Closing the Gaps: Reducing Disparities in Mental Health Treatment through Engagement
Sponsored by: National Institute of Mental Health (NIMH)
In September 2013, NIMH convened the meeting, “Closing the Gaps: Scaling Up to Reduce Mental Health Disparities in the United States.” The purpose of the meeting was to address the significant disparities in mental health care related to race and ethnicity. NIMH brought together leading experts in disparities research and practice from the public and private sectors to address specific questions and present relevant research findings. Participants included representatives from within the NIH community, other federal agencies, and researchers charged with improving the Nation’s mental health equity. The workshop was organized around the following questions:
- What areas of mental health services research are likely to result in a measurable increase in health equity within the next 10 years?
- What are the key implementation research directions most likely to result in greater mental health care equity within the next decade in varied service contexts?
- What opportunities do changing health system environments present for high impact research focused on mental health disparities reduction?
- What new intervention research directions should accompany a focused effort to implement existing effective interventions?
The meeting began with presentations by Sean Joe, PhD, LMSW and Benjamin Cook, PhD, MPH on the epidemiology of disparities in mental health service patterns. Across virtually every therapeutic intervention, minorities receive fewer procedures and poorer quality medical care than Whites. Furthermore, knowledge of geographic disparities in access to mental health care may hold potential for the development of State-based reporting systems that guide future actions to reduce disparities. Subsequent presentations by Kenneth Wells, MD, MPH, Jeanne Miranda, PhD, and Loretta Jones, MA described successes in evidence-based interventions with demonstrated efficacy in reducing disparities in initiation of and engagement in mental health services. Culturally adapted interventions using care managers improved treatment initiation, patient activation, and self-management among minorities with limited English proficiency and limited health literacy. Participants also described community-partnered participatory research using a collaborative care model (i.e., team approaches that use case managers to link primary care providers, patients, and mental health specialists) that resulted in improved mental health quality of life and reduced hospitalizations for mental disorders.
John O’Brien, MA from the Centers for Medicare and Medicaid (CMS) described planned changes in Medicaid eligibility and enrollment guidelines. He stated that CMS is focused on ensuring that services are delivered in the most integrated settings. Francisca Azocar, PhD, from Optum Health, a private health insurance company that provides counseling services and mental health treatment noted that fundamental levers are changing in health care delivery systems, and suggested that these levers be used to reduce disparities. The aims would be improved population health and patient-centered and affordable care. The first day ended with a look at efforts needed to reduce mental health disparities, presented by Margarita Alegría, PhD. The current workforce shortage, an inability to meet clients’ language needs, and a lack of culturally adapted evidence-based interventions create barriers to the treatment of increasingly diverse populations.
On the second day, Hendricks Brown, PhD, and Zac Imel, PhD, discussed the importance of identifying interventions that can reduce health disparities by synthesizing findings across trials using individual-level data. An NIMH-funded study combined data from 40 existing prevention and treatment trials. This effort indicated that a synthesis approach provides sufficient data on minority populations to determine which interventions work. Combining sources of “big data” could have a dramatic impact on disparities research. This approach will be especially effective as the field moves toward the use of common data elements across disorders.
In other sessions presented by Richard Frank, PhD, and Lisa Colpe, PhD, MPH, current health care reforms were analyzed in terms of possible benefits and barriers to disparities reduction. Reforms are expected to increase service coverage for those with mental and substance use disorders, integrate mental health treatment with general medical care, and coordinate the care of those with complex illnesses. However, the introduction of these reforms is taking place while the mental health field is still in the early stages of understanding how to scale interventions for vulnerable populations. It will be crucial to understand the effects of new organizational structures and payment systems on mental health outcomes and disparities. There will be time-critical windows for determining what is effective and institutionalizing these models. Participants agreed on the need for rapid support and dissemination mechanisms for promising research.
The final speaker, Patricia Areán, PhD, addressed the use of digital technologies in mental health. Data indicate that minorities use mobile health apps more than Whites and that there is high usage of smart phones and tablets among African Americans and Latinos. Smart phones, games, apps, and social networking all hold promise in areas such as community support, medication reminders, stigma reduction, and real-time data collection.
Facilitators Roberto Lewis-Fernández, MD, Lisa Dixon, MD, MPH, and Dr. Miranda led the group in a roundtable discussion of high-impact research that could facilitate disparities reduction. The discussion centered on:
- The need to create or reinstate a rapid-turnaround mechanism to support and disseminate research on health care reform;
- Rapid evaluation of the health system environment; and,
- How can interventions be tailored for specific communities to reduce disparities and achieve results in a short time frame?
Several key messages emerged. Participants agreed that the current workforce shortage in mental health must be addressed, as there will be a large influx of clients into the mental health system. Many will have complex needs that some providers are not equipped to address. The system therefore needs processes to identify and measure competencies, as licensure is not sufficient. In addition, solo practices and standalone facilities must prepare to link into newly emerging integrated care systems. Participants also noted that development and evaluation of mobile and Internet technologies are needed to target multilingual, underserved populations. Such efforts can build on the pervasiveness of smart phone and tablet ownership by minority populations, even in low-income areas. Research funders could also explore existing opportunities to capitalize on practice-based research, including collaboration with other federal agencies that are repositories of valuable information on mental health. As an example, practice knowledge from the Substance Abuse and Mental Health Services Administration, which does not typically conduct evaluation, could be used to inform NIMH research. As the meeting closed, participants agreed that the conversation had advanced shared ideas on how to improve access and outcomes for disadvantaged populations with mental disorders.