Faculty Bibliography

Growing awareness of health and health care disparities highlights the importance of including information about race, ethnicity, and culture (REC) in health research. Reporting of REC factors in research publications, however, is notoriously imprecise and unsystematic. This article describes the development of a checklist to assess the comprehensiveness and the applicability of REC factor reporting in psychiatric research publications. The 16-item GAP-REACH checklist was developed through a rigorous process of expert consensus, empirical content analysis in a sample of publications (N = 1205), and interrater reliability (IRR) assessment (N = 30). The items assess each section in the conventional structure of a health research article. Data from the assessment may be considered on an item-by-item basis or as a total score ranging from 0% to 100%. The final checklist has excellent IRR (kappa = 0.91). The GAP-REACH may be used by multiple research stakeholders to assess the scope of REC reporting in a research article.

OBJECTIVE: To compare the effectiveness of standard and patient-centered, culturally tailored collaborative care (CC) interventions for African American patients with major depressive disorder (MDD) over 12 months of follow-up. DATA SOURCES/STUDY SETTING: Twenty-seven primary care clinicians and 132 African American patients with MDD in urban community-based practices in Maryland and Delaware. STUDY DESIGN: Cluster randomized trial with patient-level, intent-to-treat analyses. DATA COLLECTION/EXTRACTION METHODS: Patients completed screener and baseline, 6-, 12-, and 18-month interviews to assess depression severity, mental health functioning, health service utilization, and patient ratings of care. PRINCIPAL FINDINGS: Patients in both interventions showed statistically significant improvements over 12 months. Compared with standard, patient-centered CC patients had similar reductions in depression symptom levels (-2.41 points; 95 percent confidence interval (CI), -7.7, 2.9), improvement in mental health functioning scores (+3.0 points; 95 percent CI, -2.2, 8.3), and odds of rating their clinician as participatory (OR, 1.48, 95 percent CI, 0.53, 4.17). Treatment rates increased among standard (OR = 1.8, 95 percent CI 1.0, 3.2), but not patient-centered (OR = 1.0, 95 percent CI 0.6, 1.8) CC patients. However, patient-centered CC patients rated their care manager as more helpful at identifying their concerns (OR, 3.00; 95 percent CI, 1.23, 7.30) and helping them adhere to treatment (OR, 2.60; 95 percent CI, 1.11, 6.08). CONCLUSIONS: Patient-centered and standard CC approaches to depression care showed similar improvements in clinical outcomes for African Americans with depression; standard CC resulted in higher rates of treatment, and patient-centered CC resulted in better ratings of care.

OBJECTIVE: The authors explored the process of implementing a medical student-initiated program designed to provide computerized mental health screening, referral, and education in a homeless shelter. METHOD: An educational program was designed to teach homeless shelter staff about psychiatric disorders and culturally-informed treatment strategies. Pre- and post-questionnaires were obtained in conjunction with the educational program involving seven volunteer shelter staff. A computerized mental health screening tool, Quick Psycho-Diagnostics Panel (QPD), was utilized to screen for the presence of nine psychiatric disorders in 19 volunteer homeless shelter residents. RESULTS: Shelter staffs' overall fund of knowledge improved by an average of 23% on the basis of pre-/post-questionnaires (p=0.005). Of the individuals who participated in the mental health screening, 68% screened positive for at least one psychiatric disorder and were referred for further mental health care. At the 3-month follow-up of these individuals, 46% of those referred had accessed their referral services as recommended. CONCLUSIONS: Medical student-initiated psychiatric outreach programs to the homeless community have the potential to reduce mental health disparities by both increasing access to mental health services and by providing education. The authors discuss educational challenges and benefits for the medical students involved in this project.

A crisis in the behavioral health care workforce has drawn considerable attention from consumers, families, advocates, clinical professionals, and system administrators at local, state, and federal levels in the past decade. Its effects have been felt in the recruitment, retention, and performance of psychiatrists in the public sector, where a focus on biological aspects of illness and efforts to cut costs have made it difficult for public psychiatrists to engage meaningfully in leadership, consultation, prevention, and psychosocial interventions. An array of training opportunities has recently been created to meet the needs of community psychiatrists at various stages of their careers, from psychiatrists just beginning their careers to those who have been working as medical directors for several years. This article describes the development of these initiatives and their impact on public psychiatry in four key areas--training of experienced psychiatrists, ensuring retention of psychiatrists in community programs, providing fellowship training, and creating professional identity and pride. Although these programs constitute only initial steps, opportunities for psychiatrists to obtain advanced training in community psychiatry are much greater now than they were ten years ago. These initiatives will enhance the professional identity of community psychiatrists and provide a solid foundation for future development of public service psychiatry in the behavioral health workforce.

It has been estimated that as many as two-thirds of American youth experience a potentially life-threatening event before 18 years of age and that half have experienced multiple potentially traumatic events. Race, ethnicity, and culture influence the frequency and nature of these traumas and also the ways in which children react to traumatic events. The authors discuss the varied influences of cultural background on these reactions to trauma, the varying presentations of diverse children experiencing troubling reactions, and the need to provide treatment to children and their families in a fashion that is culturally sensitive and acceptable to diverse families.

BACKGROUND: Several studies document disparities in access to care and quality of care for depression for African Americans. Research suggests that patient attitudes and clinician communication behaviors may contribute to these disparities. Evidence links patient-centered care to improvements in mental health outcomes; therefore, quality improvement interventions that enhance this dimension of care are promising strategies to improve treatment and outcomes of depression among African Americans. This paper describes the design of the BRIDGE (Blacks Receiving Interventions for Depression and Gaining Empowerment) Study. The goal of the study is to compare the effectiveness of two interventions for African-American patients with depression--a standard quality improvement program and a patient-centered quality improvement program. The main hypothesis is that patients in the patient-centered group will have a greater reduction in their depression symptoms, higher rates of depression remission, and greater improvements in mental health functioning at six, twelve, and eighteen months than patients in the standard group. The study also examines patient ratings of care and receipt of guideline-concordant treatment for depression. METHODS/DESIGN: A total of 36 primary care clinicians and 132 of their African-American patients with major depressive disorder were recruited into a cluster randomized trial. The study uses intent-to-treat analyses to compare the effectiveness of standard quality improvement interventions (academic detailing about depression guidelines for clinicians and disease-oriented care management for their patients) and patient-centered quality improvement interventions (communication skills training to enhance participatory decision-making for clinicians and care management focused on explanatory models, socio-cultural barriers, and treatment preferences for their patients) for improving outcomes over 12 months of follow-up. DISCUSSION: The BRIDGE Study includes clinicians and African-American patients in under-resourced community-based practices who have not been well-represented in clinical trials to improve depression care. The patient-centered and culturally targeted approach to depression care is a relatively new one that has not been tested in most previous studies. The study will provide evidence about whether patient-centered accommodations improve quality of care and outcomes to a greater extent than standard quality improvement strategies for African Americans with depression. TRIAL REGISTRATION: ClinicalTrials.gov NCT00243425.

Racial/ethnic minority populations are underserved in the American mental health care system. Disparity in treatment between whites and African Americans has increased substantially since the 1990s. Racial/ethnic minorities may be disproportionately affected by limited English proficiency, remote geographic settings, stigma, fragmented services, cost, comorbidity of mental illness and chronic diseases, cultural understanding of health care services, and incarceration. We present a model that illustrates how social determinants of health, interventions, and outcomes interact to affect mental health and mental illness. Public health approaches to these concerns include preventive strategies and federal agency collaborations that optimize the resilience of racial/ethnic minorities. We recommend strategies such as enhanced surveillance, research, evidence-based practice, and public policies that set standards for tracking and reducing disparities.