Mental/Behavioral Health

• Blacks and Hispanics are less likely than whites to seek treatment for mental health problems.

  Researchers used 2001-2004 Medical Expenditure Panel Survey data to explore why minorities seek mental health services less frequently than whites. Just 7 percent of those surveyed reported fair or poor mental health, and whites were more likely than blacks to associate their mental symptoms with their mental health status. According to the authors, this finding suggests that the gap between whites, blacks, and Hispanics using mental health services likely reflects underuse by minorities and not overuse by whites.

  Source: Zuvekas and Fleishman, Medical Care 46(9):915-923, 2008 (AHRQ Publication No. 09-R007)* (Intramural).

• Racial disparities affect physician-patient communication about mental health problems.

  This study involved primary care visits made by 46 white and 62 black nonelderly adults with symptoms of depression who were seen by physicians in urban community-based practices. Communication about depression occurred in only about one-third of the visits (43 percent of white visits and 27 percent of black visits). Black patients were less likely than white patients to talk about their depression (11 vs. 38 statements, respectively). Also, physicians made fewer rapport-building statements during visits with black patients (21 statements) than during visits with white patients (30 statements). Even in visits where communication about depression occurred, physicians considered fewer black (67 percent) than white (93 percent) patients as suffering significant emotional distress.

  Source: Ghods, Roter, Ford, et al., J Gen Intern Med 23(5):600-606, 2008 (AHRQ grant HS13645).

• Certain types of therapy are more effective for minority youth with psychosocial problems.

  This review of the evidence found that psychotherapy is moderately effective for many mental health problems experienced by minority youth, although some treatments seem to work better than others. For example, multisystemic therapy is the only therapy shown to reduce criminal offending among black delinquent youths. It is delivered in the young person's home or school by specially trained therapists. Cognitive behavioral therapy and individual psychotherapy are preferable when treating depression in Latino adolescents. Ethnic minority youths seem to respond best to treatments that are highly structured, time-limited, pragmatic, and goal-oriented, note the researchers.

  Source: Huey and Polo, J Clin Child Adolesc Psychol 37(1):262-301, 2008 (AHRQ grant HS10870).

• Underserved blacks and Hispanics with depression often use alternative medicine for their symptoms.

  This study involved data on 315 patients with depression from two outpatient primary care clinics in Los Angeles; 66 percent of the patients were Hispanic, and 20 percent were black. Nearly 60 percent of the patients reported using complementary and alternative medicine (CAM) to manage their symptoms sometimes, and 24 percent used it often. Lack of health insurance was one of the strongest predictors of CAM use. These findings suggest that CAM use among underserved minority individuals may serve as a substitute for conventional care when access to care is limited or unavailable, note the researchers.

  Source: Bazargan, Ani, Hindman, et al., J Altern Complement Med 14(5):537-544, 2008. See also Bazargan, Norris, Bazargan-Hejazi, et al., Ethn Dis 15:531-539, 2005 (AHRQ grant HS14022).

• Serious mood disorders may be underdiagnosed and undertreated among low-income blacks.

  Nearly all adults who commit suicide suffer from major psychiatric illness, predominantly serious mood disorders such as bipolar disorder. Researchers examined the medical records of adults enrolled in Tennessee's Medicaid program who had committed suicide between 1986 and 2004, including their use of antidepressants in the year prior to their suicide. Overall, 29 percent of blacks had filled an antidepressant prescription, compared with 51 percent of whites. Blacks who successfully committed suicide were younger than whites (mean age of 33 vs. 42 years, respectively) and were more likely to live in urban areas and low-income neighborhoods.

  Source: Ray, Hall, and Meador, Psychiatr Serv 58(10):1317-1323, 2007 (AHRQ grant HS10384).

• Study raises concern about the quality of mental health care for blacks covered by Medicaid.

  In this study of four State Medicaid programs, blacks who suffered from both depression and diabetes were less likely to be treated for their depression than whites (68 vs. 75 percent, respectively), and if treated, they were more likely than whites with the same conditions to receive older tricyclic antidepressants (TCAs) instead of newer selective serotonin reuptake inhibitors (SSRIs). TCAs may adversely alter blood sugar control, while SSRIs are less likely to do so. These findings raise concern about timely and equitable diffusion of newer, more effective treatments and racial differences in the quality of mental health care.

  Source: Sambamoorthi, Olfson, Wei, and Crystal, J Health Care Poor Underserved 17:141-161, 2006 (AHRQ grant HS09566).

• Family income and parents' behavior are related to the social well-being of black and Latino children.

  This study of low-income black and Latino families in San Francisco found that parental depression, single parent households, and more use of physical discipline (e.g., spanking) were significantly related to lower physical, emotional, and social well-being among their children. Parents of 196 black and Latino children aged 1 to 5 years who attended a nurse-managed primary care clinic were surveyed about discipline, nurturing, and expectations. Both groups of parents reported low use of discipline, high amounts of nurturing, and low rates of depressive symptoms. Children's higher functional status was significantly related to higher family income and more nurturing. Lower functional status was significantly related to having only one parent, more use of physical discipline, and increased parental depressive symptoms.

  Source: Wong, J Pediatr Nurs 21(6):434-442, 2006 (AHRQ grant HS10004).

• Researchers find a link between depression and cognitive decline in elderly Mexican Americans.

  Researchers followed a group of 2,812 Mexican Americans age 65 and older over a 7-year period to identify any links between depressive symptoms and cognitive decline. They found that individuals with depressive symptoms at baseline had a greater decline in cognitive skills over the 7-year period compared with those who did not have depression. The link was independent of age, sex, education, baseline cognitive score, limitations in activities of daily living, diabetes, stroke, heart attack, and vision impairment.

  Source: Raji, Reyes-Ortiz, Kuo, et al., J Geriatr Psychiatr Neurol 20(3):145-152, 2007 (AHRQ grant HS11618).

• Study examines racial and ethnic differences in mental health and use of mental health services.

  Researchers used 2001-2003 survey data on 134,875 individuals to compare the occurrence of mental health problems and use of mental health services among white, black, Hispanic, Asian, and American Indian/Alaska Native adults. They found that American Indian/Alaska Natives and multiracial respondents used mental health care at rates similar to whites, despite having worse mental health status. Blacks, Asians, and Hispanics used mental health care services at significantly lower rates than whites, with less than 10 percent in each group reporting use of mental health care in the preceding year. American Indians and Alaska Natives reported substantially higher rates of unmet need for mental health care compared with whites (33 vs. 18 percent and 63 vs. 35 percent, respectively).

  Source: Harris, Edlund, and Larson, Med Care 43(8):775-784, 2005 (AHRQ Publication No. 05-R064)* (Intramural).

• Post-traumatic stress disorder disproportionately affects American Indian Vietnam War veterans.

  Researchers interviewed 591 men who participated in the American Indian Vietnam Veterans Project to examine factors related to post-traumatic stress disorder (PTSD) in American Indians and found that those with childhood conduct disorder (CD)—threatening or assaulting others, cruelty to animals, willfully destroying property, repeatedly running away from home—had more PTSD symptoms than those without CD. American Indian veterans were more likely than others to have been alcohol- and/or drug-dependent prior to military service.

  Source: Dillard, Jacobsen, Ramsey, and Manson, J Trauma Stress 20(1):53-62, 2007 (AHRQ grant HS10854).

• Chinese and Vietnamese Americans report widespread use of complementary and alternative medicine therapies.

  Researchers surveyed 3,258 Chinese and Vietnamese American patients who visited 11 community health centers in 8 major U.S. cities to examine use of complementary and alternative medicine (CAM) therapies. Nearly 90 percent of those surveyed spoke little or no English. Two-thirds of survey respondents reported that they had used some form of CAM therapy in the past, and 10 to 18 percent had used CAM therapy in the week before their most recent health center visit. Chinese Americans most commonly used herbal medicine and acupuncture, while Vietnamese Americans most often used coining (rubbing a coin and menthol oil on a patient's spine and ribs), massage, and cupping (use of cups to apply suction to the skin by means of heat).

  Source: Ahn, Ngo-Metzger, Legedza, et al., Am J Public Health 96(2):647-653, 2006 (AHRQ grant HS10316).

• White children are about twice as likely to use stimulants as black and Hispanic children.

  Stimulant medications are typically prescribed for children with attention-deficit/ hyperactivity disorder (ADHD) to manage core symptoms such as impulsive behavior, restlessness and inability to focus attention. This study of stimulant use among children involved an analysis of Medical Expenditure Panel Survey (MEPS) data for children aged 5-17 for the period 2000 to 2002. Overall, at least one stimulant medication was purchased for 5.1 percent of white children, 2.8 percent of black children, and 2.1 percent of Hispanic children. Factors such as health insurance, health status, and access to care explained some, but not all, of the racial/ethnic differences in stimulant use.

  Source: Hudson, Miller, and Kirby, Med Care 45(11):1068-1075, 2007 (AHRQ Publication No. 08-R044)* (Intramural).

• Simple techniques can be used to promote physical activity among sedentary American Indians.

  Studies of geographically diverse American Indian tribes consistently show low levels of physical activity and a sedentary lifestyle, putting them at increased risk for several chronic illnesses. These researchers randomly divided 125 older (ages 50-74) American Indians into two groups. The first group received basic instruction in daily physical activity monitoring, and the second group received instruction plus a pedometer to track and record their total daily steps. At the end of the 6-week study, participant fitness was measured in a 6-minute walk test; both groups showed increases in walking frequency. Adding a pedometer did not promote an increase in physical activity scores. The researchers suggest that the act of self-monitoring may be sufficient on its own, since it can raise awareness of modifiable health habits and thus promote increased physical activity.

  Source: Sawchuk, Charles, Wen, et al., Prev Med 47:89-94, 2008. See also Garroutte, Sarkisian, Arguelles, et al., J Gen Intern Med 21:111-116, 2006 (AHRQ grant HS10854).

• Study examines link between trauma and alcohol problems among American Indians.

  Researchers conducted interviews with 432 American Indian adolescents and young adults aged 15-24 who lived on or near two closely related Northern Plains Indian reservations. As part of a larger survey on mental health, participants were asked about their use of alcohol and whether they had experienced any of 16 types of traumatic events. More than one-fourth of participants were diagnosed with alcohol use disorders. Overall, 21 percent had experienced one traumatic event, 10 percent had experienced two such events, and 16 percent had experienced three or more events. The odds for alcohol use disorders increased from nearly two-fold for one trauma to somewhat less than four-fold for three or more traumas compared with no trauma.

  Source: Boyd-Ball, Manson, Noonan, and Beals, J Traum Stress 19(6):937-947, 2006 (AHRQ grant HS10854). See also Manson, Beals, Klein, et al., Am J Public Health 95(5):851-859, 2005 (AHRQ grant HS10854).

• American Indians are more likely to smoke than other Americans, but smoking patterns vary from one tribe to another.

  This study of Southwest and Northern Plains American Indians aged 15 to 54 found that about half of Northern Plains men and women were current smokers, while only about 20 percent of Southwest men and 10 percent of Southwest women were smokers. Men and younger people were more likely to smoke in the Southwest tribe but not in the Northwest tribe, and alcohol consumption was strongly associated with smoking in both groups. Although the study did not examine the use of tobacco for ceremonial purposes, the Northern Plains tribe bases a large part of its spiritual philosophy around the concept of the "sacred pipe," much more so than the Southwest tribe. Thus, the considerable differences between the two groups in smoking patterns could have a strong cultural basis.

  Source: Nez Henderson, Jacobsen, Beals, and the AI-SUPERPFP Team, Am J Public Health 95(5):867-872, 2005 (AHRQ grant HS10854).

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Pregnancy, Childbirth, and Birth Outcomes

• Degree of acculturation affects likelihood of breastfeeding among Hispanic women.

  Although Hispanic and white mothers in the United States breastfeed at about the same rate, more acculturated Hispanic mothers have lower rates of breastfeeding than their less acculturated counterparts. These researchers went one step further and linked higher acculturation with lower odds of exclusive breastfeeding by Hispanic women. They examined medical record data for 1,635 low-income, low-risk women at one birth center and found that Hispanic women in the low acculturation group (Spanish-speaking) were 36 percent more likely (and white women were 49 percent more likely) than Hispanic women in the high acculturation group (English-speaking) to breastfeed exclusively at hospital discharge.

  Source: Gorman, Madlensky, Jackson, et al., Birth 34(4):308-315, 2007. See also Zlot, Jackson, and Korenbrot, Matern Child Health J 9(1):11-20, 2005 (AHRQ grant HS07161).

• Black women are more likely than other women to have complications during pregnancy and after delivery.

  Black women suffer from more pregnancy and childbirth complications—ranging from pregnancy-induced high blood pressure, gestational diabetes, and preterm labor to infection and hemorrhage—than white, Hispanic, and Asian/Pacific Islander women, according to this study. Infection, gestational diabetes, and high blood pressure are the most preventable of these complications, according to the researchers. They examined racial disparities in adverse maternal outcomes among the four groups of women using data on a national sample of hospital discharges for more than 1 million women aged 13 to 55 who delivered babies in 1998 and 1999. Black women had a higher risk of having 10 of 11 maternal perinatal complications compared with white women, including preterm labor and membrane disorders.

  Source: Shen, Tymkow, and MacMullen, Ethn Dis 15:492-497, 2005 (AHRQ grant HS13056).

• Black women's choice of hospital to give birth may contribute to racial disparities in neonatal deaths.

  Black infants in the United States are more than twice as likely to die as white infants during the first month of life (neonatal period). According to this study of records for all live births and deaths of very low birthweight (VLBW) infants born in 45 hospitals in New York City over a 6-year period (1996-2001), choice of birth hospital had a significant effect on the survival of these fragile newborns. Neonatal mortality rates for infants in this study ranged from 9.6 to 27.2 deaths per 1,000 births. VLBW white infants were more likely to be born in hospitals ranked in the lowest third for neonatal mortality (49 percent), compared with VLBW black infants (29 percent). If black women had delivered in these lower risk hospitals, mortality rates would have been reduced by 6.7 deaths per 1,000 VLBW births, eliminating more than one-third of the black/white disparity in VLBW neonatal mortality rates in New York City.

  Source: Howell, Hebert, Chatterjee, et al., Pediatrics 121(3):e407-e415, 2008 (AHRQ grant HS10859).

• Risk for neonatal jaundice varies by the newborn's race/ethnicity.

  Among all newborns, blacks are at the lowest risk for neonatal jaundice, and American Indian and Asian newborns are at highest risk. Mothers often mark a baby's race as black on the birth record when in fact the baby is multiracial, which may lead the doctor to underestimate the baby's risk of developing jaundice. Researchers examined the classification of infants' race entered into the medical record for 3,012 infants born at a single hospital between January 2001 and October 2002 and found that when given one choice in medical record forms, mothers of multiracial infants overselected black as their newborns' race.

  Source: Beal, Chou, Palmer, et al., Pediatrics 117(5):1618-1625, 2006 (AHRQ grant HS09782).

• Pregnant Latinas who experience intimate partner violence often suffer from depression.

  Researchers surveyed 210 Hispanic women who were pregnant about intimate partner violence, strength (e.g., social support, coping strategies), adverse social behavior (e.g., alcohol and/or tobacco use), depression, and post-traumatic stress disorder (PTSD). More than 40 percent of the women reported intimate partner abuse, including physical, emotional, or sexual abuse. All of the women reported similar levels of mastery (being in control of their lives), but social support was lower for the 92 women who reported abuse, as well as social undermining by their partner (anger, criticism, insults) and stress. Women who were abused were more likely than women who were not to be depressed or have PTSD.

  Source: Rodriguez, Heilemann, Fielder, et al., Ann Fam Med 6(1):44-52, 2008 (AHRQ grant HS11104).

• A woman's race, education, income, and social status all interact to affect her health during pregnancy.

  Researchers studied 1,802 ethnically diverse, healthy women receiving prenatal care at six San Francisco Bay area delivery sites. Differences by race/ethnicity were pronounced, with whites and Asians doing better on all measures. More Hispanic and black women were in the lower economic and educational strata, and they reported worse physical functioning than white and Asian women. After adding socioeconomic status variables to the mix, racial disparities in depression remained for all minority groups, and disparities in self-rated health remained for Asians.

  Source: Stewart, Dean, Gregorich, et al., J Health Psychol 12(2):285-3000, 2007 (AHRQ grant HS10856).

• Both maternal and paternal ethnicity affect risk of preeclampsia.

  Researchers examined outcomes for 127,544 women at low risk for preeclampsia who delivered babies from 1995 to 1999 within a managed care organization and calculated rates of preeclampsia based on maternal, paternal, and combined ethnicity. Overall, about 4 percent of the women were diagnosed with preeclampsia. Baseline rates of preeclampsia were 5.2 percent for black women, 4 percent for Hispanic women, 3.9 percent for American Indian women, 3.8 percent for white women, and 3.5 percent for Asian women. When paternal ethnicity was taken into account separately, the effect of black maternal ethnicity increased slightly, while the difference in the rate of preeclampsia for Asian women disappeared. Asian paternity was found to be associated with the lowest rate of preeclampsia. Furthermore, when the mother and father had different ethnicities, there was a 13 percent increase in the rate of preeclampsia.

  Source: Caughey, Stotland, Washington, and Escobar, Obstet Gynecol 106(1):156-161, 2005 (AHRQ grant HS10856).

• Ectopic pregnancy rates in California are declining slowly for black women.

  Overall, rates of ectopic pregnancy are declining in California. Black women have the highest rate of ectopic pregnancy in that State, and the rate of decline is slower for them than for women of other races. Researchers evaluated State-level trends in ectopic pregnancy rates for 62,829 women who were hospitalized for ectopic pregnancy from 1991 to 2000. Black women aged 35 to 44 had the highest rate of ectopic pregnancy (43.1 per 1,000 pregnancies), a rate that is comparable to that of women in developing African nations. The researchers note that a higher incidence of sexually transmitted diseases and previous ectopic pregnancy—both major risk factors for ectopic pregnancy—continue to affect black women disproportionately.

  Source: Calderon, Shaheen, Pan, et al., Ethn Dis 15(Suppl 5):20-24, 2005 (AHRQ grant HS10858).

• Compared with white women, Hispanic women have similar or better birth outcomes, but black women are more likely to have poor outcomes.

  Researchers analyzed pregnancy outcomes of 10,755 Medicaid-insured women who gave birth at Duke University Medical Center between 1994 and 2004. They found that Hispanic women were 34 percent less likely to have preterm births than white women, but black women had higher rates of preterm birth, small-for-gestational age infants, preeclampsia, and stillbirths. Also, black women, who generally were younger, were more likely than white women to have another medical condition while pregnant, to remain in the hospital for more than 4 days, and to have hospital charges over $7,500.

  Source: Brown, Chireau, Jallah, and Howard, Am J Obstet Gynecol 197:e1-e7 (AHRQ grant HS13353).

• Adverse outcomes are more likely in pregnant women with asthma, particularly minority women.

  In this study of 13,900 pregnant women with asthma, minority women had significantly higher rates of preterm labor, gestational diabetes, and infection of the amniotic cavity than white women. Black women had the highest incidence of preterm labor (5.5 percent) and pregnancy-induced high blood pressure (5 percent), while Asian/Pacific Islander women had more gestational diabetes (7.2 percent) and were more than three times as likely as white women to have infection of the amniotic cavity (5.7 vs. 1.8 percent, respectively). Black and Hispanic women also had more infections of the amniotic cavity than white women (3.1 and 2.7 vs. 1.8 percent, respectively).

  Source: MacMullen, Tymkow, and Shen, Am J Matern Child Nurs 31(4):263-268, 2006 (AHRQ grant HS13506). See also Carroll, Griffin, Gebretsadik, et al., Obstet Gynecol 106(1):66-72, 2005 (AHRQ grant HS10384).

• Very low birthweight babies treated at minority-serving hospitals have elevated death rates.

  Researchers analyzed the medical records of 74,050 black and white very low birthweight (VLBW) infants treated at 332 hospitals. They defined hospitals where more than 35 percent of VLBW infants were black as minority-serving hospitals. Both black and white VLB babies were more likely to die at minority-serving hospitals than at hospitals where less than 15 percent of such infants were black, even though the hospitals treated similarly ill infants.

  Source: Morales, Staiger, Horbar, et al., Am J Public Health 95(12):2206-2212, 2005 (AHRQ grant HS10858).

• Black and Hispanic mothers are more likely than white mothers to have early postpartum depression.

  In this survey of 655 white, black, and Hispanic mothers between 2 and 6 weeks after childbirth, 47 percent of Hispanic mothers and 45 percent of black mothers reported depressive symptoms, compared with about 31 percent of white mothers. These differences persisted even after adjustments were made for demographic, personal, and situational factors (e.g., infant with colic). Despite these racial differences in depression prevalence, the burden of physical symptoms, lack of social support, and lack of self-confidence in infant care were independently associated with postpartum depression among all of the women.

  Source: Howell, Mora, Horowitz, and Leventhal, Obstet Gynecol 105(6):1442-1450, 2005 (AHRQ grant HS09698).

• Many low-income black women are dissatisfied with their post-pregnancy body size.

  According to this study, three-fourths of low-income black women are dissatisfied with their body image 6 months after giving birth. More than half of the women thought that they were too large, and one-fifth thought that they were too small and wanted to gain weight. The researchers used a culturally sensitive rating scale to examine body perceptions among black women at four inner city clinics at 2 and 6 months postpartum. At 6 months postpartum, about 40 percent of the women thought that they had equaled or exceeded the size of a typical woman their age, which most considered to be larger than what usually would be considered healthy.

  Source: Boyington, Johnson, and Carter-Edwards, J Obstet Gynecol Neonat Nurs 36(2):144-151, 2007 (AHRQ grant HS13353).

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Preventive Services

• Culturally appropriate interventions raise flu and pneumonia vaccination rates at inner-city health centers.

  Researchers undertook a 4-year trial involving predominantly minority and economically disadvantaged patients older than age 50 using proven, culturally appropriate interventions at four inner-city health centers and compared the results with another center that received no intervention (the control). Over the 4-year trial, annual flu vaccination rates increased from 27 percent to 49 percent at the intervention sites, while the control site continued to have low rates of vaccination (20 percent). Intervention sites also increased use of pneumonia vaccinations, from 48 percent to 81 percent in patients aged 65 and older. Increases in vaccination rates were observed among white and Hispanic patients.

  Source: Nowalk, Zimmerman, Lin, et al., J Am Geriatr Soc 56(7):1177-1182, 2008 (AHRQ grant HS10864).

• Poverty-related factors underlie racial disparities in receipt of preventive care.

  Researchers analyzed 1998-2002 Medicare claims data on receipt of five preventive care services: colorectal cancer testing, influenza vaccination, cholesterol screening, mammography, and cervical cancer screening. They found that black and Hispanic individuals had lower rates of claims for each of the five preventive services, compared with whites, and that poverty-related factors—such as lack of insurance and low income and education—seemed to underlie more of the disparity than fewer primary care

  visits as suggested in previous studies.

  Source: Fiscella and Holt, J Am Board Fam Med 20(6):587-597, 2007 (AHRQ grant HS13173).

• Racial/ethnic differences in use of preventive services vary when self-reports are compared with claims data.

  Researchers found that with the exception of prostate-specific antigen (PSA) testing for prostate cancer, racial/ethnic disparities in use of preventive procedures were generally larger when using Medicare claims data than when using elderly patients' self-report. They analyzed self-report and matching 1999-2002 claims data for Medicare beneficiaries for six preventive procedures: PSA testing, flu vaccination, Pap testing, cholesterol testing, mammography, and colorectal cancer screening. Minorities were more likely than whites to self-report preventive procedures in the absence of billing claims. For Pap testing, some minority beneficiaries were up to twice as likely as whites to report Pap smear testing in the absence of claims.

  Source: Fiscella, Holt, Meldrum, and Franks, BMC Health Serv Res 6(122); online at www.biomedcentral.com (AHRQ grant HS13173).

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