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2001-2002
2002-2003
University of Maryland
Johns Hopkins University
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| Three recent studies conducted by the JHU/UMD Center for Research on Services for Severe Mental Illness focused on racial differences in the prevalence of affective disorders in general and depression in particular, and differences in use and costs of ambulatory services for mental health care. These studies point to the need for enhanced cross-cultural competence at all levels of mental health care. Background: A growing body of research suggests significant racial disparities in the delivery of medical care. Such disparities can occur at the level of detection or receipt of treatment. Studies of persons without schizophrenia have found that African-Americans are less likely to be diagnosed with an affective disorder and more likely to be diagnosed with a psychotic disorder. These differences could reflect erroneous diagnoses or true differences in prevalence. Approximately 25% of people who suffer from schizophrenia may also have depression, although the estimates vary from 7% to 70%. When depression occurs in conjunction with schizophrenia, it may be a precursor of relapse, it may increase the risk for rehospitalization, and it is likely to be associated with demoralization, hopelessness, and impaired social skills. Most important, the presence of depression may put the person with schizophrenia at risk for suicidal thoughts and, ultimately, completion of a suicide attempt. An unanswered question was whether the potential underdiagnosis of affective disorders found in the absence of schizophrenia would also be observed among persons diagnosed with schizophrenia. Current Research: The consequences of racial differences in the diagnosis of depression in people with schizophrenia have been examined closely, as has treatment for this and other disorders that sometimes occur in conjunction with schizophrenia. A consecutively admitted sample of psychiatric inpatients diagnosed with schizophrenia (n=123) was assessed for depression using the SCID and for quality of life. The odds of being diagnosed with depression were seven times greater in Caucasians than in African-Americans. Depression was significantly associated with reduced life satisfaction in Caucasians but not African-Americans. Data from a large sample of patients diagnosed with schizophrenia (n=685) interviewed in the Schizophrenia Patient Outcomes Research Team (PORT) study also showed disparities by race in self-reported past and current diagnoses, and with current treatment for depression, mania and anxiety disorders. African-Americans were significantly less likely to report having a past diagnosis, current diagnosis or current treatment of these disorders than were Caucasians. The Schizophrenia PORT project also examined claims for Medicare recipients with schizophrenia, using a 5 percent random sample of all people with at least one Medicare service claim (inpatient or outpatient) in 1991 and who were diagnosed as having schizophrenia in any care setting (n=12,440). Among adults under 65, Caucasians were almost 1.5 times more likely than African Americans to have received an ambulatory care mental health service, and 1.3 times more likely to have received individual therapy. Significance: These three studies focus attention on disparities experienced by African-Americans with schizophrenia in the diagnosis and treatment of depression and other affective disorders, and in their use of ambulatory mental health services generally. The findings concerning depression suggest it is under-diagnosed among African Americans with schizophrenia. However, the fact that quality of life ratings were lower among Caucasians with depression but not among African-Americans casts doubt on the validity of the depression diagnosis using conventional diagnostic tools. The concomitant disparity in service use by Medicare recipients under age 65 implies underprovision of care to African-Americans. While various explanations are possible, all point to the need for enhanced cross-cultural competence at all levels of mental health care. The risks of underdiagnosis and misdiagnosis of depression are very likely to be considerable and include suicide and psychotic relapse. REFERENCES: Delahanty J, Ram R, Postrado L, Balis T, Green-Paden L, Dixon L. Differences in rates of depression in schizophrenia by race. Schizophrenia Bulletin 2001; 27(1): 29-38. Dixon L, Green-Paden L, Delahanty J, Lucksted A, Postrado L, Hall J. Variables associated with disparities in treatment of patients with schizophrenia and co-morbid mood and anxiety disorders. Psychiatric Services, 2001,52(9): 1216--1222. Dixon L, Lyles A, Smith C, Hoch JS, Fahey M, Postrado L, Lucksted A, Lehman A. Use and costs of ambulatory care services among Medicare payments to persons with schizophrenia. Psychiatric Services 2001; 52: 786-792. Last Updated November 12, 2002
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