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Addressing Disparities: Advancing Mental Health Care for All Americans

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As I sit down to write this message, I’m thinking of two former patients. One of them, a Hispanic man, I met in the emergency room at NewYork-Presbyterian Hospital when I was a resident in the early 2000s. Floridly psychotic, disheveled, and homeless, he was shouting at the emergency room nurse when I first saw him, demanding medications that he said were stolen from a locker in the homeless shelter across the street. The second patient, a White woman, was referred to my private practice in Midtown Manhattan a few years later. Composed and controlled, she asked compelling questions about her illness and its management, bringing with her dozens of pages of medical records. Both patients were young adults. Both had severe bipolar disorder. Both had survived a suicide attempt. Their medication lists were the same. Their lives were not.

Differences in health outcomes like these can reflect a number of underlying factors, including biological factors or environmental exposures; social, economic, and cultural contexts; and access to quality health care. When these differences adversely affect disadvantaged populations, they are known as health disparities.

Disparities in mental health are significant and easily documented. Deaths by suicide, for example, are much more common in American Indians and Alaska Natives compared to the general population. The rate of deaths by suicide is also higher in rural areas. Another example: Black and Hispanic children may be diagnosed with autism at a later age compared to White children. That is an important factor because the earlier the diagnosis, the earlier treatment can start, and the earlier treatment starts, the better these children will do. These and other mental health disparities further disadvantage members of minority groups and increase the burden of mental illnesses on individuals, families, and communities.

Accordingly, the National Institute of Mental Health (NIMH) supports a research agenda aimed at understanding and reducing mental health disparities. One early success comes from research led by Emily Haroz, Ph.D., a promising early-career investigator at the Johns Hopkins Bloomberg School of Public Health. Using an approach that has worked for the U.S. Army, the U.S. Department of Veterans Affairs, and a group of health management organizations (HMOs), Haroz and colleagues built an algorithm that uses electronic health record data to identify individuals in the White Mountain Apache Tribe in Arizona who are at increased risk of suicide. Such a predictor could be used by health professionals to refer these individuals to appropriate mental health care. Meanwhile, NIMH continues to support three hubs for collaborative research focused on suicide prevention in Native American communities. These hubs are busy establishing common protocols for novel interventions and testing the efficacy of these interventions. This research holds the promise of making a real difference in the near term, helping health professionals and community leaders understand how to reduce deaths by suicide in their communities.

Similar efforts are underway in other communities to help families with children who may have autism. The Autism Spectrum Disorder Pediatric, Early Detection, Engagement and Services Network (ASD PEDS) is an NIMH-funded network of investigators studying a diverse array of strategies and interventions aimed at identifying and treating children with autism as early as possible. This collaborative group is committed to eliminating disparities by reducing the age at which children from underserved populations are diagnosed and has several projects that are nearing completion. For example, Alice Carter, Ph.D., at the University of Massachusetts Boston, is finishing a study designed to test whether a system-level intervention can reduce these disparities. The intervention involves outreach to primary care pediatricians, a comprehensive multi-stage screening process, and motivational interviewing with parents and other caregivers. Wendy Stone, Ph.D., at the University of Washington, is testing a complementary intervention that aims to reduce disparities by improving screening and referral procedures in primary care pediatric practices. Stone and colleagues will examine the acceptability and efficacy of the intervention in four diverse communities.

While we at NIMH are justifiably proud of these and other investments in research on mental health disparities, I can’t help but ask whether similar projects would remedy the disparate situations faced by my former patients. Would early intervention have saved my first patient from homelessness? Are there treatment approaches for bipolar disorder that work better for individuals from disadvantaged backgrounds? How can we promote better access to and engagement in community-based mental health care? These are the sorts of questions we need to answer to ensure that improved mental health care meets the needs of all Americans.

References

Allen. J., Rasmus, S. M., Fok, C. C. T., Charles, B., Henry, D., & Qungasvik Team. (2018). Multi-level cultural intervention for the prevention of suicide and alcohol use risk with Alaska Native youth: A nonrandomized comparison of treatment intensity. Prevention Science, 19(2), 174-185. doi:10.1007/s11121-017-0798-9

Daniels, A. M., & Mandell, D. S. (2014). Explaining differences in age at autism spectrum disorder diagnosis: a critical review. Autism, 18(5), 583-597. doi: 0.1177/136236131348027

Haroz, E. E., Walsh, C. G., Goklish, N., Cwik, M. F., O'Keefe, V., & Barlow, A. (2019). Reaching those at highest risk for suicide: Development of a model using machine learning methods for use with Native American communities. Suicide and Life-Threatening Behavior. doi:10.1111/sltb.12598

Ibañez, L. V., Stoep, A. V., Myers, K., Zhou, C., Dorsey, S., Steinman, K. J., Stone, W. L. (2019). Promoting early autism detection and intervention in underserved communities: Study protocol for a pragmatic trial using a stepped-wedge design. BMC Psychiatry, 19, 169. doi:10.1186/s12888-019-2150-3

Ivey-Stephenson, A. Z., Crosby, A. E., Jack, S. P., Haileyesus, T., & Kresnow-Sedacca, M. (2017). Suicide trends among and within urbanization levels by sex, race/ethnicity, age group, and mechanism of death — United States, 2001–2015. MMWR Surveillance Summary, 66(No. SS-18), 1–16. doi:10.15585/mmwr.ss6618a1

O'Keefe, V. M., Haroz, E. E., Goklish, N., Ivanich, J., The Celebrating Life Team, Cwik, M. F., & Barlow, A. (2019). Employing a sequential multiple assignment randomized trial (SMART) to evaluate the impact of brief risk and protective factor prevention interventions for American Indian youth suicide. BMC Public Health, 19, 1675. doi:10.1186/s12889-019-7996-2.