Ethnic differences in the diagnosis of schizophrenia and mood disorders during admission to an academic safety-net psychiatric hospital
Introduction
Eliminating health disparities and achieving health equity among Americans is a major goal of Healthy People 2020 (U.S. Department of Health and Human Services [DHHS], 2018). Yet, compared with the majority population, members of ethnic minority groups in the U.S. are less likely to have access to and utilize outpatient mental health services (Wang et al., 2005), have a higher likelihood of hospitalization and emergency department visits (Samnaliev et al., 2009), and are more likely to receive lower quality care (Alegria et al., 2008). U.S. Hispanics, now the single largest minority group in the country, face unique mental health disparities (Safran et al., 2009). Compared to non-Hispanic whites, Hispanics have a lower lifetime risk of psychiatric disorders but a higher likelihood of persistent disorders (Breslau et al., 2005). Hispanics frequently experience longer delays in receiving mental health treatment and have higher levels of impairment once in treatment compared to non-Hispanic whites (DHHS, 2001). Language barriers among Spanish-speaking Hispanics with limited English proficiency (LEP) in the U.S. may impede access to mental health services, with as few as 8% of non-English speaking Hispanics receiving needed mental health services (Sentell et al., 2007).
Current healthcare standards require that all ethnic groups have access to quality mental health care that includes applying the same diagnostic assessment and treatment criteria (Minsky et al., 2003). However, psychiatric diagnostic measures developed in general population samples may not automatically apply to ethnic minority groups. Only a few studies have examined ethnic disparities in the diagnosis of psychiatric conditions with specific attention to Hispanic populations, and the results have been mixed. In a national study of U.S. veterans (n = 134,523), compared to non-Hispanic whites, Hispanics were 3.15 times more likely to be diagnosed with schizophrenia after controlling for patient need characteristics and illness severity (Blow et al., 2004). Another study found a greater likelihood to diagnose Hispanic males with schizophrenia and non-Hispanic white females with a mood disorder (Choi et al., 2012). In a large behavioral health system in New Jersey, Hispanics were found to be disproportionately diagnosed with major depressive disorder (MDD) rather than schizophrenia despite having higher levels of self-reported psychotic symptoms (Minsky et al., 2003). Challenges in diagnosing psychiatric conditions among Hispanics may be complicated by the higher rate of endorsement of psychotic symptoms compared to other ethnic groups (Kendler et al., 1996, Minsky et al., 2003, Olfson et al., 2002, Posternak and Zimmerman, 2005). Hispanics endorsing psychotic symptoms have not been found to consistently meet criteria for psychotic disorders when subjected to standardized diagnostic assessments (Minsky et al., 2003, Olfson et al., 2002). In fact, only a minority of Hispanics with psychotic symptoms were shown to meet full DSM-IV criteria for Schizophrenia in two regional studies (Geltman and Chang, 2004, Olfson et al., 2002). Additionally, a quarter of Hispanics with MDD report psychosis-like symptoms (Choi et al., 2012). Clinical factors such as co-occurring substance use have been associated with psychotic symptom endorsement among U.S. Hispanics (Lewis-Fernández et al., 2009, Minsky et al., 2003, Mueser and Butler, 1987, Vega et al., 2006). Further, psychosis symptoms among Hispanics have been associated with functional impairment and high service utilization (Cassano et al., 2012). Hence, studies examining ethnic disparities in clinical settings may provide clinically relevant information to better understand this population and improve psychiatric treatment. Research using validated psychiatric symptom measures is needed because research examining ethnic differences has not consistently included symptom measures in diagnosing psychotic disorders (Choi et al., 2012).
The current study addresses a gap in the literature by utilizing Andersen's Behavioral Model of Health Services Use to systematically explore differential factors associated with receiving a schizophrenia or mood disorder diagnosis among Hispanic, African American and non-Hispanic white patients. The Andersen model provides a conceptual framework for examining research questions related to disparities in health service use among disadvantaged populations including ethnic minorities (Andersen, 1995, Andersen and Newman, 1973). We employed this framework for examining ethnic disparities in the diagnosis of schizophrenia among historically underserved patients at an academic safety-net psychiatric hospital. To our knowledge, this is the first study to examine ethnic disparities in psychiatric hospital admission in a large and diverse region that includes a substantial Spanish-speaking population.
Section snippets
Study design
Our retrospective cohort study examined electronic health records (EHR) at a regional academic safety-net psychiatric hospital. We gathered data on all adult (18+ years) Hispanic, African American and non-Hispanic white patients admitted between January 1, 2010 and December 31, 2013. Our study included visit-level data for all adult patients with a primary diagnosis of schizophrenia or a mood disorder admitted for inpatient psychiatric treatment and assessed with the Brief Psychiatric Rating
Demographic and clinical characteristics of the sample
Within the sample, 33.6% of the patients were diagnosed with schizophrenia and 66.4% were diagnosed with a mood disorder. The majority of the 5571 participants included in the study were male (60.1%) and the mean age was 35.4 years. More patients were non-Hispanic white (40.7%) or African American (44.8%) compared to Hispanic (14.6%). While the participants were largely uninsured (73.8%), larger percentages of Hispanics and non-Hispanic whites were uninsured (79.4% and 79.2%, respectively)
Discussion
Our study found a marginally significant relationship between Hispanic ethnicity and a greater likelihood of receiving a diagnosis of schizophrenia at psychiatric hospital admission. While this finding is consistent with one prior study (Blow et al., 2004), other research has reported Hispanics to be underdiagnosed with schizophrenia and to be more likely to receive a mood disorder diagnosis, even when reporting more psychotic symptoms (Minsky et al., 2003). Further, research comparing gold
Conclusion
The current, large-sampled study examined factors predicting ethnic disparities in schizophrenia and mood disorder diagnoses using the Andersen Behavioral Model of Health Services Use. Predisposing factors included race/ethnicity, language, age, gender, and marital status. Enabling factors included system and structural factors related to health service resources availability. Need factors included patient symptom severity and presentation. Our findings include evidence of factors in each of
References (94)
- et al.
Gender and health services use for mental health problem
Social Sci. Med.
(2001) - et al.
Duration of untreated psychosis and negative symptoms – a systematic review and meta-analysis of individual patient data
Schizophr. Res.
(2012) - et al.
Anxiety disorders in the joint hypermobility syndrome
Psychiatry Res.
(1993) - et al.
Schizophrenia in Croatia: age of onset differences between males and females
Schizophr. Res.
(1994) - et al.
Hallucinations in Latino psychiatric outpatients: a preliminary investigation
Gen. Hosp. Psychiatry
(2004) - et al.
Racial disparities during admission to an academic psychiatric hospital in a large urban area
Compr. Psychiatry
(2015) - et al.
Apathy, cognitive deficits and functional impairment in schizophrenia
Schizophr. Res.
(2011) - et al.
Avolition and expressive deficits capture negative symptom phenomenology: implications for DSM-5 and schizophrenia research
Clin. Psychol. Rev.
(2011) - et al.
Negative symptoms of schizophrenia: clinical characteristics, pathophysiological substrates, experimental models and prospects for improved treatment
Eur. Neuropsychopharmacol.
(2014) - et al.
Association of social support and quality of life among people with schizophrenia receiving community psychiatric service: a cross-sectional study
Compr. Psychiatry
(2017)