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Cover of Disparities Within Serious Mental Illness

Disparities Within Serious Mental Illness

Technical Briefs, No. 25

Investigators: , MOP, , PhD, , MD, MPH, , MD, MPH, and , PhD, MSPH.

Author Information
Rockville (MD): Agency for Healthcare Research and Quality (US); .
Report No.: 16-EHC027-EF

Structured Abstract


Adults with serious mental illness (SMI) often experience gaps in access to needed health care compared with other populations. Such disparities may be even more pronounced between certain groups of patients with SMI, differing by race, ethnicity, gender, economic disadvantage (including housing stability) and socioeconomic status, and geographic location (chiefly, rural versus urban residence); disparities arise as well for individuals identifying as lesbian, gay, bisexual, and transgender (LGBT) and those who have difficulty communicating in English (because it is a second language).


The primary goal of this Technical Brief is to describe and review the effectiveness of interventions that address disparities among adult patients with SMI in these important groups.


We reviewed the published and gray literature and interviewed Key Informants (KIs) to address four Guiding Questions (GQs). The four refined GQs for this Technical Brief focus on the critical areas of concern in relation to mental health treatment disparities—access to health insurance with appropriate coverage for these SMI conditions, accurate diagnostic evaluations, receipt of necessary and appropriate therapeutic services, quality of the health services, adherence to treatment over the long term, and various outcomes of care. The principal focus for the first three GQs is a description of the interventions (GQ 1), the context in which they are implemented (GQ 2), and a description of the evidence about the effectiveness of the interventions (GQ 3); GQ 4 presents conclusions, examines the gaps in the knowledge base, and identifies high-priority needs for future research. We include interventions addressing diagnosis, access to, and quality of treatment and support services among disparity groups of adults with SMI.


We identified 42 descriptive articles meeting inclusion criteria for GQs 1, 2, and 4, plus 37 articles measuring intervention effectiveness reporting on 26 unique studies (GQ 3). For GQ 1, the goals of each intervention were related to the specific diagnosis and disparity group that the intervention was targeting. Increased service use and treatment adherence were the most common intervention goals. For GQ 2, settings involved primarily mental health specialists being colocated in nonpsychiatric locations. These were usually primary care, but sometimes they were obstetrics-gynecology clinics, perinatal health care settings, and community mental health entities.

For GQ 3, most interventions tested adding enhanced services to usual available care, including culturally adapted collaborative care or other therapies, integrated services, case management and telemedicine. We found no studies of interventions for individuals identifying as LGBT or focusing only on English as a second language, addressing access to health care coverage, or addressing diagnostic accuracy. We found one study of the elderly, a group that can be predicted to have a larger number of physical comorbidities and difficulties obtaining necessary care because of their SMI.


Future research should identify interventions that are effective in reducing disparities all along the health care continuum and determine whether such interventions are equally effective for particular groups within the SMI population. Many promising interventions focused on disadvantaged individuals, including homeless individuals and racial or ethnic minority disparity groups. Future research can include comparative findings between minority and majority group patients and subgroup analyses to evaluate effectiveness among different disparity groups.

Most interventions targeted depressive and psychotic disorders. The use of collaborative care, intensive case management approaches, such as the Critical Time Intervention (CTI) and Assertive Community Treatment (ACT), and specific culturally adapted therapies, including those involving families of individuals with SMI, were the most noticeable modifications to interventions, but were not widely applied across groups. Gaps persist both in terms of the diversity of disparity groups included in studies (particularly individuals who identify as LGBT and the elderly) and approaches considered.


Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1 . Contract No. 290-2015-00011-I, Prepared by: RTI International–University of North Carolina Evidence-based Practice Center, Research Triangle Park, NC

Suggested citation:

Swinson Evans T, Berkman N, Brown C, Gaynes B, Palmieri Weber R. Disparities Within Serious Mental Illness. Technical Brief No. 25. (Prepared by the RTI International–University of North Carolina Evidence-based Practice Center under Contract No. 290-2015-00011-I). AHRQ Publication No.16-EHC027-EF. Rockville, MD: Agency for Healthcare Research and Quality; May 2016.

This report is based on research conducted by the RTI International–University of North Carolina Evidence-based Practice Center under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2015-00011-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

None of the investigators have any affiliation or financial involvement that conflicts with the material presented in this report.

The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.

AHRQ or U.S. Department of Health and Human Services endorsement of any derivative products that may be developed from this report, such as clinical practice guidelines, other quality enhancement tools, or reimbursement or coverage policies may not be stated or implied.


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Bookshelf ID: NBK368427PMID: 27336120


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