across sites. Overall, the percentage of individuals living in community housing increased over time in both the McKinney intensive case management demonstrations and the traditional case management programs. The ACCESS program was conducted at 18 sites, with the goal to improve outcomes through enhancing system integration. Sites also provided outreach and intensive case management.50-53 Limited data were available on the effect of the program on use of health services. Like the McKinney demonstration, access to independent housing improved over time for both participants in ACCESS and those receiving services in comparison programs that had not received funding for system integration.
The CTI program provided services to homeless participants over an 18-month period. During the first 9 months, a CTI worker provided individualized assistance in bridging the transition from institutional care to obtaining services and promoting independent living in the community, based on a long-term ACT model. In the second 9 months, referral was available to a range of usual community-based mental health and rehabilitation services. In two RCTs of the comparative effectiveness of CTI, the comparison groups had access only to referral to usual care.35-42 The earlier trial found mixed results in relation to mental health outcomes; the CTI group experienced a greater decrease in negative symptoms after 6 months but no difference in positive or general psychopathology outcomes. In a more recent trial, CTI participants had lower odds of psychiatric rehospitalization, greater perceived access to mental health services, and greater satisfaction with family relations. Both trials found that CTI was more likely to reduce homelessness.
Choices, an intensive case management day program, provided outreach and participant engagement, including food, showers, assistance with obtaining services, socializing, and respite housing.55 An RCT evaluating the comparative effectiveness of Choices and referral to usual care found no differences in health service use (emergency department, inpatient, or outpatient) but better psychological status, greater use of shelters, and life satisfaction.
An RCT compared one of the ACT program sites with other local community-based organizations providing case management.48 After 12 months, ACT participants had better use of psychiatric services (fewer inpatient and emergency department visits and more outpatient visits), no difference in general medical care service use, but better clinical outcomes. ACT participants also had more days in stable community housing.
LA's HOPE provided enhanced assistance with housing and employment compared with other similar programs but without the enhancements.43 After approximately 1 year, LA's HOPE participants were more likely to have secured housing and employment.43
An RCT for homeless HIV-positive patients with depression randomized participants to either DOT with fluoxetine or referral to a mental health clinic. The DOT intervention was associated with reduced depression symptom severity, but it had no effect on antiretroviral therapy adherence.34
Interventions for Low-Income Individuals
Overview
Two of the five studies that evaluated interventions for low-income individuals (not identified as homeless) were grouped together because they similarly include CBT in at least one of the intervention arms30,31,33 (Table 5). Both CBT studies also provided support services and were found to be superior to treatment as usual. A third study, a collaborative care model designed to ease various barriers that can be faced by low-income SMI patients in accessing primary care, was found to be effective in patients' receipt of recommended services.58 A fourth study, limited to a low-income population, concerned telepsychiatry; it is discussed with studies of interventions to address disparities based on rural residence.24 A fifth, concerning a collaborative care intervention for low-income Chinese Americans with MDD, is discussed with other studies focusing on racial/ethnic minority individuals with SMI.59
Table 5
Characteristics of studies of interventions to address disparities based on being low income among individuals with SMI.
Detailed Program Descriptions and Outcomes
The two studies focusing on CBT treatment for low-income women with MDD were RCTs that evaluated the comparative effectiveness of this treatment for depression with usual care. In one of the studies, entitled Women Entering Care, a pharmacotherapy arm was also compared with usual care.30,31 In both studies, usual care provided education and referral to community mental health providers; only a small percentage of women adequately followed up on the referral and received psychotherapy services. In contrast, in the intervention arms, women were more likely to receive CBT or pharmacotherapy. Both interventions being tested were offered on-site at a clinic in which women were already receiving services. Also, both provided support services. The Women Entering Care study offered materials in Spanish, services through culturally aware clinicians, preliminary educational sessions for those who may be reluctant to enter treatment, and financial assistance for day care and transportation. The second intervention, focusing on low-income perinatal women, included active outreach to help women schedule and, if necessary, repeatedly reschedule appointments.33 In both studies, depression outcomes were superior in the intervention arms.
The third study is a large RCT (N=407), called the PCARE study, which evaluated the efficacy of a manualized enhanced collaborative care intervention delivered by nurses to overcome patient-, provider-, and system-level barriers to primary care among a low-income patient population with SMI, who were receiving mental health services in an urban community mental health clinic. Services included information about medical conditions, motivational interviewing, and assistance in communicating with clinicians and enrolling in health insurance. Patients in the intervention arm, compared with usual care (lists of providers), obtained a significantly larger percentage of recommended preventive services, including physical exams, screening tests, educational interventions, and vaccinations. The intervention arm also showed significantly greater improvement in sustaining a primary source of care and higher scores on measurements of mental health quality of life.
Interventions for Racial and Ethnic Minority Groups
Overview
Fourteen studies evaluated enhanced interventions for particular racial or ethnic disparity groups. Of these, 11 are discussed in this section of the report (Table 6). The 3 remaining studies are discussed in other sections of the results: The first is presented in relation to interventions for the elderly,25,26 the second in relation to interventions for rural populations,24 and the third in relation to interventions for low-income groups.30,31
Table 6
Characteristics of studies of interventions to address disparities based on race or ethnicity among individuals with SMI.
Each of the interventions was culturally tailored to the particular group. Of the 11 studies discussed in this section, 2 studies compared culturally adapted collaborative care strategies to more traditional care-enhanced models in primary care settings, primarily among patients diagnosed with MDD (African American, Chinese American), and found that treatment improved in both groups.27,59 A third study found superior results among Hispanic patients with MDD through a telepsychiatry intervention provided by a bilingual psychiatrist compared with standard of care by a PCP.32 A fourth study tested case management support for depression delivered via telephone among Latino patients with MDD in addition to usual care, and found no difference in access to care or health outcomes.78
The remaining seven studies evaluated various forms of culturally adapted therapy; each provided services in a language other than English. Among these, three interventions focused on Hispanic or Latino populations with schizophrenia. Two of the studies added an approach to enhance family engagement in care to support a family member with schizophrenia,44,47 and a third provided patients with a cognitive behavioral intervention intended to improve their everyday functioning.45 Results were mixed. Two studies focused on Latino populations with MDD and tested motivational interviewing, successfully improving medication adherence and retention in treatment.28,29 One study found superior results by enhancing individual supportive therapy: For Korean patients with schizophrenia, the study added a psychoeducational intervention that integrated traditional Korean disease concepts.46 The final study discussed in this section compared the effectiveness of no treatment to culturally adapted CBT provided to Cambodian refugees with PTSD and comorbid panic attacks.56 Mental health outcomes in the intervention group were superior.
Detailed Program Descriptions and Outcomes
Two studies examined collaborative care models among patients with MDD receiving care in primary care settings. In one, African-American patients were provided with depression care managers who were African American,27 and in a second study, the researchers sought to provide Chinese-American patients with depression care managers as well as culturally and linguistically relevant materials.59 Both studies examining culturally tailored collaborative care models compared the new approach with a more standard collaborative care or enhanced physician-patient engagement approach. Patient outcomes improved over time in both arms of each study.
One study tested a telepsychiatry intervention, using commonly available Webcam technology among Hispanic patients with MDD receiving health care in a community health center.32 Compared with treatment as usual with a PCP, patients in the intervention arm showed greater improvement in depression symptoms, quality of life, and level of disability. The researchers concluded that the intervention was both effective and acceptable as a treatment modality.
In one report, the Depression Health Enhancement for Latino Patients (D-HELP) study tested enhanced bilingual case management support for depression delivered via telephone among Latino patients with MDD receiving health care in a Medicaid health maintenance organization.78 Patients in both arms received treatment as usual through a PCP and antidepressant medication. The intervention was considered promising by the researchers, but the results did not reach statistically significant differences (p<0.05) for any outcomes measured, including number of visits, medication adherence, quality of care, depression severity, and functional status.
The remaining seven studies discussed in this section tested some form of culturally adapted therapy. Two of these studies were RCTs that focused on Hispanic patients with schizophrenia and examined the effect of greater family engagement in treatment support compared with treatment limited to the individual patient.44,47 The larger study, conducted across eight mental health facilities in the Los Angeles area, examined two culturally adapted multifamily group therapy interventions: One was described as addressing standard issues in managing the disease, including understanding and managing problem situations, and the second as focusing on medication adherence. Both interventions were conducted for 12 months and included “survival skills” sessions for family members. This study found no differences between the intervention groups and treatment as usual in medication adherence but did find support for reduced hospitalizations (both time to hospitalization and number of hospitalizations).44 The second study, also conducted in the Los Angeles area, found that a behavioral family intervention that sought to provide family members with education about the disease, communication skills, and problem-solving skills might actually worsen results, including exacerbation of symptoms among less acculturated patients.47 Among more acculturated patients, outcomes were more likely to be related to medication compliance. Overall, the researchers concluded that patient acculturation was an important characteristic to consider in relation to treatment outcomes.
The third study focusing on Latino patients with schizophrenia, Program for Training and Development of Skills in Latinos (PEDAL), provided 24 twice-weekly group educational sessions to patients to promote improvement in functional skills, including medication management, social and communication skills, organization and planning, transportation, and financial management.45 Limited to only 29 participants, this manualized cognitive behavioral intervention was compared with participation in a friendly support group. Results were equivocal and likely underpowered; no outcome was consistently better in the intervention group at end of treatment and at the 6- or 12-month followup.
Two studies, an RCT compared with usual care called Motivational Enhancement Therapy for Antidepressants (META)28 and a pre-post study29 examined the effect of culturally adapted motivational pharmacotherapy on antidepressant medication adherence among Latino patients with MDD. The interventions in both studies found greater improvement in adherence and mixed results in depression symptom outcomes.
An RCT compared a psychoeducational intervention to individual supportive therapy for Korean Americans with schizophrenia.46 Conducted in an outpatient mental health clinic by a psychiatric social worker, the intervention integrated traditional Korean disease concepts into the sessions. At 10 weeks, the intervention group was found to have a greater decrease in psychiatric symptoms, felt less stigma related to their mental illness, and reported better coping skills.
Lastly, Cambodian refugees with PTSD and comorbid panic attacks were randomized to culturally adapted CBT and delayed treatment.56 Both arms received supportive psychotherapy and pharmacotherapy in a community-based outpatient clinic providing specialized services to this population. Participants in the CBT intervention had lower levels of PTSD and anxiety symptoms at the 12-week followup.
Interventions for the Elderly
We identified only one study that examined enhanced treatment for MDD specifically for elderly patients25,26 (Table 7). The intervention in this large multisite RCT, conducted in primary care sites, followed a collaborative care, stepped-care approach. Intervention components included (1) education for PCPs about late-life depression; (2) a depression care manager to work with the patient and PCP to activate the patient to manage his or her care, provide ongoing monitoring of mood and medication, and provide brief psychotherapy; (3) a clinical information tracking system; and (4) access to consultation with a psychiatrist when needed. In comparison with usual care, which could be any care or no care, intervention participants were more likely to use treatment services for their MDD and to experience better depression outcomes. Superior results were experienced across race and ethnicity groups (African American, Hispanic, and white) and income groups (low and high).
Table 7
Characteristics of studies of interventions to address disparities based on being elderly among individuals with SMI.
Interventions for Rural Populations
Three studies examined the use of telemedicine services for individuals living in rural areas and receiving services in clinics considered to have inadequate availability of local psychiatric services (Table 8). The telemedicine services were provided in addition to locally based care. Two of the interventions were implemented in Department of Veterans Affairs Community-based Outpatient Clinics (CBOCs): one for male veterans with PTSD49 and one small study for female veterans with PTSD, MDD, chronic pain, or combinations of these diagnoses.57 The third intervention was provided to low-income Hispanic patients with MDD who were receiving services at a community health center.24 These interventions were found to be feasible enhancements to local services. Improvement in health outcomes were mixed.
Table 8
Characteristics of studies of interventions to address disparities based on rural residence among individuals with SMI.
Guiding Question 4. Summary and Implications
Using our findings from the GQs (GQs 1, 2, and 3), we now discuss important issues that have not been adequately addressed in the current research base and that merit high-priority attention for future research. These include gaps in the knowledge base and the evidence for the effectiveness or comparative effectiveness of strategies addressing critical disparities among groups of people with SMI. In addition, we comment on future areas of research (including research that may be in a planning stage, but not yet completed). Finally, we discuss major implications to be drawn from the findings of this Technical Brief and next steps.
Summary Findings
Based on the topic nomination, the focus of this Technical Brief is adults with SMI who also fall within specific, generally established, disparity groups: (1) racial/ethnic minorities; (2) women; (3) economically disadvantaged individuals (including homeless individuals); (4) elderly individuals (≥65); (5) individuals living in rural areas; (6) individuals identifying as LGBT; and (7) individuals with difficulty communicating in English because it is a second language. These groups were among a larger list considered a priori, and we developed the final set after input from our KIs, who emphasized the importance of the elderly, homeless, and LGBT populations.
Interventions were required to target one of the above listed groups, and we categorized them along the continuum of health care as points of possible intervention. Briefly, again, these were (1) access to health care (including health insurance), (2) accurate diagnostic evaluation, (3) quality of treatments, (4) access to other health-sustaining services such as housing or other supports necessary to maintain health and adherence to treatment, and (4) final health care outcomes. We kept this context in mind when designing our literature search criteria (as described in Methods). GQ 3 was limited to a review of studies that could provide information on effectiveness, with the goal of this Technical Brief being to map the existing evidence, rather than to systematically review comparative effectiveness.
Across all the 26 GQ 3 included studies (covered in 37 articles), many studies included individuals of more than one disparity group and discussed interventions for multiple disparity groups at once. This factor complicated our analyses because, generally, we strove to describe a study only once. Examples of these “overlapping” groups include the following: elderly minority patients25,26 and low-income minority women.30 See Table 3 for a full description of the overlapping disparity groups targeted in interventions included as evidence for GQ 3.
When we combined the homeless group with the low SES disparity group, interventions mostly focused on economically disadvantaged individuals, followed by racial or ethnic minority groups, and were least focused on elderly individuals. Specifically, within the SMI population disparity groups, 15 of the 26 identified studies focused on economically disadvantaged individuals (combining the homeless disparity group and the low SES disparity group).24-26,30,31,33-43,48,50-55,58,59,78 Fourteen studies included minority racial or ethnicity populations24-32,44-47,56,59,78; 10 of which were focused on the Latino community,24-26,28-32,44,45,47,78 3 on African Americans,25-27,30,31 and 2 on Asian Americans.46,59 Three studies addressed rural populations,24,49,57 3 studies focused on women,30,31,33,57 and one study addressed elderly individuals.25,26 No studies focused on LGBT populations or individuals who have difficulty communicating in English, outside of more comprehensive culturally competent interventions.
In relation to the continuum of health care as points of possible intervention: 7 studies addressed access to health care, although none addressed health insurance specifically; no studies addressed receipt of accurate diagnostic evaluation; 14 studies addressed quality of care; and 5 studies addressed final health care and other related outcomes, with 2 studies looking specifically at housing.
A variety of interventions to reduce disparities have been studied. Eight studies looked at some form of case management,36-43,47,48,54,55,78 including two studies employing ACT48,54 and two employing CTI.35-42 Eight studies also tested some form of culturally adapted therapy (including individual, group, and family).28-31,33,44-46,56 Four studies examined a collaborative care intervention25-27,58,59; four studies used telepsychiatry,24,32,49,57 one study tested integrated systems service delivery,50-53 and one study examined DOT.34
From a diagnostic perspective, 13 studies were based in a population with depressive disorders,24-34,57-59,78 9 studies included populations with psychotic disorders,35-48,55 4 with anxiety disorders,49,56,57,59 and 3 studies did not specify the type of SMI.50-55
In the context of evaluating the effectiveness of interventions to address disparities in SMI, current research has mainly focused on economically disadvantaged individuals, especially those who are homeless, and racial or ethnic minority disparity groups. Along the health care continuum, access to health care (not specifically health care insurance) is the targeted point for intervention. Enhancing case management services and using some form of culturally adapted therapy are the most common types of interventions used to address disparities in SMI. Depressive and psychotic disorders are the main diagnosis types treated in these types of interventions, which may be a result of the high prevalence of these conditions in economically disadvantaged individuals, including homeless individuals, and racial or ethnic minority disparity groups.
Overall, many studies reported effects in improving outcomes across diagnostic and disparity groups. However, few interventions were replicated, and comparisons varied greatly across studies. Because of this, the evidence can only suggest what are likely to be successful intervention models or useful enhancements to existing interventions. More specifically, for the homeless, interventions were complex and multifaceted; they combined a number of services delivered by treatment teams. These programs tended to improve housing outcomes and health care service use. Culturally adapted collaborative care models that provide psychiatric services to patients beyond those that would normally be available in the primary care setting or help patients coordinate and manage their care were found to enhance health outcomes.
Telepsychiatry is a promising approach among individuals who are isolated from needed mental health services because they live in rural areas or because they are members of a minority culture and would be more comfortable receiving treatment in a language other than English, particularly if it is delivered by someone from a similar cultural background. Culturally adapted therapy, including CBT, showed promise, as did motivational interviewing and DOT. The effectiveness of several approaches requires further study. Telephone management delivered by nonclinical staff did not improve outcomes in one small study. Interventions to enhance family involvement in the care of Latino family members with schizophrenia were mixed. In one study, results were worse than those through patient-only care.
Gaps in Evidence Base
Significant gaps in the evidence base exist both for the disparities studied in the included literature of this Technical Brief and for key disparity groups for which we could find no research. There is a growing need for additional research to be conducted before the comparative effectiveness of interventions to reduce disparities among individuals with SMI can be accurately assessed. There is a striking absence of interventions addressing disparities faced by individuals identifying as LGBT with SMI, and there is still a need for more research addressing racial and ethnic groups. For example, there were no studies looking at the Native American population, and only 3 studies directly focused on African Americans. Estimates of SMI are similar between African Americans and Latinos, approximately 3 percent, according to the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA),9 yet there were still only 3 studies focusing on an African-American population and only 10 focusing on a Latino population. The literature emphasized the importance of not assuming that one intervention will be effective in all minority populations. As an example, when all 4 years of the ACCESS data were examined, ACT was associated with a reduction in service use disparities for African Americans but not for Latinos.64
Furthermore, researchers have called for more carefully designed intervention studies to allow for racial/ethnic minority-specific analyses.82 Rural, female, and elderly populations with SMI were poorly represented in the current literature, despite the fact that they each represent significant groups within the total SMI population. Although no studies targeted only the issue of SMI patients who experience difficulty communicating in English, several studies (focusing on Latino and Asian-American populations) did make services or materials available in languages other than English, as part of a more complex culturally adapted intervention addressing more than one problem area for the disparity group.
Along the health care continuum, gaps are evident where there are opportunities for interventions. Although several studies examined access to health care (i.e., therapeutic services), none addressed access to health care insurance (or coverage within health care plans), and none addressed receipt of accurate diagnostic evaluation, despite evidence that such a disparity exists.83
Thus, numerous gaps in the evidence base exist, both in terms of particular disparity groups and along the continuum of health care, particularly in terms of access to health insurance and accurate diagnosis. There is a need for additional research looking at interventions in different diagnostic groups, such as testing telepsychiatry interventions for individuals with schizophrenia located in rural areas. In fact, one could imagine almost endless combinations of different disparity groups, different interventions types, different diagnostic populations, and different health care outcomes. This is a critical point, because the literature to date does not suggest that a proven intervention type works across all disparity and diagnostic groups. For example, collaborative care has been primarily studied in racial minority groups with depressive disorders by helping this specific population obtain access to and use quality treatments for depression; however, whether these findings generalize to the LGBT population with depression is unknown.
KI discussions mirrored the gaps discussed above that we found in the literature. Multiple KIs mentioned the absence of literature addressing the LGBT population with SMI. They also agreed that relatively little literature addresses either rural populations with SMI or elderly persons and that the latter are of particular concern because of the aging U.S. population. Furthermore, one KI pointed out that no research is available on cultural competency at the assessment (diagnostic) level for these SMI subpopulations and how this capability can affect patients' outcomes (for better or worse). KIs generally agreed with the importance of Federal funding for disparity research and the need to conduct such research rigorously and dispassionately. Compared with usual care, most of these interventions produced improvement in the targeted outcomes within the disparity group that was the focus of the study. For example, in one study, CBT to treat depression was enhanced with specific perinatal content and an interpersonal component.33
Limitations of the Technical Brief
The ability to review the relevant evidence base for this topic has some general limitations. First, as noted in the text, many of the disparities overlapped (e.g., sometimes a population had patients selected both because of older age and race/ethnicity); in these cases, we tried to group the intervention by the primary disparity targeted by the intervention. Such overlap, however, complicates the attribution of those outcomes to the intervention effect for a particular disparity group.
Second, the definitions and categorization of the disparity groups continue to evolve, making the area at risk of inconsistent terminology. As a result, the comprehensive search for relevant literature for an area (e.g., gender disparity or difficulty communicating in a secondary language) can be challenging, and it is possible that some relevant eligible literature was missed. Ideally, KI input, peer review, and public comment can help address this limitation. Similarly, this technical brief was limited to seven disparity groups, but there are clearly others that were not addressed, such as the incarcerated SMI population.
Third, this Technical Brief used a very broad definition of SMI. Per the Federal Government,9 SMI is defined as the presence of a diagnosable mental illness, per the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), that results in serious functional impairment (excluding substance use and developmental disorders).9 However, we could not use degree of functional impairment as part of our criteria, because the available literature does not provide this information, and even this definition will have to be updated to accommodate the recently released DSM-V.
Finally, because the focus of this Technical Brief was on groups with SMI, literature addressing the SMI population, as a whole, in comparison to the general population did not meet our inclusion criteria, thus was not reviewed. However, interventions to address the disparity between individuals with and without SMI was clearly cited as an important need, both by KIs and in the literature.58 Indeed, the literature establishes overall decreased life expectancy (in some studies up to 25 years) for individuals with SMI,58,84 in comparison to the general population, and the American Psychiatric Association (APA) has now released a position statement on the role of psychiatrists in reducing physical health disparities.85,86
Only one study compared findings in a SMI disparity group with patients in the SMI majority group (white race, not low income). Therefore, we have virtually no information concerning whether the available interventions that improved outcomes did so to a sufficient degree to equalize groups. We also cannot know if the tested approaches (such as additional support and ancillary services) might be useful for larger groups of the SMI population.
Future Areas of Research
The gaps in the evidence base noted above provide a framework for potential areas of future research. In terms of disparity groups, the gaps highlight the need for interventions focused on the LGBT and elderly SMI populations, in addition to research within specific racial/ethnic minorities. As data from the newly released 2014 National Survey on Drug Use and Health are further analyzed, we will have more current estimates of racial/ethnic differences in mental health service use to further characterize specific areas of need. More diversity of studied interventions is also called for, such as examining the effectiveness of peer-based interventions in reducing disparities among individuals with SMI70 and the use of culturally informed behavioral intervention technologies (i.e., Web sites, virtual reality, and mobile-based applications).87 Furthermore, given preliminary effectiveness data for particular types of interventions, additional research focused on telepsychiatry, collaborative care, and culturally adapted therapies, across the diagnostic spectrum, within the SMI population (i.e., telepsychiatry for not only depressive and anxiety disorders, but also psychotic disorders) is warranted.
The identified gaps also emphasize the need for additional research along the continuum of health care outcomes, particularly in access to health care coverage and accurate diagnostic evaluation. In the future, we can assume that health care reform (broadly understood) and health insurance (more particularly focused on employer-based insurance, Medicare, Medicaid, and the Patient Portability and Affordable Care Act) will be active areas of research. Some studies on these topics might well address various kinds of disparities or mental health population groups defined either by specific SMI diagnosis or by sociodemographic characteristics. Moreover, KIs mentioned additional projects related to homelessness and disability that have yet to appear in the literature. One example is the SOAR initiative of the North Carolina Coalition to End Homelessness (the SSI/SSDI Outreach, Access and Recovery program of SAMHSA). It is intended to help individuals who are homeless and disabled by their mental health condition to obtain disability benefits (http://www.ncceh.org/ncsoar/).
In addition to future research suggested by evidence gaps, the literature specifically identified areas for future research. Some of these ideas overlapped with those pointed out by our KIs. Examples include the need to study larger samples of minority elderly patients with SMI, in terms of both examining comparative effectiveness of psychotherapy versus pharmacotherapy,25 and engaging elderly people with very low incomes who do not have basic services such as transportation or telephones.88 Many articles echoed the need for studies of all disparity groups with larger, more representative samples, over longer time periods, and in various settings, both in terms of geography and clinical setting type.25,27,33,41,77 Other investigators mentioned the need for RCTs of various interventions, rather than other, less rigorous study designs,57 even though some authors noted the difficulty of enrolling and retaining these patients in a trial.59 Yet others highlighted the importance of studies of cost-effectiveness of specific interventions.24,53 KIs and the literature mentioned some research projects currently under way that will hopefully shed additional light on these topics. One such project, the Cultural Formulation Interview Project,89,90 focuses on helping clinicians include cultural factors in their psychiatric assessments. This interview is, in fact, included in the emerging measures and models section of the DSM-V.91 KIs mentioned ongoing research in the use of interpreters (e.g., how interpreter services compare and contrast with bilingual clinicians) and the use of video interpretation. Another study protocol identified in the literature describes a collaborative planning intervention to improve the physical health of Latino individuals with SMI who are at risk for cardiovascular disease.73 KIs also mentioned the development of mobile behavioral health technologies that have yet to be formally studied.
For all areas of future research, it is important to consider whether the correct outcomes have been measured in existing research and which outcomes should be addressed going forward. Housing outcomes were well represented in the literature included in this Technical Brief, as well as health care service use; adherence to treatment, including medication; and various measures of symptom reduction. There was also some mention of cost and quality of life outcomes. With the exception of the PCARE study,58 there were no studies included in the literature that examined physical health outcomes, which is an important need for the SMI population. Thus, in general, the correct outcomes are being measured with simply a need for more of the same and an increased focus on physical health outcomes, including mortality. However, it is worth noting that experts in mental health disparities research have also recommended involving multiple stakeholders when determining the most important outcomes for future research, including consumers.92
Implications and Next Steps
The findings of this Technical Brief point to several next steps for the research community, policymakers, and patient advocates.
1. Establish a consistent definition of SMI across stakeholders to facilitate future research
As mentioned previously, we used a broad definition of SMI, based on the intent of the topic nominator. Thus, we included a wide range of diagnostic categories and range of severity—from dysthymia (as a milder form of depression) or anxiety to bipolar or psychotic disorders. Even with such a broad scope, we identified relatively few interventions, and there is not yet a large enough body of evidence to allow for assessments of comparative effectiveness. Given the fact that there are several different definitions of SMI in use, the first logical step in conducting future research would be to reach a consensus definition for SMI across stakeholders so that studies will be homogeneous enough to be considered replications, allowing for meaningful comparisons and combined results through meta-analyses. Including the degree of functional impairment in the definition of SMI would be useful (as some definitions currently do), given that it would be presumably correlated with both direct and indirect costs to both the individual and society. It is worth noting, however, that the higher the degree of impairment, the more a sample would be composed of individuals with lower income and public health insurance, by virtue of having more individuals meeting Federal criteria for disability. In addition, obtaining a consensus definition across a broad range of stakeholders, one that includes not only researchers but also consumers and patient advocates, is necessary for wide and successful implementation of interventions once proven effective in smaller study samples.
2. Consider whether SMI is a disparity group in and of itself and how this affects future study design
Indeed, SMI may be a particularly large health disparity (in the United States) given the stark data showing reduced life expectancy. As further support for this concept, a 2015 meta-analysis estimated that approximately 8 million deaths worldwide each year are attributable to mental disorders.93 Unfortunately, although there is general agreement that there is a large mortality gap between individuals with SMI and the general population, the distribution based on race, ethnicity, or other disparity groups within the SMI population is not yet clear. Nonetheless, such information is sorely needed to design interventions so that they have the greatest effect on reducing the mortality gap.
3. Conduct more disparity research in mental health
The findings of this Technical Brief make it abundantly clear that more funding needs to be allocated to disparity research in the area of mental health. Many promising interventions exist, such as collaborative care, telepsychiatry, and various case management strategies and therapies. However, there is still an overall paucity of interventions to reduce disparities among individuals with SMI. Furthermore, some groups, such as the LGBT population, and some points along the health care continuum, such as access to accurate diagnosis, have been left out completely. Moreover, despite clear evidence that disparities exist, there is a lack of research comparing SMI disparity groups directly to the majority group to determine whether interventions equalize the two groups. There is a need for all of these questions to be answered. This research can be accomplished by conducting more primary studies of different interventions across disparity and diagnostic groups or by conducting large enough studies of general SMI interventions to allow for disparity group sub-analyses. Ideally, future research would comprise some combination of both approaches.
Conclusions
We sought to identify promising interventions that would improve access, quality, and outcomes among individuals with SMI who, because of their demographic characteristics, are at greater risk for poorer outcomes than others with SMI. We found a number of promising interventions mainly focused on economically disadvantaged individuals, including homeless individuals and racial or ethnic minority disparity groups. Depressive and psychotic disorders are the most targeted diagnoses in the interventions seeking to address disparities in SMI.
The most salient intervention enhancements included the use of collaborative care; intensive case management approaches, such as CTI and ACT; and specific culturally adapted therapies, including those involving families of individuals with SMI. Telepsychiatry also appears to be a promising intervention, and there is ongoing research in this area as well as other behavioral health technologies, which will hopefully enhance access and adherence to treatment. However, we did not find that these types of interventions were widely applied across groups, and many gaps remain, both in terms of the diversity of disparity groups (particularly individuals who identify as LGBT and the elderly) and approaches that were considered.
- Description of Interventions to Reduce Disparities Among SMI Groups
- Context of Interventions to Reduce Disparities Among SMI Groups
- Current Evidence About the Effectiveness (or Comparative Effectiveness) of Interventions
- Summary and Implications
- Limitations of the Technical Brief
- Future Areas of Research
- Implications and Next Steps
- Conclusions
- Disparities Within Serious Mental IllnessDisparities Within Serious Mental Illness
- Findings - Disparities Within Serious Mental IllnessFindings - Disparities Within Serious Mental Illness
- Health Information ExchangeHealth Information Exchange
- Models of Cancer Survivorship CareModels of Cancer Survivorship Care
- The Empirical Evidence of Bias in Trials Measuring Treatment DifferencesThe Empirical Evidence of Bias in Trials Measuring Treatment Differences
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