Depression is Associated with Increased Risk for Metabolic Syndrome in Latinos with Type 2 Diabetes.

OBJECTIVE: Latino adults are 66% more likely to have diabetes relative to non-Latino white adults. Prior research identifies depression as a significant risk factor for metabolic syndrome (MetS), but research examining this among Latinos is lacking. This study sought to examine the links between depression and MetS and clinically significant elevations in cardiovascular disease risk markers of MetS in a sample of community-dwelling older Latinos with type 2 diabetes. METHODS: Participants were 332 community-dwelling older (≥60 years) Latinos with type 2 diabetes who completed the nine-item Patient Health Questionnaire and received a health checkup assessing body mass index (BMI), triglyceride and high-density lipoprotein (HDL) cholesterol levels, and blood pressure. Logistic regression analysis compared MetS rates of those meeting criteria for depression with those who did not. Secondary analyses examined the associations between depression and individual MetS components. All analyses controlled for demographic (e.g., income, age) and other potential MetS risk factors (e.g., smoking status, physical activity, alcohol level consumption). RESULTS: Depression was significantly associated with an increased risk of MetS (OR: 5.79; 95% CI: 1.32-25.42) and clinically significant elevations in triglycerides (OR: 2.71; 95% CI: 1.15-6.42) and reduced (HDL) cholesterol (OR: 2.46; 95% CI: 1.11-5.45). A significant association was not observed between depression and either BMI or hypertension. CONCLUSION: Depression is significantly linked to MetS, and most notably dyslipidemia, in older Latinos with diabetes. Causation, however, cannot be inferred from these analyses given the cross-sectional nature of the study. Future research should prospectively examine the directionality of this effect.

Predisposing, enabling, and need factors associated with high service use in a public mental health system.

The purpose of this study was twofold: (1) To investigate the individual- and system-level characteristics associated with high utilization of acute mental health services according to a widely-used theory of service use-Andersen's Behavioral Model of Health Service Use -in individuals enrolled in a large, public-funded mental health system; and (2) To document service utilization by high use consumers prior to a transformation of the service delivery system. We analyzed data from 10,128 individuals receiving care in a large public mental health system from fiscal years 2000-2004. Subjects with information in the database for the index year (fiscal year 2000-2001) and all of the following 3 years were included in this study. Using logistic regression, we identified predisposing, enabling, and need characteristics associated with being categorized as a single-year high use consumer (HU: >3 acute care episodes in a single year) or multiple-year HU (>3 acute care episodes in more than 1 year). Thirteen percent of the sample met the criteria for being a single-year HU and an additional 8% met the definition for multiple-year HU. Although some predisposing factors were significantly associated with an increased likelihood of being classified as a HU (younger age and female gender) relative to non-HUs, the characteristics with the strongest associations with the HU definition, when controlling for all other factors, were enabling and need factors. Homelessness was associated with 115% increase in the odds of ever being classified as a HU compared to those living independently or with family and others. Having insurance was associated with increased odds of being classified as a HU by about 19% relative to non-HUs. Attending four or more outpatient visits was an enabling factor that decreased the chances of being defined as a HU. Need factors, such as having a diagnosis of schizophrenia, bipolar disorder or other psychotic disorder or having a substance use disorder increased the likelihood of being categorized as a HU. Characteristics with the strongest association with heavy use of a public mental health system were enabling and need factors. Therefore, optimal use of public mental services may be achieved by developing and implementing interventions that address the issues of homelessness, insurance coverage, and substance use. This may be best achieved by the integration of mental health, intensive case management, and supportive housing, as well as other social services.

Access to public mental health services among older adults with severe mental illness.

OBJECTIVE: Limited data are available on how older adults access public mental health systems. This study examines how uninsured or publicly insured older adults with severe mental illness in San Diego County initially accessed the public mental health system, as well as their subsequent use of public mental health services, as compared to younger adults. METHODS: Data from San Diego County, 2002-2006, were used to examine how older adults initially accessed the public mental health system, and their utilization over the subsequent 90 days. Multivariate regression models were used to control for demographic and clinical characteristics. RESULTS: Older adults (age 60 +) were more likely to access the public mental health system through the Psychiatric Emergency Response Team (PERT), a combined law-enforcement and psychiatric service that responds to psychiatric related 911 calls. Older adults were also less likely to receive follow-up care. This lower rate of follow-up was due to both the initial site of service--and an associated lower rate of follow-up among PERT clients--as well as a lower rate of follow-up among older adult clients initiating services in other sectors. CONCLUSIONS: This paper suggests two areas for intervention that would improve access to care for older adults: improving linkages and referrals between PERT and outpatient providers; and additional efforts to retain older adults at outpatient programs.

Public-academic partnerships: improving care for older persons with schizophrenia through an academic-community partnership.

Translating evidence-based mental health interventions designed in research settings into community practice is a priority for multiple stakeholders. Partnerships between academic and public institutions can facilitate this translation. To improve care for middle-aged and older adults with schizophrenia, the authors developed a collaboration between a university research center and a public mental health service system using principles from community-based participatory research and cultural exchange theory. They describe the process that has led to a number of mutually beneficial products. Despite the challenges involved, building and maintaining academic-public collaborations will be essential for improving mental health care for persons with schizophrenia.

Unmet needs for mental health services for latino older adults: perspectives from consumers, family members, advocates, and service providers.

This study qualitatively assessed the need for mental health services among Latino older adults in San Diego, California. The primary mental health issue was depression. Primary organizational barriers to accessing services were language and cultural barriers secondary to a lack of translators, dearth of information on available services, and scarcity of providers representative of the Latino community. Other challenges included a lack of transportation and housing, and the need for socialization and social support. Latino older adults experienced their unmet needs in ways associated with their cultural background and minority status. Age- and culturally-appropriate services are needed to overcome these barriers.

A longitudinal study of the use of mental health services by persons with serious mental illness: do Spanish-speaking Latinos differ from English-speaking Latinos and Caucasians?

OBJECTIVE: Reports of mental health care use by Latinos compared to Caucasians have been mixed. To the authors' knowledge, no large-scale studies have examined the effects of language on mental health service use for Latinos who prefer Spanish compared to Latinos who prefer English and to Caucasians. Language is the most frequently used proxy measure of acculturation. The authors used the administrative database of a mental health system to conduct a longitudinal examination of mental health service use among Spanish-speaking versus English-speaking Latinos and Caucasians with serious mental illness. METHOD: There were 539 Spanish-speaking Latinos, 1,144 English-speaking Latinos, and 4,638 Caucasians initiating treatment for schizophrenia, bipolar disorder, or major depression during 2001-2004. Using multivariate regressions, the authors examined the differences among the groups in the type of service first used. The authors also examined the probability of use of each of four types of mental health services and the intensity of outpatient treatment. RESULTS: Spanish-speaking Latinos differed from both English-speaking Latinos and Caucasians on most measures. Compared to patients in the other groups, the Spanish-speaking Latinos were less likely to enter care through emergency or jail services and more likely to enter care through outpatient services. There were no group differences in the proportion that stayed in treatment or used inpatient hospitalization. CONCLUSIONS: This study suggests that for Latinos, preferred language may be more important than ethnicity in mental health service use. Future studies comparing mental health use may need to differentiate between Spanish- and English-speaking Latinos.

Anxiety disorders in a public mental health system: clinical characteristics and service use patterns.

BACKGROUND: Anxiety disorders are among the most common forms of psychiatric disorder, yet few investigations have examined the prevalence or service use of clients with anxiety disorders in the public mental health sector. METHODS: We examined demographics, clinical information, and service use in clients with anxiety disorders enrolled in San Diego County Adult and Older Adult Mental Health Services in fiscal 2002-2003. RESULTS: Almost 15% of the sample had a diagnosis of an anxiety disorder based on administrative billing data. Most anxiety disorder clients had additional psychiatric diagnoses, most commonly depression. Clients with both anxiety disorders and depression were more likely than those with anxiety or depression alone to use emergency psychiatric services and outpatient services than those with depression alone. Those with anxiety disorders alone used more outpatient services than those with depression alone. LIMITATION: Data were taken from an administrative database. CONCLUSIONS: Data indicate that anxiety disorders are not uncommon in public mental health settings and are associated with higher utilization of outpatient mental health services.

Initiation and use of public mental health services by persons with severe mental illness and limited english proficiency.

OBJECTIVE: Few studies have examined the effect of limited English proficiency on use of mental health services by persons with mental illness from ethnic minority groups who are uninsured or publicly insured. This study examined how indigent or publicly insured Latino and Asian adults with limited English proficiency initially accessed the public mental health system and how their use of services changed over time compared with English-proficient peers. METHODS: Data from San Diego County for fiscal years 2000-2005 were used to examine point of first contact and use of inpatient, emergency, and outpatient services in the 18 subsequent months among 9,243 clients with a psychiatric diagnosis of schizophrenia, bipolar disorder, or major depression. Multivariate regression models were used to compute standardized estimates of utilization. RESULTS: Latino and Asian clients with limited English proficiency were significantly less likely to first access the system through emergency services and more likely to access the system through outpatient services (p<.001 for each comparison). In two outpatient programs that were focused on delivering services to clients with limited English proficiency, clients had a higher intensity of outpatient service use than clients in clinics that did not have such a focus (p<.05 for each). CONCLUSIONS: The initial pattern of service use was favorable for both groups. However, over time this pattern persisted for Asian clients with limited English proficiency but not for Latino clients with limited English proficiency. Findings suggest that ethnically focused programs may be an effective approach to engaging populations that are underrepresented in the mental health system.

Prevalence and risk factors for homelessness and utilization of mental health services among 10,340 patients with serious mental illness in a large public mental health system.

OBJECTIVE: The authors examined the prevalence of and risk factors for homelessness among all patients treated for serious mental illnesses in a large public mental health system in a 1-year period. The use of public mental health services among homeless persons was also examined. METHOD: The study included 10,340 persons treated for schizophrenia, bipolar disorder, or major depression in the San Diego County Adult Mental Health Services over a 1-year period (1999-2000). Analytic methods that adjusted for potentially confounding variables were used. Multivariate logistic regression analyses were used to calculate odds ratios for the factors associated with homelessness, including age, gender, ethnicity, substance use disorder, Medicaid insurance, psychiatric diagnosis, and level of functioning. Similarly, odds ratios were computed for utilization of mental health services by homeless versus not-homeless patients. RESULTS: The prevalence of homelessness was 15%. Homelessness was associated with male gender, African American ethnicity, presence of a substance use disorder, lack of Medicaid, a diagnosis of schizophrenia or bipolar disorder, and poorer functioning. Latinos and Asian Americans were less likely to be homeless. Homeless patients used more inpatient and emergency-type services and fewer outpatient-type services. CONCLUSIONS: Homelessness is a serious problem among patients with severe mental illness. Interventions focusing on potentially modifiable factors such as substance use disorders and a lack of Medicaid need to be studied in this population.

Tri-ethnic variations of co-morbid substance and alcohol use disorders in schizophrenia.

OBJECTIVES: This study examined the differential prevalence of substance and alcohol use disorders among European Americans, African Americans, and Latinos with schizophrenia (n = 6424) who received public mental health services in San Diego County during fiscal year 2002-2003. METHODS: Data were obtained from the public mental health database used by the San Diego County Mental Health System. Chi-Square analyses and stepwise logistic regression analyses were used to examine differences regarding the prevalence of substance and alcohol use among clients with schizophrenia and schizoaffective disorder, and to analyze the sociodemographic variables associated with this co-morbidity. RESULTS: Significant differences in the prevalence of diagnosed co-morbidity were found across the ethnic groups. Rates of co-morbid diagnosis among African Americans (25%) were significantly higher than those among European Americans (22%) and Latinos (19%). Logistic regression results revealed ethnicity was a significant predictor of co-morbid substance and alcohol use, as was being homeless and male. Among Latinos, language preference was also a significant predictor. Latinos who denoted English as their primary language were 1.7 times more likely to be diagnosed with co-morbid substance or alcohol use disorders than Latinos who denoted Spanish. CONCLUSIONS: Among people with schizophrenia, there were significant differences in prevalence rates and predictors of diagnosed co-morbid substance and alcohol use disorders. Future research is needed to examine the relationship among language preference, level of acculturation, and subsequent diagnosing barriers for Latinos. Among African Americans, the reasons behind increased co-morbidity rates need to be examined, and homelessness should be carefully addressed among all three ethnic groups.