Racial-Ethnic Differences in Psychiatric Diagnoses and Treatment Across 11 Health Care Systems in the Mental Health Research Network.

OBJECTIVE: The objective of this study was to characterize racial-ethnic variation in diagnoses and treatment of mental disorders in large not-for-profit health care systems. METHODS: Participating systems were 11 private, not-for-profit health care organizations constituting the Mental Health Research Network, with a combined 7,523,956 patients age 18 or older who received care during 2011. Rates of diagnoses, prescription of psychotropic medications, and total formal psychotherapy sessions received were obtained from insurance claims and electronic medical record databases across all health care settings. RESULTS: Of the 7.5 million patients in the study, 1.2 million (15.6%) received a psychiatric diagnosis in 2011. This varied significantly by race-ethnicity, with Native American/Alaskan Native patients having the highest rates of any diagnosis (20.6%) and Asians having the lowest rates (7.5%). Among patients with a psychiatric diagnosis, 73% (N=850,585) received a psychotropic medication. Non-Hispanic white patients were significantly more likely (77.8%) than other racial-ethnic groups (odds ratio [OR] range .48-.81) to receive medication. In contrast, only 34% of patients with a psychiatric diagnosis (N=548,837) received formal psychotherapy. Racial-ethnic differences were most pronounced for depression and schizophrenia; compared with whites, non-Hispanic blacks were more likely to receive formal psychotherapy for their depression (OR=1.20) or for their schizophrenia (OR=2.64). CONCLUSIONS: There were significant racial-ethnic differences in diagnosis and treatment of psychiatric conditions across 11 U.S. health care systems. Further study is needed to understand underlying causes of these observed differences and whether processes and outcomes of care are equitable across these diverse patient populations.

Psychiatric comorbidity and 30-day readmissions after hospitalization for heart failure, AMI, and pneumonia.

OBJECTIVE: In 2012, the Centers for Medicare and Medicaid Services implemented a policy that penalizes hospitals for "excessive" all-cause hospital readmissions within 30 days after discharge from an index hospitalization for heart failure (HF), acute myocardial infarction (AMI), and pneumonia. The aim of this study was to investigate the influence of psychiatric comorbidities on 30-day all-cause readmissions following hospitalizations for HF, AMI, and pneumonia. METHODS: Data from 2009-2011 were derived from the HMO Research Network Virtual Data Warehouse of 11 health systems affiliated with the Mental Health Research Network. All index inpatient hospitalizations for HF, AMI, and pneumonia were captured (N=160,169). Psychiatric diagnoses for the year prior to admission were measured. All-cause readmissions within 30 days of discharge were the outcome variable. RESULTS: Approximately 18% of all individuals with index inpatient hospitalizations for HF, AMI, and pneumonia were readmitted within 30 days. The rate of readmission was 5% greater for individuals with a psychiatric comorbidity compared with those without a psychiatric comorbidity (21.7% and 16.5%, respectively, p<.001). Depression, anxiety, and dementia were associated with more readmissions of persons with index hospitalizations for each general medical condition and for all the conditions combined (p<.05). Substance use and bipolar disorders were linked with higher readmissions for those with initial hospitalizations for HF and pneumonia (p<.05). Readmission rates declined overall from 2009 to 2011. CONCLUSIONS: Individuals with HF, AMI, and pneumonia experience high rates of readmission, but psychiatric comorbidities appear to increase that risk. Future interventions to reduce readmission should consider adding mental health components.

Chronic opioid use emerging after bariatric surgery.

PURPOSE: Little is known about opioid use after bariatric surgery among patients who did not use opioids chronically before surgery. Our purpose was to determine opioid use the year after bariatric surgery among patients who did not use opioids chronically pre-surgery and to identify pre-surgery characteristics associated with chronic opioid use after surgery. METHODS: This retrospective cohort study across nine US health systems included 10 643 patients aged 21 years or older who underwent bariatric surgery and who were not chronic opioid users pre-surgery. The main outcome was chronic opioid use the post-surgery year (excluding 30 post-operative days) defined as ≥10 dispensings over ≥90 days or ≥120 total days' supply. RESULTS: Overall, 4.0% (n = 421) of patients became chronic opioid users the post-surgery year. Pre-surgery opioid total days' supply was strongly associated with chronic use post-surgery (1-29 days adjusted odds ratio [OR] 1.89 [95%CI, 1.24-2.88]; 90-119 days OR, 14.29 [95%CI, 6.94-29.42] compared with no days). Other factors associated with increased likelihood of post-surgery chronic use included pre-surgery use of non-narcotic analgesics (OR, 2.22 [95%CI, 1.39-3.54]), antianxiety agents (OR, 1.67 [95%CI, 1.12-2.50]), and tobacco (OR, 1.44 [95%CI, 1.03-2.02]). Older age (OR, 0.84 [95%CI, 0.73-0.97] each decade) and a laparoscopic band procedure (OR, 0.42 [95%CI, 0.25-0.70] vs. laparoscopic bypass) were associated with decreased likelihood of chronic opioid use post-surgery. CONCLUSIONS: Most patients who became chronic opioid users the year after bariatric surgery used opioids intermittently before surgery.

The effect of bariatric surgery on psychiatric course among patients with bipolar disorder.

OBJECTIVE: Bariatric surgery is the most effective therapy for severe obesity. People with bipolar disorder have increased risk of obesity, yet are sometimes considered ineligible for bariatric surgery due to their bipolar disorder diagnosis. This study aimed to determine if bariatric surgery alters psychiatric course among stable patients with bipolar disorder. METHODS: A matched cohort study (2006-2009) with mean follow-up of 2.17 years was conducted within Kaiser Permanente Northern California, a group practice integrated health services delivery organization that provides medical and psychiatric care to 3.3 million people. Participants were 144 severely obese patients with bipolar disorder who underwent bariatric surgery, and 1,440 control patients with bipolar disorder, matched for gender, medical center, and contemporaneous health plan membership. Controls met referral criteria for bariatric surgery. Hazard ratio for psychiatric hospitalization, and change in rate of outpatient psychiatric utilization from baseline to Years 1 and 2, were compared between groups. RESULTS: A total of 13 bariatric surgery patients (9.0%) and 153 unexposed to surgery (10.6%) had psychiatric hospitalization during follow-up. In multivariate Cox models adjusting for potential confounding factors, the hazard ratio of psychiatric hospitalization associated with bariatric surgery was 1.03 [95% confidence interval (CI): 0.83-1.23]. In fully saturated multivariate general linear models, change in outpatient psychiatric utilization was not significantly different for surgery patients versus controls, from baseline to Year 1 (-0.4 visits/year, 95% CI: -0.5 to 0.4) or baseline to Year 2 (0.4 visits/year, 95% CI: -0.1 to 1.0). CONCLUSIONS: Bariatric surgery did not affect psychiatric course among stable patients with bipolar disorder. The results of this study suggest that patients with bipolar disorder who have been evaluated as stable can be considered for bariatric surgery.

Obesity and mental illness: implications for cognitive functioning.

A priority research and clinical agenda is to identify determinants of cognitive impairment in individuals with neuropsychiatric disorders (NPD). The bidirectional association between NPD and cognitive performance has been reported to be mediated and/or moderated by obesity in a subset of individuals. Obesity can be conceptualized as a neurotoxic phenotype among individuals with NPD as evidenced by alterations in the structure and function of neural circuits and disseminated networks, diminished cognitive performance, and adverse effects on illness trajectory. The neurotoxic effect of obesity provides a rationale for screening, treating, and preventing obesity in neuropsychiatric populations. Research endeavors that aim to refine mediators and moderators of this association as well as novel strategies to reverse the injurious process of obesity on cognition are warranted.

A comparison of lifestyle and behavioral cardiovascular disease risk factors between Asian Indian and White non-Hispanic men.

OBJECTIVE: We compared lifestyle CVD risk factors between Asian Indian and White non-Hispanic men within categories of BMI. DESIGN/SETTING/PARTICIPANTS: Participants included 51,901 White non-Hispanic men and 602 Asian Indian men enrolled in the California Men's Health Study cohort. Men were aged 45-69 years and members of Kaiser Permanente Southern or Northern California at baseline (2001-2002). MAIN OUTCOME MEASURES: Lifestyle characteristics including diet, physical activity, alcohol intake and smoking were collected from a survey. Multivariable logistic regression, adjusting for demographics, was performed. RESULTS: Asian Indians more often reported a healthy BMI (18.5-24.9), and consumed < 30% calories from fat within each BMI category (healthy weight and overweight/obese). Among healthy weight men, Asian Indians were less likely to eat -5 fruit and vegetables a day. Overall, Asian Indians were more likely to have never smoked and to abstain from alcohol. Asian Indians were less likely to report moderate/vigorous physical activity > or = 3.5 hours/week. No differences were found in sedentary activity. CONCLUSIONS: We identified health behaviors that were protective (lower fat intake, lower levels of smoking and alcohol) and harmful (lower levels of physical activity and fruit and vegetable intake) for cardiovascular health among the Asian Indians in comparison to White non-Hispanics. Results stratified by BMI were similar to those overall. However, the likelihood of consuming a low fat diet was lower among healthy weight men, while fruit and vegetable consumption, physical activity and alcohol intake was greater. These results suggest risk factors other than lifestyle behaviors may be important contributors to CVD in the Asian Indian population.

Perceptions of middle school educators in Hawai'i about school-based gardening and child health.

BACKGROUND: Childhood obesity prevention is a national priority. School-based gardening has been proposed as an innovative obesity prevention intervention. Little is known about the perceptions of educators about school-based gardening for child health. As the success of a school-based intervention depends on the support of educators, we investigated perceptions of educators about the benefits of gardening programs to child health. METHODS: Semi-structured interviews of 9 middle school educators at a school with a garden program in rural Hawai'i were conducted. Data were analyzed using a grounded theory approach. RESULTS: Perceived benefits of school-based gardening included improving children's diet, engaging children in physical activity, creating a link to local tradition, mitigating hunger, and improving social skills. Poverty was cited as a barrier to adoption of healthy eating habits. Opinions about obesity were contradictory; obesity was considered both a health risk, as well as a cultural standard of beauty and strength. Few respondents framed benefits of gardening in terms of health. CONCLUSIONS: In order to be effective at obesity prevention, school-based gardening programs in Hawai'i should be framed as improving diet, addressing hunger, and teaching local tradition. Explicit messages about obesity prevention are likely to alienate the population, as these are in conflict with local standards of beauty. Health researchers and advocates need to further inform educators regarding the potential connections between gardening and health.

Surgical treatment of morbid obesity among patients with bipolar disorder: a research agenda.

INTRODUCTION: Persons with bipolar disorder (BD) have an increased risk of obesity and associated diseases. Success of current behavioral treatment for obesity in patients with BD is inadequate. METHODS: Existing literature on bariatric surgery outcomes in populations with BD were reviewed, and needed areas of research were identified. RESULTS: Knowledge about bariatric surgery outcomes among patients with BD is limited. Available evidence indicates that bariatric surgery is a uniquely effective intervention for achieving and sustaining significant weight loss and improving metabolic parameters. Notwithstanding the benefits of bariatric surgery in nonpsychiatric samples, individuals with BD (and other serious and persistent mental illnesses) have decreased access to this intervention. Areas of needed research include: (1) current practice patterns; (2) metabolic course after bariatric surgery; (3) psychiatric course after bariatric surgery; and (4) mechanisms of psychiatric effect. CONCLUSION: The considerable hazards posed by obesity in BD, as measured by illness complexity and premature mortality, provide the basis for hypothesizing that bariatric surgery may prevent and improve morbidity in this patient population. In addition to physical health benefits, bariatric surgery may exert a robust and favorable effect on the course and outcome of BD and reduce obesity-associated morbidity, the most frequent cause of premature mortality in this patient population.

Heterogeneity of diabetes outcomes among asians and pacific islanders in the US: the diabetes study of northern california (DISTANCE).

OBJECTIVE: Ethnic minorities with diabetes typically have lower rates of cardiovascular outcomes and higher rates of end-stage renal disease (ESRD) compared with whites. Diabetes outcomes among Asian and Pacific Islander subgroups have not been disaggregated. RESEARCH DESIGN AND METHODS: We performed a prospective cohort study (1996-2006) of patients enrolled in the Kaiser Permanente Northern California Diabetes Registry. There were 64,211 diabetic patients, including whites (n = 40,286), blacks (n = 8,668), Latinos (n = 7,763), Filipinos (n = 3,572), Chinese (n = 1,823), Japanese (n = 951), Pacific Islanders (n = 593), and South Asians (n = 555), enrolled in the registry. We calculated incidence rates (means ± SD; 7.2 ± 3.3 years follow-up) and created Cox proportional hazards models adjusted for age, educational attainment, English proficiency, neighborhood deprivation, BMI, smoking, alcohol use, exercise, medication adherence, type and duration of diabetes, HbA(1c), hypertension, estimated glomerular filtration rate, albuminuria, and LDL cholesterol. Incidence of myocardial infarction (MI), congestive heart failure, stroke, ESRD, and lower-extremity amputation (LEA) were age and sex adjusted. RESULTS: Pacific Islander women had the highest incidence of MI, whereas other ethnicities had significantly lower rates of MI than whites. Most nonwhite groups had higher rates of ESRD than whites. Asians had ~60% lower incidence of LEA compared with whites, African Americans, or Pacific Islanders. Incidence rates in Chinese, Japanese, and Filipinos were similar for most complications. For the three macrovascular complications, Pacific Islanders and South Asians had rates similar to whites. CONCLUSIONS: Incidence of complications varied dramatically among the Asian subgroups and highlights the value of a more nuanced ethnic stratification for public health surveillance and etiologic research.

Mental health services utilization among women experiencing intimate partner violence.

OBJECTIVE: To examine the patient and provider characteristics associated with utilization of mental health services (MHS) among women experiencing intimate partner violence (IPV). STUDY DESIGN: Cross-sectional study among 6870 women aged 18 to 65 years with first IPV identification between May 2004 and December 2009 in Kaiser Permanente Northern California. METHODS: Utilization of MHS within 60 days after first IPV identification was determined. Multivariate generalized estimating equation logistic regression models that controlled for patient and provider characteristics were used to determine predictors of utilization. RESULTS: Thirty-seven percent of women utilized MHS. In multivariate generalized estimating equation models, the strongest predictor of utilization was electronic referral (odds ratio [OR], 4.40; 95% confidence interval [CI], 3.66-5.28). Odds of utilization were lower among black (OR, 0.71; 95% CI, 0.57-0.89), Latina (OR, 0.62; 95% CI, 0.41-0.95), and Spanish-speaking (OR, 0.71; 95% CI, 0.57-0.89) patients and were higher among those with prior posttraumatic stress disorder (OR, 2.38; 95% CI, 1.17-3.44) or depression (OR, 1.35; 95% CI, 1.17-1.57). Emergency department identification of IPV was associated with lower odds of MHS utilization (OR, 0.46; 95% CI, 0.37-0.59), while older provider identification of IPV was associated with higher odds of MHS utilization (OR, 1.33; 95% CI, 1.07-1.65). CONCLUSIONS: Additional training for providers, particularly those who are younger or are practicing in emergency departments, may be needed to increase rates of MHS utilization among patients affected by IPV. Addressing language barriers to care and cultural appropriateness may improve MHS utilization.

The impact of limited English proficiency and physician language concordance on reports of clinical interactions among patients with diabetes: the DISTANCE study.

OBJECTIVE: To assess the association of limited English proficiency (LEP) and physician language concordance with patient reports of clinical interactions. METHODS: Cross-sectional survey of 8638 Kaiser Permanente Northern California patients with diabetes. Patient responses were used to define English proficiency and physician language concordance. Quality of clinical interactions was based on 5 questions drawn from validated scales on communication, 2 on trust, and 3 on discrimination. RESULTS: Respondents included 8116 English-proficient and 522 LEP patients. Among LEP patients, 210 were language concordant and 153 were language discordant. In fully adjusted models, LEP patients were more likely than English-proficient patients to report suboptimal interactions on 3 out of 10 outcomes, including 1 communication and 2 discrimination items. In separate analyses, LEP-discordant patients were more likely than English-proficient patients to report suboptimal clinician-patient interactions on 7 out of 10 outcomes, including 2 communication, 2 trust, and 3 discrimination items. In contrast, LEP-concordant patients reported similar interactions to English-proficient patients. CONCLUSIONS: Reports of suboptimal interactions among patients with LEP were more common among those with language-discordant physicians. PRACTICE IMPLICATIONS: Expanding access to language concordant physicians may improve clinical interactions among patients with LEP. Quality and performance assessments should consider physician-patient language concordance.

The association between the number of prescription medications and incident falls in a multi-ethnic population of adult type-2 diabetes patients: the diabetes and aging study.

BACKGROUND: Use of four or more prescription medications is considered a risk factor for falls in older people. It is unclear whether this polypharmacy-fall relationship differs for adults with diabetes. OBJECTIVE: We evaluated the association between number of prescription medications and incident falls in a multi-ethnic population of type-2 diabetes patients in order to establish an evidence-based medication threshold for fall risk in diabetes. DESIGN: Baseline survey (1994-1997) with 5 years of longitudinal follow-up. PARTICIPANTS: Eligible subjects (N = 46,946) had type-2 diabetes, were >or=18 years old, and enrolled in the Kaiser Permanente Northern California Diabetes Registry. MEASUREMENTS AND MAIN RESULTS: We identified clinically recognized incident falls based on diagnostic codes (ICD-9 codes: E880-E888). Relative to regimens of 0-1 medications, regimens including 4 or more prescription medications were significantly associated with an increased risk of falls [4-5 medications adjusted HR 1.22 (1.04, 1.43), 6-7 medications 1.33 (1.12, 1.58), >7 medications 1.59 (1.34, 1.89)]. None of the individual glucose-lowering medications was found to be significantly associated with a higher risk of falls in predictive models. CONCLUSIONS: The prescription of four or more medications was associated with an increased risk of falls among adult diabetes patients, while no specific glucose-lowering agent was linked to increased risk. Baseline risk of falls and number of baseline medications are additional factors to consider when deciding whether to intensify diabetes treatments.

Ethnic differences in anemia among patients with diabetes mellitus: the Diabetes Study of Northern California (DISTANCE).

To examine ethnic differences in hemoglobin testing practices and to test the hypothesis that ethnicity is an independent predictor of anemia among patients with diabetes mellitus. We conducted a panel study to assess the rate of hemoglobin testing during 1999-2001 and the period prevalence and incidence of anemia among 79,985 adults with diabetes mellitus receiving care within Kaiser Permanente of Northern California. Anemia was defined as hemoglobin <13.0 g/dL in men or < 12.0 g/dL in women. Overall, 82.1% of the cohort was tested for anemia at least once during the 3-year study period. Mixed ethnicity patients were most likely to be tested, followed by whites, blacks, Latinos, and Asians (P < 0.0001). Fifteen percent of the cohort had prevalent anemia at baseline, and an additional 22% of those tested developed anemia during the study period. Anemia was more prevalent among blacks and mixed ethnicity persons compared with other racial/ethnic groups. Anemia was also more prevalent among those >/=70 years of age or with estimated glomerular filtration rate <60 ml/min/1.73 m(2). In multivariable models, blacks had higher and Asians had lower odds of prevalent anemia and hazard ratios of incident anemia compared with whites. Within a large, diverse cohort with diabetes, ethnicity was predictive of anemia, even after adjustment for age, level of kidney function, and other potential confounders. Blacks with diabetes are at increased risk of anemia relative to whites. These differences may account for some of the observed ethnic disparities in diabetes complications.

Generational status and duration of residence predict diabetes prevalence among Latinos: the California Men's Health Study.

BACKGROUND: Diabetes disproportionately affects Latinos. However, examining Latinos as one group obscures important intra-group differences. This study examined how generational status, duration of US residence, and language preference are associated with diabetes prevalence and to what extent these explain the higher prevalence among Latinos. METHODS: We determined nativity, duration of US residence, language preference, and diabetes prevalence among 11 817 Latino, 6109 black, and 52 184 white participants in the California Men's Health Study. We combined generational status and residence duration into a single migration status variable with levels: > or = third generation; second generation; and immigrant living in the US for > 25, 16-25, 11-15, or < or = 10 years. Language preference was defined as language in which the participant took the survey. Logistic regression models were specified to assess the associations of dependent variables with prevalent diabetes. RESULTS: Diabetes prevalence was 22%, 23%, and 11% among Latinos, blacks, and whites, respectively. In age-adjusted models, we observed a gradient of risk of diabetes by migration status among Latinos. Further adjustment for socioeconomic status, obesity and health behaviors only partially attenuated this gradient. Language preference was a weak predictor of prevalent diabetes in some models and not significant in others. In multivariate models, we found that odds of diabetes were higher among US-born Latinos than US-born blacks. CONCLUSION: Generational status and residence duration were associated with diabetes prevalence among middle-aged Latino men in California. As the Latino population grows, the burden of diabetes-associated disease is likely to increase and demands public health attention.

New prescription medication gaps: a comprehensive measure of adherence to new prescriptions.

OBJECTIVE: Describe a novel approach to comprehensively summarize medication adherence. DATA SOURCES/STUDY SETTING: Kaiser Permanente Northern California Diabetes Registry (n approximately 220,000) STUDY DESIGN: In a new prescription cohort design (27,329 subjects prescribed new medications), we used pharmacy utilization data to estimate adherence during 24 months follow-up. Proportion of time without sufficient medications (medication gaps) was estimated using a novel measure (New Prescription Medication Gaps [NPMG]) and compared with a traditional measure of adherence. DATA COLLECTION/EXTRACTION METHODS: Data derived from electronic medical records and survey responses. PRINCIPAL FINDINGS: Twenty-two percent of patients did not become ongoing users (had zero or only one dispensing of the new prescription). The proportion of newly prescribed patients that never became ongoing users was eightfold greater than the proportion who maintained ongoing use, but with inadequate adherence. Four percent of those with at least two dispensings discontinued therapy during the 24 months follow-up. NPMG was significantly associated with high out-of-pocket costs, self-reported adherence, and clinical response to therapy. CONCLUSIONS: NPMG is a valid adherence measure. Findings also suggest a larger burden of inadequate adherence than previously thought. Public health efforts have traditionally focused on improving adherence in ongoing users; clearly more attention is needed to address nonpersistence in the very first stages after a new medication is prescribed.

The relationship between alcohol consumption and glycemic control among patients with diabetes: the Kaiser Permanente Northern California Diabetes Registry.

BACKGROUND: Alcohol consumption is a common behavior. Little is known about the relationship between alcohol consumption and glycemic control among people with diabetes. OBJECTIVE: To evaluate the association between alcohol consumption and glycemic control. DESIGN: Survey follow-up study, 1994-1997, among Kaiser Permanente Northern California members. PATIENTS: 38,564 adult diabetes patients. MEASUREMENTS: Self-reported alcohol consumption, and hemoglobin A1C (A1C), assessed within 1 year of survey date. Linear regression of A1C by alcohol consumption was performed, adjusted for sociodemographic variables, clinical variables, and diabetes disease severity. Least squares means estimates were derived. RESULTS: In multivariate-adjusted models, A1C values were 8.88 (lifetime abstainers), 8.79 (former drinkers), 8.90 (<0.1 drink/day), 8.71 (0.1-0.9 drink/day), 8.51 (1-1.9 drinks/day), 8.39 (2-2.9 drinks/day), and 8.47 (>/=3 drinks/day). Alcohol consumption was linearly (p < 0.001) and inversely (p = 0.001) associated with A1C among diabetes patients. CONCLUSIONS: Alcohol consumption is inversely associated with glycemic control among diabetes patients. This supports current clinical guidelines for moderate levels of alcohol consumption among diabetes patients. As glycemic control affects incidence of complications of diabetes, the lower A1C levels associated with moderate alcohol consumption may translate into lower risk for complications.

Racial discrimination & health: pathways & evidence.

This review provides an overview of the existing empirical research of the multiple ways by which discrimination can affect health. Institutional mechanisms of discrimination such as restricting marginalized groups to live in undesirable residential areas can have deleterious health consequences by limiting socio-economic status (SES) and creating health-damaging conditions in residential environments. Discrimination can also adversely affect health through restricting access to desirable services such as medical care and creating elevated exposure to traditional stressors such as unemployment and financial strain. Central to racism is an ideology of inferiority that can adversely affect non-dominant groups because some members of marginalized populations will accept as true the dominant society's ideology of their group's inferiority. Limited empirical research indicates that internalized racism is inversely related to health. In addition, the existence of these negative stereotypes can lead dominant group members to consciously and unconsciously discriminate against the stigmatized. An overview of the growing body of research examining the ways in which psychosocial stress generated by subjective experiences of discrimination can affect health is also provided. We review the evidence from the United States and other societies that suggest that the subjective experience of discrimination can adversely affect health and health enhancing behaviours. Advancing our understanding of the relationship between discrimination and health requires improved assessment of the phenomenon of discrimination and increased attention to identifying the psychosocial and biological pathways that may link exposure to discrimination to health status.