Organizations in science and medicine must hold each other accountable for discriminatory practices.

Many organizations persist in working with others that engage in known, remediable structural discrimination. We name this practice interorganizational structural discrimination (ISD) and argue it is a pivotal contributor to inequities in science and medicine. We urge organizations to leverage their relationships and demand progress from collaborators.

Overcoming the Impact of Students for Fair Admission v Harvard to Build a More Representative Health Care Workforce: Perspectives from Ending Unequal Treatment.

Policy Points In a recently commissioned report on solutions for eliminating racial and ethnic health care inequities entitled Ending Unequal Treatment, the National Academies of Sciences, Engineering, and Medicine found a health workforce that is representative of the communities it serves is essential for health care equity. The Supreme Court decision to ban race-conscious admission constraints pathways toward health workforce representativeness and equity. This paper draws on the National Academies report's findings that health care workforce representativeness improves care quality, population health, and equity to discuss policy and programmatic options for various participants to promote health workforce representativeness in the context of race-conscious admissions bans.

Associations Between Two Domains of Social Adversity and Recovery Among Persons with Serious Mental Illnesses Being Treated in Community Mental Health Centers.

As mental health services are increasingly embracing the recovery model, we conducted a study to better understand how social adversity impacts recovery. We also examined how associations between social adversity and recovery are influenced (moderated or mediated) by symptom severity. Data on seven social adversity measures, eight recovery measures, and symptom severity were collected from 300 English-speaking participants, ages 18-65 years, with a diagnosis of a psychotic or mood disorder, from five community mental health agencies in diverse neighborhoods in Washington, D.C. We employed standard correlation, exploratory factor analyses, analysis of variance, and hierarchic regression procedures. Diagnostic category and gender impacted Home Environment Adversities (e.g., food insecurity, perceived neighborhood disorder), the diagnostic category-by-gender interaction influenced Social and Economic Adversities (e.g., years of education and income), and gender affected Recovery. Controlling for diagnostic category and gender, Social and Economic Adversities accounted for 1.7% of variance in Recovery, while Home Environment Adversities accounted for 8.6% (their joint influence was 3.4%). Although symptom severity did not moderate these associations, it partially mediated the effect of Social and Economic Adversities on Recovery, and substantially mediated the effect of Home Environment Adversities on Recovery. The extent to which patients with serious mental illnesses experience recovery may be meaningfully influenced not only by symptoms, but by their social and environmental circumstances.

Predictors of Client Satisfaction with Outpatient Mental Health Clinic Services in Italy and New York.

The aim of this cross-sectional study was to assess factors associated with client satisfaction in two mental health outpatient settings in Italy and the US. Sociodemographic and clinical variables, hope, and personality characteristics were evaluated in 18-65-year-old patients who had been receiving services for at least 2 months in one of two outpatient clinics, in Italy and the US. Patients were administered: the Healthy Days Core Module, the Kessler Screening Scale for Psychological Distress, the Verona Service Satisfaction Survey, the Client Satisfaction Inventory, the Health Service OutPatient Experience questionnaire, the Herth Hope Index, and the NEO Five-Factor Inventory-3. Bivariate tests for differences between the two samples were conducted, a Satisfaction Composite z-score was computed, and a stepwise, backward elimination, multiple linear regression model-including the variables that were significantly associated with Satisfaction Composite Score in bivariate tests-was built. From July 1, 2015 to April 30, 2016, 184 patients (121 in Foligno, 63 in New York City) were enrolled in the study. Predictors of client satisfaction included: receiving services in New York City, being older, having lower educational attainment, having inner positive readiness and expectancy as well as interconnectedness with self and others, and high scores on the agreeableness personality domain. Interestingly, diagnosis and treatment characteristics did not influence satisfaction. Client satisfaction with outpatient mental health services is mainly influenced by sociodemographic characteristics and personality factors more than clinical variables or patterns of care. These findings could have implications regarding trends toward value-based payment models.

Predictors of Mental Health Treatment Seeking and Engagement in a Community Mental Health Center.

Disparities in behavioral health treatment outcomes are multifactorial, but treatment engagement and dropout from treatment often contribute to unequal mental health outcomes in individuals with serious mental illnesses. Alcohol and other substance use disorders have been associated with poor treatment adherence and premature discontinuation of treatment, but few studies have examined these factors in a predominantly African American sample of individuals with serious mental illnesses. This study examined predictors of mental health treatment engagement and dropout in a sample of 90 African American individuals presenting for treatment at a community mental health treatment facility in Atlanta, Georgia. Having an alcohol use disorder was associated with being less likely to attend mental health follow up (OR 0.32, 95% CI 0.12-0.88). Among African American individuals with alcohol use disorders, specific, targeted interventions may be necessary to help reach individuals that are at extremely high risk of poor health and poor adherence to treatment.

Racial/Ethnic Disparities in Mental Health Service Utilization among Youth Participating in Negative Externalizing Behaviors.

PURPOSES: Racial/ethnic differences in mental health service utilization were examined among youth who reported participating in negative externalizing behaviors. METHODS: The study utilized merged data from the 2007-2010 National Survey on Drug Use and Health (NSDUH) to examine differences in utilization of inpatient or outpatient mental health services not related to substance or alcohol use by White, Black and Hispanic youth who reported engaging in negative externalizing behaviors ("acting out"). Differences in service utilization in these groups were assessed using logistic regression models. RESULTS: Race/ethnicity was a significant predictor of outpatient mental health service use. Black and Hispanic children were less likely to use outpatient services. Inpatient service use decreased with increasing income. Parental presence in the household increased the likelihood of outpatient service use for minorities. CONCLUSION: Racial/ethnic minority youth in the United States continue to use outpatient mental health services at lower rates. This may lead to high prevalence of untreated negative externalizing behaviors among minority adolescent groups and, in turn, lead to use of inpatient services from systems such as juvenile justice and foster care. Such severe treatment alternatives can be prevented if timely and culturally tailored outpatient intervention is provided.

Racial disparities in economic and clinical outcomes of pregnancy among Medicaid recipients.

To explore racial-ethnic disparities in adverse pregnancy outcomes among Medicaid recipients, and to estimate excess Medicaid costs associated with the disparities. Cross-sectional study of adverse pregnancy outcomes and Medicaid payments using data from Medicaid Analytic eXtract files on all Medicaid enrollees in fourteen southern states. Compared to other racial and ethnic groups, African American women tended to be younger, more likely to have a Cesarean section, to stay longer in the hospital and to incur higher Medicaid costs. African-American women were also more likely to experience preeclampsia, placental abruption, preterm birth, small birth size for gestational age, and fetal death/stillbirth. Eliminating racial disparities in adverse pregnancy outcomes (not counting infant costs), could generate Medicaid cost savings of $114 to $214 million per year in these 14 states. Despite having the same insurance coverage and meeting the same poverty guidelines for Medicaid eligibility, African American women have a higher rate of adverse pregnancy outcomes than White or Hispanic women. Racial disparities in adverse pregnancy outcomes not only represent potentially preventable human suffering, but also avoidable economic costs. There is a significant financial return-on-investment opportunity tied to eliminating racial disparities in birth outcomes. With the Affordable Care Act expansion of Medicaid coverage for the year 2014, Medicaid could be powerful public health tool for improving pregnancy outcomes.

Characterizing depression and comorbid medical conditions in African American women in a primary care setting.

BACKGROUND: African American women are more likely to seek treatment for depression in primary care settings; however, few women receive guideline-concordant depression treatment in these settings. This investigation focused on the impact of depression on overall functioning in African American women in a primary care setting. METHODS: Data was collected from a sample of 507 African American women in the waiting room of an urban primary care setting. The majority of women were well-educated, insured, and employed. The CESD-R was used to screen for depression, and participants completed the 36-Item Short-Form Survey to determine functional status. RESULTS: Among the participants with depression, there was greater functional impairment for role-physical (z = -0.88, 95% CI = -1.13, -0.64) when compared to individuals with diabetes and hypertension. Individuals with depression also had greater role-emotional impairment (z = -1.12, 95% CI = -1.37, -0.87) than individuals with diabetes and hypertension. African American women with comorbid hypertension and depression had greater functional impairment in role-physical when compared to African American women with hypertension and no depression (t(124) = -4.22, p < 0.01). CONCLUSION: African American women with depression are more likely to present with greater functional impairment in role function when compared to African American women with diabetes or hypertension. Because African American women often present to primary care settings for treatment of mental illness, primary care providers need to have a clear understanding of the population, as well as the most effective and appropriate interventions.

Toward Greater Accountability in Mental Health Care.

Lack of accountability contributes to the gap between best practices and potential outcomes. Few mental health providers routinely practice evidence-based care. In fact, within the mental health field, there is significant controversy over the use of evidence-based practices. Lack of accountability affects individuals receiving care at the patient level, provider level, and systems level. The authors identify several impediments to accountability in behavioral health care. These include failure to develop a diverse, well-trained workforce; challenges in measurement; misalignment of payment incentives; and misguided regulations. Accountability arrangements typically consist of several elements: a clear articulation of goals, objectives, or standards; metrics so that progress toward achieving goals can be tracked; and consequences for insurers, providers, and professionals for achieving or failing to achieve objectives. To advance system goals, the full complement of accountability tools should be consistently applied to all sources of behavioral health care and supports. The authors focus on three sets of accountability tools-performance metrics, payment incentives, and regulatory standards-that when implemented thoughtfully can help move the field toward more positive outcomes in behavioral health.

Mental comorbidity and quality of diabetes care under Medicaid: a 50-state analysis.

BACKGROUND: Patients with comorbid medical and mental conditions are at risk for poor quality of care. With the anticipated expansion of Medicaid under health reform, it is particularly important to develop national estimates of the magnitude and correlates of quality deficits related to mental comorbidity among Medicaid enrollees. METHODS: For all 657,628 fee-for-service Medicaid enrollees with diabetes during 2003 to 2004, the study compared Healthcare Effectiveness Data and Information Set (HEDIS) diabetes performance measures (hemoglobin A1C, eye examinations, low density lipoproteins screening, and treatment for nephropathy) and admissions for ambulatory care-sensitive conditions (ACSCs) between persons with and without mental comorbidity. Nested hierarchical models included individual, county, and state-level measures. RESULTS: A total of 17.8% of the diabetic sample had a comorbid mental condition. In adjusted models, presence of a mental condition was associated with a 0.83 (0.82-0.85) odds of obtaining 2 or more HEDIS indicators, and a 1.32 (1.29-1.34) increase in odds of one or more ACSC hospitalization. Among those with diabetes and mental comorbidities, living in a county with a shortage of primary care physicians was associated with reduced performance on HEDIS measures; living in a state with higher Medicaid reimbursement fees and department of mental health expenses per client were associated both with higher quality on HEDIS measures and lower (better) rates of ACSC hospitalizations. CONCLUSIONS: Among persons with diabetes treated in the Medicaid system, mental comorbidity is an important risk factor for both underuse and overuse of medical care. Modifiable county and state-level factors may mitigate these quality deficits.

Health-related quality of life in elderly black and white patients with cancer: results from Medicare managed care population.

OBJECTIVE: To compare differences in various aspects of health-related quality of life (HRQOL) between Black and White individuals diagnosed with cancer. DESIGN: The data were extracted from 2005-2007 Medicare Health Outcome Survey, a health outcomes measure for the Medicare population in managed care settings. A total of 14089 Black and White respondents aged > or = 65 with cancer were included in the study. Multivariable linear regressions were used to assess the association between race and the HRQOL after accounting for age, sex, education years, marital status, and non-cancer comorbid conditions. RESULTS: When compared with their White counterparts, Black patients had lower scores for the physical component summary (PCS) and mental component summary (MCS), and all health domains with the exception of vitality. After adjusting for demographic features and comorbid conditions, the MCS scores of Black patients were still lower than that of White patients. However, the mean PCS was not different for Black and White patients. Black patients had significantly lower HRQOL in general health, social functioning, and role emotion, whereas they had a higher mean score in vitality. CONCLUSIONS: Race had a significant impact on quality of life for older cancer patients. The effect was likely to be moderated by comorbid conditions and socioeconomic indicators. To optimize cancer outcomes at the population level, it is important to identify subgroups of cancer patients with an increased risk of low quality of life and to develop appropriate supportive interventions of cancer care.

Racial/ethnic disparities, social support, and depression: examining a social determinant of mental health.

OBJECTIVE: We examined the risk of depression as it relates to social support among individuals from African American, Caribbean black, and non-Hispanic White backgrounds. METHODS: 6,082 individuals participated in the national survey of American life (NSAL), a nationally representative, psychiatric epidemiological, cross-sectional survey of household populations. The survey is designed to explore racial and ethnic differences in mental disorders. NSAL survey questions were used as a proxy for social support. Logistic regression analysis was used to examine the correlates between having a DSM-IV diagnosis of major depressive disorder in the past year, demographic variables, and social support. RESULTS: African American race/ethnicity was associated with decreased odds of depression when compared to non-Hispanic whites, even when controlling for social support variables and demographics (OR = 0.51, 95% CI = 0.43-0.60). We found a three-fold increase in risk of depression among individuals who reported feeling "not very close at all" with family members compared to those who reported feeling "very close" to family (OR = 3.35, 95% CI = 1.81-6.19). CONCLUSIONS: These findings reinforce previous research documenting the important relationship between social support and depression, and perhaps should lead us to reexamine the individualistic models of treatment that are most evaluated in United States. The lack of evidence-based data on support groups, peer counseling, family therapy, or other social support interventions may reflect a majority-culture bias toward individualism, which belies the extensive body of research on social support deficits as a major risk factor for depression.

Opioid addiction and abuse in primary care practice: a comparison of methadone and buprenorphine as treatment options.

Opioid abuse and addiction have increased in frequency in the United States over the past 20 years. In 2009, an estimated 5.3 million persons used opioid medications nonmedically within the past month, 200000 used heroin, and approximately 9.6% of African Americans used an illicit drug. Racial and ethnic minorities experience disparities in availability and access to mental health care, including substance use disorders. Primary care practitioners are often called upon to differentiate between appropriate, medically indicated opioid use in pain management vs inappropriate abuse or addiction. Racial and ethnic minority populations tend to favor primary care treatment settings over specialty mental health settings. Recent therapeutic advances allow patients requiring specialized treatment for opioid abuse and addiction to be managed in primary care settings. The Drug Addiction Treatment Act of 2000 enables qualified physicians with readily available short-term training to treat opioid-dependent patients with buprenorphine in an office-based setting, potentially making primary care physicians active partners in the diagnosis and treatment of opioid use disorders. Methadone and buprenorphine are effective opioid replacement agents for maintenance and/or detoxification of opioid-addicted individuals. However, restrictive federal regulations and stigmatization of opioid addiction and treatment have limited the availability of methadone. The opioid partial agonist-antagonist buprenorphine/naloxone combination has proven an effective alternative. This article reviews the literature on differences between buprenorphine and methadone regarding availability, efficacy, safety, side-effects, and dosing, identifying resources for enhancing the effectiveness of medication-assisted recovery through coordination with behavioral/psychological counseling, embedded in the context of recovery-oriented systems of care.

Telepsychiatry services for Korean immigrants.

Asian Americans often face cultural and language barriers when obtaining mental health treatment. With the small number of Asian mental health providers, it is difficult to ensure the linguistic and ethnic matching of providers and patients. Telepsychiatry holds great promise to address the unique needs of Asian Americans. We developed a project to establish telepsychiatry services that connect Korean mental health patients in Georgia with a linguistically and culturally competent psychiatrist in California and assessed the level of acceptability of psychiatric treatment via real-time teleconferencing among these patients. Upon the completion of the program, 16 patients (5 men, 11 women) completed a questionnaire that measured their acceptability of the telepsychiatry service. The findings indicate a high level of acceptance of the program among Korean patients. The quantitative and qualitative data show that they especially appreciated the cultural sensitivity of the consultation and the comfortable interaction with the provider. However, challenges such as technical issues of teleconferencing may negatively affect the quality of the clinical interaction. Our study expands the knowledge base regarding the acceptability of such services to a population that experiences disparities in mental health care. Future research should extend telepsychiatry services to other Asian population groups that experience lower access to mental health services.

Social Determinants of Health, Structural Racism, and the Impact on Child and Adolescent Mental Health.

In recent years, there has been a greater emphasis on examining the factors, particularly the social factors, that affect health outcomes and contribute to population health inequities. The social determinants of health, as defined by the World Health Organization, are "the conditions in which people are born, grow, work, live, and develop, and the wider set of forces, including economic policies, social norms, and political systems, that shape the conditions of daily life and impact health outcomes."1 The social determinants of mental health (SDoMH) are similar, but include the added societal stigma associated with mental health and substance use disorders. The SDoMH often receive less focus and study, particularly in youth. Table 1 lists several examples of social determinants of mental health for children and adolescents and examples of how to address them in the clinical setting.1 The SDoMH are particularly relevant for children, as they are reliant on the adults who care for them and have even less control over these societal factors. Additionally, the physical, cognitive, emotional, and social development that occurs during this critical time lays the foundation for mental health and well-being into adulthood. It is important that mental health providers recognize these SDoMH, as they invariably impact the clinical presentation of the children they treat. However, to truly address the SDoMH and improve outcomes for all children, clinicians must understand the major driving force behind them-structural racism.