Faculty Bibliography

This column discusses "cultural activation," defined as a consumer's recognition of the importance of providing cultural information to providers about cultural affiliations, challenges, views about, and attitudes toward behavioral health and general medical health care, as well as the consumer's confidence in his or her ability to provide this information. An aid to activation, "Cultural Activation Prompts," and a scale that measures a consumer's level of activation, the Cultural Activation Measurement Scale, are described. Suggestions are made about ways to introduce cultural activation as a component of usual care.

Adolescent obesity continues to be a major public health issue with a third of American adolescents being overweight or obese. Excess weight is associated with cardiovascular risk factors and pre-diabetes. High school students identified as carrying excess weight [body mass index (BMI) >/=25 kg/m2, or BMI percentile >/=85 %] were invited to participate in The BODY Project, an intervention that included a medical evaluation and a personalized medical report of the results of that evaluation sent to the parent/guardian at home. The medical evaluation and report was repeated 12 months later. The reports also contained advice on how the individual student could modify their lifestyle to improve the specific medical parameters showing abnormalities. Outcomes were change in BMI, blood pressure, high-density lipoprotein (HDL), low-density lipoprotein (LDL), fasting glucose, and fasting insulin. Students participating in The BODY Project intervention demonstrated modest, yet significant, reductions in BMI (p < 0.001) 1 year later, and also had significant improvements in systolic blood pressure (p < 0.001) and cholesterol profile (HDL p = 0.002; LDL p < 0.001) at follow-up. The BODY Project, by means of a minimal educational program anchored on the principle of teachable moments around the students' increased perception of their own risk for disease from the medical abnormalities uncovered, demonstrates evidence of potential effectiveness in addressing adolescent obesity.

Adolescent overweight/obesity (OW/O) has reached epidemic proportions. The Youth Self-Report (YSR) was administered to 514 primarily Hispanic urban high school students to examine the relationship between weight and psychological distress. YSR and study population-specific norms were used to assess risk on Anxious/Depressed, Withdrawn/Depressed, Somatic Complaints, and Social Problems scales. OW/O status increased Social Problems regardless of norms. OW/O students endorsed greater Withdrawn/Depressed symptoms with YSR norms; greater Anxious/Depressed and Somatic Complaints were endorsed with population-specific norms. Females drive results. Findings suggest norms need to incorporate minority and economically disadvantaged groups.

OBJECTIVE Nationwide studies contrasting service use of racial-ethnic groups provide an overview of disparities, but because of variation in populations and service systems, local studies are required to identify specific targets for remedial action. The authors report on the use of non-inpatient services regulated in New York State (NYS) and report use by the state's larger cultural groups. METHODS Data from the NYS Patient Characteristics Survey were used to estimate annual treated prevalence and treatment intensity, defined as the average number of annual weeks in service for non-Hispanic blacks, Hispanics, Asians, and non-Hispanic whites. The latter rates were obtained for specific types of treatment use, by person's age and diagnosis, for the state and for population density-defined regions. Statistical methods contrasted rates of whites with other groups. RESULTS A total of 578,496 individuals in these racial-ethnic groups were served in 2,500 programs, and 51% of those served were nonwhite. Treated prevalence rates of whites were lower than those of blacks and Hispanics and were substantially higher than prevalence rates for Asians. Statewide treatment intensity rates of all racial-ethnic and age groups were comparable except for lower use among Asians >65. Key findings from granular analyses were lower treatment intensity rates for black youths with disruptive disorders, Hispanic adults with anxiety disorders, and Asians >65 with depression compared with white counterparts. In upstate metropolitan areas, black youths and Hispanic adults received services in fewer weeks than whites, and in the New York City metropolitan area, whites >65 had higher treatment intensity rates than contrast groups. CONCLUSIONS Findings suggest a need for assistance to black families in negotiating the multiple systems used by their children, clinical training focusing on cultural symptom presentation, screening of Asians in community settings, and mandated cultural competency assessments for all programs.

BACKGROUND: Falling duration of psychiatric inpatient stays over the past 2 decades and recent recommendations to tighten federal regulation of electroconvulsive therapy (ECT) devices have focused attention on trends in ECT use, but current national data have been unavailable. METHODS: We calculated the annual number of inpatient stays involving ECT and proportion of general hospitals conducting the procedure at least once in the calendar year with a national sample of discharges from 1993 to 2009. We estimated adjusted probabilities that inpatients with severe recurrent major depression (n = 465,646) were treated in a hospital that conducts ECT and, if so, received the procedure. RESULTS: The annual number of stays involving ECT fell from 12.6 to 7.2/100,000 adult US residents, driven by dramatic declines among elderly persons, whereas the percentage of hospitals conducting ECT decreased from 14.8% to 10.6%. The percentage of stays for severe recurrent major depression in hospitals that conducted ECT fell from 70.5% to 44.7%, whereas receipt of ECT where conducted declined from 12.9% to 10.5%. For depressed inpatients, the adjusted probability that the treating hospital conducts ECT fell 34%, whereas probability of receiving ECT was unchanged for patients treated in facilities that conducted the procedure. Adjusted declines were greatest for elderly persons. Throughout the period inpatients from poorer neighborhoods or who were publicly insured or uninsured were less likely to receive care from hospitals conducting ECT. CONCLUSIONS: Electroconvulsive therapy use for severely depressed inpatients has fallen markedly, driven exclusively by a decline in the probability that their hospital conducts ECT.

OBJECTIVE: The aim of this study was to identify components of cultural competence in mental health programs developed for cultural groups by community and mental health professionals from these groups. METHODS: Three programs were studied: a prevention program primarily serving African-American and Afro-Caribbean youth, a Latino adult acute inpatient unit, and a Chinese day treatment program in a community-based agency. Nine study-trained field researchers used a semistructured instrument that captures program genealogy, structure, processes, and cultural infusion. Program cultural elements were identified from field notes and from individual and group interviews of consumers and staff (N=104). A research-group consensus process with feedback from program staff was used to group elements by shared characteristics into the program components of cultural competence. RESULTS: Components included communication competencies (with use of colloquialisms and accepted forms of address); staff in culturally acceptable roles; culturally framed trust building (such as pairing youths with mentors), stigma reduction, friendly milieus (such as serving culturally familiar foods and playing music popular with the culture), and services; and peer, family, and community involvement (including use of peer counselors and mentors, hosting parent weekends, and linking clients with senior center and community services). CONCLUSIONS: Incorporating these components into any program in which underserved cultural populations are seen is recommended for improving cultural competence.

The NKI Cultural Competency Assessment Scale measures organizational CC in mental health outpatient settings. We describe its development and results of tests of its psychometric properties. When tested in 27 public mental health settings, factor analysis discerned three factors explaining 65% of the variance; each factor related to a stage of implementation of CC. Construct validity and inter-rater reliability were satisfactory. In tests of predictive validity, higher scores on items related to linguistic and service accommodations predicted a reduction in service disparities for engagement and retention outcomes for Hispanics. Disparities for Blacks essentially persisted independent of CC scores

There is considerable public concern about health disparities among different cultural/racial/ethnic groups. Important process measures that might reflect inequities are treated prevalence and the service utilization rate in a defined period of time. We have previously described a method for estimating N, the distinct number who received service in a year, from a survey of service users at a single point in time. The estimator is based on the random variable 'time since last service', which enables the estimation of treated prevalence. We show that this same data can be used to estimate the service utilization rate, E(J), the mean number of services in the year. If the sample is typical with respect to the time since last visit, the MLE of E(J) is asymptotically unbiased. Confidence intervals and a global test of equality of treated prevalence and service utilization rates among several groups are given. A data set of outpatient mental health services from a county in New York State for which the true values of the parameters are known is analyzed as an illustration of the methods and an appraisal of their accuracy