The Role of Bias by Emergency Department Providers in Care for American Indian Children.

BACKGROUND: American Indian children have high rates of emergency department (ED) use and face potential discrimination in health care settings. OBJECTIVE: Our goal was to assess both implicit and explicit racial bias and examine their relationship with clinical care. RESEARCH DESIGN: We performed a cross-sectional survey of care providers at 5 hospitals in the Upper Midwest. Questions included American Indian stereotypes (explicit attitudes), clinical vignettes, and the Implicit Association Test. Two Implicit Association Tests were created to assess implicit bias toward the child or the parent/caregiver. Differences were assessed using linear and logistic regression models with a random effect for study site. RESULTS: A total of 154 care providers completed the survey. Agreement with negative American Indian stereotypes was 22%-32%. Overall, 84% of providers had an implicit preference for non-Hispanic white adults or children. Older providers (50 y and above) had lower implicit bias than those middle aged (30-49 y) (P=0.01). American Indian children were seen as increasingly challenging (P=0.04) and parents/caregivers less compliant (P=0.002) as the proportion of American Indian children seen in the ED increased. Responses to the vignettes were not related to implicit or explicit bias. CONCLUSIONS: The majority of ED care providers had an implicit preference for non-Hispanic white children or adults compared with those who were American Indian. Provider agreement with negative American Indian stereotypes differed by practice and respondents' characteristics. These findings require additional study to determine how these implicit and explicit biases influence health care or outcomes disparities.

Elder mistreatment in underserved populations: Opportunities and challenges to developing a contemporary program of research.

This article provides an overview of the status of research on elder mistreatment among underserved populations in the United States, including gaps in our current knowledge base and scientific and structural barriers to growing research on the exploitation, neglect, and abuse of older people from diverse and disadvantaged ethnic/racial, geographic, sexual identity, and socioeconomic groups. High-priority areas in need of new elder mistreatment research with underserved populations are identified, and suggestions are given for how this research can be facilitated by researchers, university institutional review boards, and funding agencies.

Cumulative Effects of Stressful Childhood Experiences on Delusions and Hallucinations.

The association between stressful childhood experiences (SCE) and psychotic symptoms is still not clearly understood, and different causal pathways have been proposed. Generalized estimating equation modeling was used to test the dose-response relationship between SCE and delusions and hallucinations at baseline and follow-up periods and the possible confounding effects of dissociation on this relationship. The prevalence of SCE in individuals with psychotic disorders was high, with more co-occurring SCE categories being positively associated with more types of delusions and hallucinations. Each additional SCE was associated with a 1.20 increase in the incidence rate ratio (95% confidence interval [CI; 1.09, 1.32]) for hallucinations and a 1.19 increase (CI [1.09, 1.29]) for delusions, supporting a dose-response association. After we controlled for the mediating effects of dissociative symptoms at follow-up, SCE remained independently associated with delusions. We propose that cumulative SCE can result in complex trauma reactions that present with a broad range of symptomatology, including dissociative, posttraumatic stress disorder, and psychotic symptoms.

Evaluation of Client Services (ECS): a measure of treatment satisfaction for people with chronic mental illnesses.

This article describes the development and psychometric assessment of the Evaluation of Client Services (ECS) measure of treatment satisfaction for people with chronic mental illnesses in community treatment settings. The ECS, a 20-item instrument, was validated in a sample of 184 individuals receiving outpatient mental health treatment in New York City. The four dimensions of the ECS, (1) treatment management and treatment outcome, (2) treatment relationship, (3) communication and information exchange, and (4) reachability of treatment facilities are internally consistent and stable over time. Analyses also show that the ECS is a valid indicator of satisfaction with mental health services which meaningfully correlates with quality of life and another measure of treatment satisfaction. The ECS is a brief and easy to understand treatment satisfaction tool with good psychometric properties.

Home Blood Pressure Monitoring Devices: Device Performance in an Alaska Native and American Indian Population.

Objectives: Home blood pressure monitoring (HBPM) is an important component of blood pressure (BP) management. We assessed performance of two HBPM devices among Alaska Native and American Indian people (ANAIs). Methods: We measured BP using Omron BP786 arm cuff, Omron BP654 wrist cuff, and Baum aneroid sphygmomanometer in 100 ANAIs. Performance was assessed with intraclass correlation, paired t-tests, and calibration models. Results: Compared to sphygmomanometer, average BP was higher for wrist cuff (systolic = 4.8 mmHg and diastolic = 3.6 mmHg) and varied for arm cuff (systolic = -1.5 mmHg and diastolic = 2.5 mmHg). Calibration increased performance from grade B to A for arm cuff and from D to B for wrist cuff. Calibration increased false negatives and decreased false positives. Discussion: The arm HBPM device is more accurate than the wrist cuff among ANAIs with hypertension. Most patients are willing to use the arm cuff when accuracy is discussed.

Stigma and coercion in the context of outpatient treatment for people with mental illnesses.

The policies and institutional practices developed to care for people with mental illnesses have critical relevance to the production of stigma as they can induce it, minimize it or even block it. This manuscript addresses two prominent and competing perspectives on the consequences for stigma of using coercion to insure compliance with outpatient mental health services. The Coercion to Beneficial Treatment perspective (Torrey, E. F., & Zdanowicz, M. (2001). Outpatient commitment: what, why, and for whom. Psychiatric Services, 52(3), 337-341) holds that the judicious use of coercion facilitates treatment engagement, aides in symptom reduction, and, in the long run, reduces stigma. The Coercion to Detrimental Stigma perspective (Pollack, D. A. (2004). Moving from Coercion to Collaboration in Mental Health Sevices DHHS (SMA) 04-3869. In Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration) claims that coercion increases stigmatization resulting in low self-esteem, a compromised quality of life, and increased symptoms. We examine these differing perspectives in a longitudinal study of 184 people with serious mental illness, 76 of whom were court ordered to outpatient treatment and 108 who were not. They were recruited from treatment facilities in the New York boroughs of the Bronx and Queens. We measure coercion in two ways: by assignment to mandated outpatient treatment and with a measure of self-reported coercion. The longitudinal analysis allows stringent tests of predictions derived from each perspective and finds evidence to support certain aspects of each. Consistent with the Coercion to Beneficial Treatment perspective, we found that improvements in symptoms lead to improvements in social functioning. Also consistent with this perspective, assignment to mandated outpatient treatment is associated with better functioning and, at a trend level, to improvements in quality of life. At the same time the Coercion to Detrimental Stigma perspective is supported by findings showing that self-reported coercion increases felt stigma (perceived devaluation-discrimination), erodes quality of life and through stigma leads to lower self-esteem. Future policy needs not only to find ways to insure that people who need treatment receive it, but to achieve such an outcome in a manner that minimizes circumstances that induce perceptions of coercion.

Arrest outcomes associated with outpatient commitment in New York State.

OBJECTIVE: This study examined whether assisted outpatient treatment (AOT) under New York's "Kendra's Law" is associated with reduced arrests for violent and nonviolent offenses. METHODS: Arrest records of 183 study participants attending outpatient clinics in New York City, 86 of whom were ever and 97 of whom were never assigned to AOT, were compiled to yield 16,890 months of observation. For each month the data indicated whether an arrest did or did not occur and whether a participant was or was not assigned to AOT. Generalized estimating equations and fixed-effects analyses were used to compare arrest rates within different periods (before, during or shortly after, and more than six months after) for those ever assigned and between the ever- and never-assigned groups. RESULTS: For those who received AOT, the odds of any arrest were 2.66 times greater (p<.01) and the odds of arrest for a violent offense 8.61 times greater (p<.05) before AOT than they were in the period during and shortly after AOT. The group never receiving AOT had nearly double the odds (1.91, p<.05) of arrest compared with the AOT group in the period during and shortly after assignment. CONCLUSIONS: Outpatient commitment under Kendra's Law in New York State is associated with a reduced risk of arrest. The coercion necessitated by application of the law may forestall, at least for some people, the potentially more potent and consequential coercion they would have experienced in the criminal justice system.

Effectiveness and outcomes of assisted outpatient treatment in New York State.

OBJECTIVE: Outpatient commitment has been heralded as a necessary intervention that improves psychiatric outcomes and quality of life, and it has been criticized on the grounds that effective treatment must be voluntary and that outpatient commitment has negative unintended consequences. Because few methodologically strong data exist, this study evaluated New York State's outpatient commitment program with the objective of augmenting the existing literature. METHODS: A total of 76 individuals recently mandated to outpatient commitment and 108 individuals (comparison group) recently discharged from psychiatric hospitals in the Bronx and Queens who were attending the same outpatient facilities as the group mandated to outpatient commitment were followed for one year and compared in regard to psychotic symptoms, suicide risk, serious violence perpetration, quality of life, illness-related social functioning, and perceived coercion and stigma. Propensity score matching and generalized estimating equations were used to achieve the strongest causal inference possible without an experimental design. RESULTS: Serious violence perpetration and suicide risk were lower and illness-related social functioning was higher (p<.05 for all) in the outpatient commitment group than in the comparison group. Psychotic symptoms and quality of life did not differ significantly between the two groups. Potential unintended consequences were not evident: the outpatient commitment group reported marginally less (p<.10) stigma and coercion than the comparison group. CONCLUSIONS: Outpatient commitment in New York State affects many lives; therefore, it is reassuring that negative consequences were not observed. Rather, people's lives seem modestly improved by outpatient commitment. However, because outpatient commitment included treatment and other enhancements, these findings should be interpreted in terms of the overall impact of outpatient commitment, not of legal coercion per se. As such, the results do not support the expansion of coercion in psychiatric treatment.