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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.)

Cover of Disparities Within Serious Mental Illness

Disparities Within Serious Mental Illness [Internet].

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Serious mental illness (SMI) commonly refers to a diagnosis of psychotic disorders, bipolar disorder, and either major depression with psychotic symptoms or treatment-resistant depression; SMI can also include anxiety disorders, eating disorders, and personality disorders, if the degree of functional impairment is severe.1,2 SMIs are long-term illnesses involving substantial functional impairment over multiple symptom domains. These impairments often lead to an inability to maintain gainful employment, poor social support, repeated psychiatric hospitalizations, homelessness, incarceration, and coexisting substance use disorders.

The prevalence of SMI and morbidity from these illnesses in the United States is striking. Rates of SMI for adults range from 4 percent to 6 percent, affecting more than 11 million adults.3,4 Furthermore, SMI is frequently under- or misdiagnosed or undertreated, and many people with an SMI receive no treatment at all. Among adults with an SMI in 2008, less than 60 percent had used mental health services in the previous year, and only 40 percent had used any outpatient health care services.5

Individuals with SMI often experience disparities in health care, specifically differences or gaps in care compared with patient populations with a mental health diagnosis but without a diagnosis of SMI.6 Such disparities may be even more pronounced in certain groups of patients with SMI. Such groups include minority race or ethnicity, gender, economic disadvantage (including housing instability and low socioeconomic status), and geographic location (chiefly rural 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). We focus on these disparity groups in this report. In describing Hispanic or Latino individuals included in specific studies, we used the terminology favored by the study author.

Research has provided empirical support for variation in how patients from diverse ethnic and racial backgrounds interpret and define SMI.7 Studies have illustrated the complex and sometimes overlapping relationship among different groups in regard to disparities; for example, a study found that African-American and Hispanic SMI clients were less likely to travel as far for treatment as white patients.8 The Substance Abuse and Mental Health Services Administration (SAMHSA) recently published a report on racial and ethnic difference in mental health service use among adults, highlighting the persistence of disparities in SMI patients' access and receipt of such services; the report highlights findings such as the greater prevalence of inpatient mental health services among African-American adults (1.4 percent) compared with white adults (0.7 percent).9

Considering how to reduce these disparities effectively at each stage of care is crucial for optimizing care for patients with SMI who often have complex and chronic treatment needs. These differences or gaps in care between groups reflect inefficiencies in the health care system and can pose substantial economic burdens on the health care system as a whole.10

Although disparities in access to needed care exist between patient populations with and without SMI, the focus of this Technical Brief is limited to disparities among groups within the SMI population. For example, among Medicaid beneficiaries with schizophrenia, the quality of mental health care differs among white, African-American, and Hispanic or Latino patients. A measure of quality of care, incorporating indicators of pharmacological, psychosocial, and health services utilization, was lowest for African-American patients in all states and was lower for Latino than white patients in three of the four states sampled.11 Appropriate use of atypical antipsychotics by veterans with schizophrenia differs by race.12 Individuals who lived in rural geographic areas had higher death rates from suicide than those who resided in large fringe metropolitan areas (suburbs) from 2008 to 2011, based on a 2013 National Health Care Disparities Report from the Agency for Healthcare Research and Quality (AHRQ).13 Research related to mental health care among individuals identifying as LGBT is limited, but gaining a greater understanding is important because this population experiences higher rates of mood and anxiety disorders and suicidal ideation and behavior.14,15

This Technical Brief stems from important perceptions by clinicians, patients, and families that disparities can occur at multiple points along the health care continuum.16 Concerns include access to affordable health insurance that includes coverage for needed treatments; receiving accurate diagnosis of the SMI; receiving appropriate, standard-of-care therapies for the SMI as well as access to adequate health care generally; and adequate monitoring of the SMI through both short- and long-term followup.

The American Psychological Association highlights that lack of access to mental health care is quite pronounced in various racial groups.17 For example, research has found that barriers to care for ethnic minorities include a lack of insurance, distrust of care providers, and racism by providers.18 Moreover, disparities in the quality of care (both processes and end results of care) (i.e., differences in health care services available to SMI patients or in the outcomes of those services) are often related to racial, ethnic, geographic, and socioeconomic differences. A study comparing African-American with white inpatients in state psychiatric hospitals found a higher percentage of African-American inpatients diagnosed with schizophrenia.19 Other research has explored the contributory effects of setting in the over diagnosis of African-American patients.20

Adherence to treatment over the long term and various outcomes of care, which can include, but would not be limited to, remission of the disorder, symptom relapse, physical health and functioning, broader quality-of-life domains, and satisfaction with care, are other points along the continuum of interest. Complicating this topic are a wide range of challenges that individuals with SMI may be facing: housing stability, social support, clinical engagement, criminal justice involvement, suicidality and other self-injurious behaviors, and homicide and other aggressive behaviors.

Although interventions have been studied to address these disparities along the health care continuum within the SMI population, findings describing their effectiveness (or comparative effectiveness) across studies have not been previously gathered in one report. The topic emerged from a priority listing developed through an Agency for Healthcare Research and Quality (AHRQ) Issues Exploration Forum that the RTI International–University of North Carolina Evidence-based Practice Center conducted early in the fourth round of AHRQ's EPC program.21 An individual made the nomination of this topic on behalf of the National Alliance for Mental Illness, Urban Los Angeles Affiliate, via the Web as a followup to participation in the Issues Explorations Forum discussion. The nominator of this topic seeks to identify solutions to promote equal access to diagnosis and treatment and to improve the quality of care and outcomes for SMI patients, within the specified disparity groups.

Thus, the primary goal of this Technical Brief is to describe the literature addressing the effectiveness of interventions to reduce disparities among patients with SMI in these important groups. We aim to identify and summarize issues about interventions to reduce access and treatment disparities of the types noted above among specified groups with SMI. As a Technical Brief, however, this report does not attempt to be the definitive summary or synthesis of evidence on these matters, or interventions meant to address them, as one would expect in a full systematic review report. Rather, it describes and maps the available evidence and clarifies the gaps in the knowledge base.


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