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The role of primary care in the use of specialty mental health services: an investigation of utilization patterns among African Americans and non-Hispanic Whites

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The role of primary care in the use of specialty mental health services: an investigation of utilization patterns among African Americans and non-Hispanic Whites

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Content Running Head: ROLE OF PRIMARY CARE IN SPECIALTY CARE USE The Role of Primary Care in the Use of Specialty Mental Health Services: An Investigation of Utilization Patterns among African Americans and Non-Hispanic Whites Nina Jhaveri, M.B.A., B.A. Faculty Advisor: Stanley Huey Jr., Ph.D. May 2019 Master of Arts (PSYCHOLOGY) University of Southern California Table of Contents Abstract 3 Introduction 4 Mental health care in general medical settings 4 The relationship between the use of primary and specialty care 6 Methods 9 Sample 9 Procedures 9 Measures 10 Analysis 14 Results 14 Study 1 14 Study 2 15 Discussion 16 Tables 21 References 23 ROLE OF PRIMARY CARE IN SPECIALTY CARE USE 3 Abstract Racial disparities in mental health care in the United States are well documented, particularly with regard to service access, quality of treatment, and treatment outcomes (AHRQ, 2013; Ault-Brutus, 2012; USDHHS, 2001). African Americans are more likely to receive mental health care in primary care settings (Snowden & Pingitore, 2002), where their mental health problems are more likely to go undetected and where they are less likely to receive referrals to specialty care compared to Whites (Borowsky et al., 2000; Lukachko & Olfson, 2012; Miller & McCrone, 2005). Across two studies, we assessed support for three competing hypotheses (i.e., facilitation effect, barriers effect, or inhibition effect) regarding the relationship between primary care and specialty care use for mental health problems. Study 1 tested this relationship in the National Survey of American Life, a national sample of African Americans, and Study 2 replicated this analysis in a second national sample, the National Comorbidity Survey – Replication. Adjusting for covariates and sociodemographic factors in both studies, we found that individuals who used primary care for their mental health needs were less likely to utilize specialty care (Study 1: OR =0.52; 95% CI = 0.35, 0.76; Study 2: OR = 0.21; 95% CI = 0.14, 0.33). Thus, Studies 1 and 2 suggest an inhibition effect of primary care use on specialty care use. Study 2 further examined ethnicity as a moderator of the relationship between primary care and specialty care use, but no effects were found, suggesting a prevalent utilization trend that exists across both ethnic groups. Additional research is warranted to deconstruct the underlying causes of the inhibition effect in order to develop adequate care models that link patients with mental health needs to appropriate care. ROLE OF PRIMARY CARE IN SPECIALTY CARE USE 4 The Role of Primary Care in the Use of Specialty Mental Health Services: An Investigation of Utilization Patterns among African Americans and Non-Hispanic Whites Introduction Racial and ethnic disparities in mental health care have long been recognized as a national concern (AHRQ, 2013; Ault-Brutus, 2012; Cook, McGuire, & Miranda, 2007). The landmark Surgeon General’s report on Mental Health (USDHHS, 2001) highlighted three main issues regarding these disparities: Compared to Whites, individuals from racial and ethnic minority groups have less access to health care, are less likely to receive treatment for mental illnesses, and are more likely to receive care of poor quality when they do obtain treatment. Analysis of nationally representative samples shows that compared to Whites, African Americans were more likely to report no access to mental health care in the previous 12 months (25% versus 12.5%), even after accounting for perceived need for mental health care (Wells, Klap, Koike, & Sherbourne, 2001). Additional studies also document disparities in treatment outcomes, such as lower response and remission rates among African Africans (Shao, Richie, & Bailey, 2016; Simpson, Krishnan, Kunik, & Ruiz, 2007). Given that effective mental health treatment can mitigate symptomatology and improve quality of life (Cuijpers et al., 2011; Gloaguen, Cottraux, Cucherat, & Blackburn, 1998; Kolovos, Kleiboer, & Cuijpers, 2016), these findings highlight the importance of timely and appropriate treatment for African American populations. Mental health care in general medical settings One factor speculated to contribute to racial disparities in treatment access and quality is that African Americans are more likely to receive mental health services in general medical settings rather than in specialty care (Snowden & Pingitore, 2002; Wang et al., 2006). Why is ROLE OF PRIMARY CARE IN SPECIALTY CARE USE 5 this a concern? Mental illness is often under-recognized and undertreated by primary care providers (Borowsky et al., 2000; Simon & VonKorff, 1995), with one meta-analysis showing that more than half of depression cases go undetected by non-psychiatric medical providers (Cepoiu et al., 2008). Moreover, the likelihood of receiving minimally adequate treatment is lower in the general medical sector compared to the mental health specialty sector (Wang, Demler, & Kessler, 2002) due to shorter and fewer visits and insufficient training of providers to treat mental illness, among other factors (Ettner et al., 2010; Wang et al., 2006, 2002). The limits of primary care are particularly acute for African Americans. Studies show that mental illness among African American patients is more likely to be under-diagnosed by general medical providers compared to Whites. In a study of over 19,000 patients, Borowsky et al. (2000) found that primary care physicians were less likely to identify mental health problems among African Americans than among non-Hispanic Whites. These disparities were documented even though the researchers attempted to avoid underestimation by adopting an inclusive definition of detection that simply asked physicians to report evidence of any “mental health problem.” More recent studies also document a higher likelihood of failure to detect depression or anxiety among African American primary care patients (Lukachko & Olfson, 2012; Stockdale, Lagomasino, Siddique, McGuire, & Miranda, 2008). Thus, it is perhaps not surprising that African Americans are less likely to receive minimally adequate mental health care compared to Whites (Ault- Brutus, 2012). Such ethnic disparities in primary care are concerning, especially given that the general medical care system is considered a critical site of intervention to screen for and diagnose mental disorders and refer patients to specialty mental health treatment (Anthony et al., 2010; Cook et al., 2014). This is partly driven by formal gatekeeping systems in which primary care providers ROLE OF PRIMARY CARE IN SPECIALTY CARE USE 6 are responsible for determining the health care needs of their patients and identifying specialized healthcare services to meet those needs (Forrest, 2003; Trude & Stoddard, 2003). Given the inadequate quality of mental health care provided in general medical settings, timely and appropriate recommendation by primary care providers to specialty mental health professionals is of paramount importance. The relationship between the use of primary and specialty care While the importance of mental health specialty referrals is well documented, there is a paucity of research on how primary care use impacts specialty mental health service use. Few studies have investigated utilization rates of specialty mental health care following primary care use (Bartels et al., 2004; Grembowski et al., 2002; Pfeiffer et al., 2011) and no studies have tested whether this relationship differs for African American patients compared to Whites. Thus, two critical questions are whether the use of primary care facilitates the use of specialty mental health care services, and whether this relationship differs by ethnicity. The current study aimed to address this gap in the literature by testing three competing hypotheses regarding the association between primary care and specialty care utilization. A facilitation effect would be supported if individuals who use primary care are more likely to use specialty care. As noted above, the primary care setting is a critical site of intervention to identify patients who require treatment for a mental health disorder and to recommend use of specialty providers (Anthony et al., 2010; Cook et al., 2014; Forrest, 2003; Trude & Stoddard, 2003; WHO, 2001); therefore, using primary care may facilitate the eventual use of specialty care. A barriers effect would be supported if there is a lack of association between the use of primary care and specialty care services. Patients with mental illness may fail to utilize specialty mental health care due to under-detection of mental illness by the primary care provider and inadequate ROLE OF PRIMARY CARE IN SPECIALTY CARE USE 7 referrals to specialty care. Patients may also face additional constraints that include lack of mental health insurance coverage and less geographic access to or appointment availability for specialty care (Stockdale et al., 2008; Wang et al., 2006). Such patient-level barriers would remain unchanged even after entering the healthcare system at the primary care level, and may thus impede the development of the primary care – specialty care pathway. An inhibition effect would be supported if individuals who use primary care are less likely to use specialty care. As suggested by Le Meyer et al. (Le Meyer, Zane, Cho, & Takeuchi, 2009), primary care may substitute for specialty mental health services. Factors contributing to the inhibition effect may include patient preference for primary care and stigmatizing beliefs towards specialty mental health providers (Chapa, 2004), due to which the patient may seek primary care in lieu of specialty services. As noted earlier, African Americans are more likely than Whites to seek mental health services in the primary care versus specialty care sector (Snowden & Pingitore, 2002; Wang et al., 2006). Furthermore, several studies have shown that African American patients with mental health problems may be less likely than Whites to be referred by general medical care providers to specialty mental care (Miller & McCrone, 2005; Stockdale et al., 2008). Given that the relationship between primary care and specialty care use is impacted by the detection of mental illness in primary care, and considering the racial disparities reported in service utilization, diagnosis of mental illness, and referrals to specialty care by primary care providers, it is possible that ethnicity influences the association between primary and specialty care use. Specifically, primary care use may be associated with specialty care use among Whites but not among African Americans, since African Americans are less likely to be diagnosed with a mental illness or be referred to specialty providers while in primary care settings. Therefore, we ROLE OF PRIMARY CARE IN SPECIALTY CARE USE 8 investigated whether the association between primary and specialty care is moderated by ethnicity. The goal of the current study is to examine the relationship between the use of general medical care and specialty mental health care use and test whether ethnicity moderates this relationship. Our hypotheses are as follows: HI. We propose three competing hypotheses regarding the association between primary care and specialty care use. HIa. Primary care use will be positively associated with specialty care use (facilitation effect). HIb. Primary care use will not be associated with specialty care use (barriers effect). HIc. Primary care use will be negatively associated with specialty care use (inhibition effect). HII. Ethnicity will moderate the relationship between primary care and specialty care use. Primary care use will be positively associated with the use of specialty care among Whites, and will not be associated with the use of specialty care among African Americans. To test the generalizability of our findings, analyses were conducted on two national datasets from the Inter-University Consortium for Political and Social Research. Study 1 employed a national sample of African Americans surveyed as part of the National Survey of American Life (NSAL). Study 2 attempted to replicate and extend these findings in a second national sample, the National Comorbidity Survey – Replication (NCS-R). The NSAL was chosen because it includes a large representative sample of African Americans and is designed to ROLE OF PRIMARY CARE IN SPECIALTY CARE USE 9 explore patterns and prevalence of mental disorders and formal service use (“National Survey of American Life, 2001-2003,” n.d.). The NCS-R was used because it is a large nationally representative general population survey designed to assess racial/ethnic differences in psychiatric disorders and service use. By analyzing data collected in the NCS-R, Study 2 tests whether ethnicity moderates the association between primary and specialty care use. Furthermore, Study 2 extends the analyses by documenting referral requirements of each respondent’s insurance and whether the individual has a Health Maintenance Organization (HMO) plan, factors that were not measured in the NSAL (Study 1). Prior research suggests that HMO insurance and referral requirements may have an effect on a patient’s use of specialty care (Cook, Doksum, Chen, Carle, & Alegría, 2013; Hurley, Freund, & Gage, 1991). Methods Sample Study 1 employed data from the NSAL, which was collected between February 2001 and March 2003 as part of the Collaborative Psychiatric Epidemiology Surveys (CPES; Jackson et al., 2004). The NSAL interview was carried out in predominantly black neighborhoods and included 3,570 African American adults aged 18 or older. The overall response rate was 71.5% (Pennell et al., 2004). Study 2 employed data from the NCS-R, which is also part of the CPES collection. Individual-level interviews were administered between February 2001 and April 2003 (Kessler & Merikangas, 2004). The full NCS-R sample consisted of 9,282 English-speaking adults aged 18 and older, including 1,176 African Americans and 6,696 Whites. The overall response rate was 70.9%. Procedures ROLE OF PRIMARY CARE IN SPECIALTY CARE USE 10 Procedures followed in the NSAL and NCS-R were similar. Both surveys were conducted in the continental United States with a nationally representative sample of respondents. Data were collected using a stratified and clustered sample design, and weights were used to account for unequal probabilities of selection and non-response and to post-stratify the final sample to approximate the distribution of the 2000 Census on a range of socio- demographic variables. The primary mode of data collection was in-person interviewing in the respondent’s home using computer-assisted personal interview (CAPI) methods by trained survey interviewers employed by the Institute for Social Research at the University of Michigan. Both surveys employed the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) developed for the WHO World Mental Health (WMH) Survey Initiative. This instrument, a fully structured diagnostic interview, is called the WMH-CIDI. Measures Service use. Lifetime service use was measured in an identical fashion for the NSAL and NCS-R. Respondents were asked the question, “Which of the following types of professionals did you ever see about problems with your emotions or nerves or your use of alcohol or drugs?” Respondents were allowed to select as many response options as were applicable. Primary care use was defined as seeing a physician (other than a psychiatrist), a nurse, and any other health care professional in a non-mental health setting. Specialty mental health care use included seeing a psychiatrist, psychologist, counselor, or any other professional in a mental health setting. These definitions follow the classification used in other studies of service use among CPES respondents (Ault-Brutus, 2012; Le Meyer et al., 2009; Wang, Lane, et al., 2005). To account for the temporal ordering of service use, we attempted to identified respondents who had first seen a primary care provider before seeing a specialty care provider ROLE OF PRIMARY CARE IN SPECIALTY CARE USE 11 for their mental health needs. Respondents were asked the question, “How old were you the first time you talked to [provider type] about your emotions, nerves, or mental health?” Therefore, the age at which individuals met a provider for the first time was used as a proxy measure to identify the sequencing of service utilization. Individuals who did not meet our criterion (i.e., reported using specialty care for the first time before using primary care for the first time) were excluded from analyses. Diagnostic assessment. Both surveys employed the WMH-CIDI to diagnose a wide range of mental disorders. The WMH-CIDI generates both ICD-10 and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnoses (American Psychiatric Association, 1994). For this study, only respondents who were diagnosed with a mental health disorder were included in the analyses. This criterion aligns with the methodology of a similar study (Le Meyer et al., 2009) that examined the impact of primary care use on specialty care use among Asian Americans. Limiting inclusion criteria to respondents with a diagnosed mental illness helps determine utilization patterns among individuals with an established clinical need for services and may help avoid an underestimation of service use. Respondents with a diagnosis of substance use disorder were excluded from analyses. The literature on mental health service use suggests that individuals with substance use disorder may follow a utilization pattern that is fundamentally different from that of individuals with other mental disorders. Specifically, substance using patients are likely to directly utilize substance abuse self-help groups or specialized addiction treatment or rehabilitation facilities that may include inpatient and residential treatment or intensive outpatient treatment (SAMHSA, 2014). Indeed, of the 4.1 million persons who received treatment for substance use in 2013, over half reported attending a self-help group (SAMHSA, 2014). While substance use patients may ROLE OF PRIMARY CARE IN SPECIALTY CARE USE 12 still utilize primary and specialty care providers in a manner similar to individuals with other mental disorders (Chartier & Caetano, 2011), the presence of the additional utilization pattern described here may confound the results of the study. Insurance type, status and requirements. Based on similar studies investigating service utilization (Meyer, Saw, Cho, & Fancher, 2015), insurance type and status were categorized into one of three options in Study 1: publicly insured, privately insured, and uninsured. When investigating the role that general medical providers play in an individual’s use of specialty mental health care, the status and type of insurance need to be considered. For instance, individuals without insurance are less likely to obtain specialty mental health care (Alegría, Bijl, Lin, Walters, & Kessler, 2000; Ferrer, 2007; Wang, Berglund, et al., 2005). The patient’s insurance status may also influence the primary care provider’s decision to refer to specialty care (Anthony et al., 2010). Respondents aged 65 or older were excluded from the analyses to account for the shift in insurance coverage to Medicare (Card, Dobkin, & Maestas, 2009). Study 2 also accounted for insurance type and status and respondent age as described above. Study 2 accounted for two additional insurance factors: whether the respondent’s health plan is a health maintenance organization (HMO; assessed by the question “Is your health plan an HMO?”) and whether referrals are required to access specialty care (determined by asking “Does your health insurance plan require you to get approval or a referral to see a specialist or to get special care?”). In addition to the type and status of insurance, the structure and requirements of an individual’s insurance may play a role in the relationship between primary and specialty care. HMOs are one type of managed care health plan that delivers care to their members through a network of medical providers and hospitals. Studies have shown that HMO insurance may have an impact on the patient’s use of specialty care (Cook et al., 2013; Stockdale, Tang, ROLE OF PRIMARY CARE IN SPECIALTY CARE USE 13 Zhang, Belin, & Wells, 2007; Weissman, Pettigrew, Sotsky, & Regier, 2000). In addition, specific insurance requirements such as whether a referral is required for the patient to access specialty care may also impact the use of specialty care. Commonly known as “gatekeeping,” wherein primary care providers are responsible for referrals to specialty care professionals, this managed care strategy has been shown to alter the channels through which patients receive care and is associated with greater first contact with a primary care provider (Forrest, 2003). Prior utilization research has shown that patients enrolled in gatekeeping health plans are less likely to see a specialist than those in non-gatekeeping plans with less restricted access to specialists (Hurley et al., 1991; Martin, Diehr, Price, & Richardson, 1989). Using the NCS-R, Study 2 extended the analysis conducted in Study 1 by taking these additional factors into account. Pharmacological treatment. NSAL and NCS-R respondents reported whether they received a prescription for their mental health needs by answering the question, “Did you ever get a prescription or medicine for your emotions, nerves or mental health (or substance use) from any type of professional?” This measure was assessed in an identical fashion across both studies. Pharmacological treatment needs to be considered given that it may impact an individual’s use of specialty mental health care. In a study that investigated national patterns in antidepressant medication treatment from 1996 to 2005, individuals treated with antidepressants were less likely to undergo psychotherapy (Mark Olfson & Marcus, 2009). Studies 1 and 2 therefore took each respondent’s use of pharmacological treatment into account. Sociodemographic correlates. Sociodemographic factors that have been shown to correlate with utilization patterns were adjusted for in Studies 1 and 2; these include age, gender, level of educational attainment, household income, employment status and marital status. Similar ROLE OF PRIMARY CARE IN SPECIALTY CARE USE 14 studies investigating the use of mental health services have adjusted for these correlates (see Le Meyer et al., 2009; Neighbors et al., 2007). Analyses The complex samples module of SPSS 25.0 was used to apply Taylor series linearization and to incorporate the complex sample design of the CPES into survey analyses. The presence of strata, clusters, and sampling weights complicate the estimation of a statistic’s variance. Taylor series linearization is a commonly used method to estimate the variance of such complex survey data and was therefore employed in the analyses. Logistic regressions were performed across Studies 1 and 2. For both studies, the independent variable was primary care use and the dependent variable was specialty care use. For Study 1, insurance status, use of pharmacological treatment and sociodemographic variables were added as covariates to the regression model. Study 2 accounted for the same covariates as those in Study 1 as well as whether the respondent’s health plan was a HMO and whether referrals were required to access specialty care. Primary care use*ethnicity was added as an interaction term to the logistic regression model of Study 2 to test for the moderating effect of ethnicity on the association between primary and specialty care use. Missing values were handled using list-wise deletion; that is, any case without valid data on any dependent or independent variable was excluded from the analyses. Results Study 1 Table 1 shows the demographic characteristics of the sample. Of the original NSAL sample, the present study examined the 1,252 African Americans who met criteria for a psychiatric disorder, were between 18 and 65 years of age, and met criteria for the temporal ROLE OF PRIMARY CARE IN SPECIALTY CARE USE 15 ordering of service use. While all individuals had a diagnosable mental health disorder, 21% used primary care services and 32% used specialty mental health care services. Table 2 presents the odds ratios for variables associated with specialty mental health service utilization. Individuals who received a prescription for their mental health needs were 12 times more likely to use specialty care services than those with no prescription (OR =12.56; 95% CI = 8.28, 19.07). No other covariates were statistically significant in predicting specialty mental health care use. After controlling for insurance, prescription use and sociodemographic variables, individuals who utilized primary care services were less likely to utilize specialty mental health care services than those who did not utilize primary care (OR =0.52; 95% CI = 0.35, 0.76). These findings support the inhibition hypothesis that using primary care may have an inhibitive effect on the use of specialty care. Study 2 Table 2 displays the demographic characteristics and service use of the NCS-R sample. The current study examined 2,075 non-Hispanic Whites and 342 African Americans that met all study criteria, including having a psychiatric diagnosis, ranging from 18 to 65 years, and meeting criteria for the temporal ordering of service use. Among non-Hispanic Whites, 28% and 47% of individuals used primary and specialty care, respectively. Among African Americans, 13% and 30% of individuals reported using primary and specialty care, respectively. Table 2 presents the odds ratios for variables associated with specialty mental health service utilization. Similar to Study 1, individuals who received a prescription were 10 times more likely to use specialty care services than those who had not received a prescription (OR = 10.45; 95% CI = 7.71, 14.16). Unemployed respondents were more likely to utilize specialty care than those who were employed (OR = 1.33; 95% CI = 1.06, 1.67). The odds of using specialty ROLE OF PRIMARY CARE IN SPECIALTY CARE USE 16 care were greater for individuals who were divorced, separated or widowed (OR = 1.98; 95% CI = 1.37, 2.85), when compared to married or cohabiting respondents. After controlling for insurance, HMO status, referral requirements of insurance, prescription use, and sociodemographic variables, individuals who utilized primary care services were less likely to utilize specialty mental health care services than those who did not utilize primary care (OR = 0.21; 95% CI = 0.14, 0.33). Thus, Study 2 replicated the Study 1 findings in support of the inhibition hypothesis. Results from the interaction model showed that the primary care use*ethnicity interaction term was not statistically significant, indicating that ethnicity did not moderate the association between primary care and specialty care use. Finally, one apparent anomaly should be noted for the insurance status variable in Study 2. The odds ratios for insurance status were unexpectedly small and the standard errors were relatively large. Removing insurance status from the model did not impact the overall association between primary and specialty care. Discussion The current study demonstrated that when individuals utilize primary care services for their mental health needs, they are less likely to utilize specialty mental health services. These findings hold across two large, nationally representative samples of adults, thus extending the generalizability of this relationship. This study thus provides evidence for an inhibition effect of primary care on specialty care use among individuals with a diagnosed psychiatric disorder. Specifically, we determined that after controlling for insurance status and type, prescription use, and several sociodemographic factors, individuals in the NSAL (Study 1) were 0.5 times less likely to utilize specialty care if they had used a primary care provider. Similarly, NCS-R respondents (Study 2) who had used primary care were 0.2 times less likely to use a specialty ROLE OF PRIMARY CARE IN SPECIALTY CARE USE 17 provider for their mental health needs, even after controlling for additional insurance-related factors that included HMO plan status and insurance referral requirements for specialty care. Furthermore, and contrary to our expectations, ethnicity did not moderate the association between primary and specialty care use, thus demonstrating an inhibition effect for both African American and non-Hispanic White respondents. Several theoretical interpretations may be put forth for the inhibitory effect of primary care use on specialty care use. First, differing patient perceptions of primary and specialty care settings may impact their help-seeking behavior. Chapa (2004) suggests that many consumers view mental health treatment in primary care settings to be less stigmatizing than services delivered in specialty settings, which may have led to some individuals seeking primary care providers in lieu of specialists. Second, of the respondents who utilized both primary and specialty providers, only those who reported seeking primary care for the first time before seeking specialty care for the first time were included in the analysis to account for temporal ordering of service utilization. It is possible that some patients perceived their mental health needs had been met in the primary care setting. Prior work has shown that individuals who sought care in the primary sector had a lower chance of meeting criteria for major depression one year later than those seen in the specialty mental health sector (Cooper-Patrick, Crum, & Ford, 1994). Primary care may have therefore substituted for specialty care if individuals no longer required additional services beyond primary care. Lastly, the nature and severity of psychopathology may affect the patient’s choice of care providers. Mojtabai, Olfson and Mechanic (2002) suggests that individuals with severe comorbid disorders may be more likely to seek care from mental health specialists than those with no comorbidity. Cooper-Patrick et al. (1994) compared the characteristics of patients who received ROLE OF PRIMARY CARE IN SPECIALTY CARE USE 18 mental health services in the general medical setting with those who saw specialty mental health providers, and found that patients who sought primary care exhibited less severe psychopathology. While illness severity was not assessed in the current study, it is possible that a number of respondents may have exhibited relatively less severe mental illness, and therefore sought services in primary care settings in lieu of seeing specialist providers. Our study found that respondents who received a prescription were more likely to seek specialty providers. This result should be interpreted with caution since in the current study, both primary care and specialty care included providers who were able to prescribe medication. Specifically, primary care providers included physicians other than psychiatrists and specialty care providers included psychiatrists. Furthermore, the type of provider from whom a respondent received a prescription was not recorded. As such, there are several plausible explanations for the positive association between prescription use and specialty care use. Respondents who received a prescription may have procured one from a psychiatrist, who is categorized as a specialty care provider (Olfson et al., 1998). Alternatively, respondents may have received a prescription from a primary care physician, but their mental health needs were so great that they sought out additional services from mental health specialists. Prior work has shown that compared to depressed patients who received mental health services from either general medical providers or specialty providers, only, patients who received care from both types of providers included a higher proportion of adults prescribed medication for their depression (Kuramoto-Crawford, Han, Jacobus-Kantor, & Mojtabai, 2016). Indeed, as noted earlier, respondents who had received a prescription were more likely to use specialty care; supplementary analyses further demonstrated that respondents who had received a prescription were more likely to use primary care. ROLE OF PRIMARY CARE IN SPECIALTY CARE USE 19 The current study has important clinical implications. In the NSAL sample of African Americans, while all individuals had a diagnosable mental health disorder, only 21% used primary care services and 32% used specialty mental health care services. Within the NCS-R sample, 13% and 30% of African Americans reported using primary and specialty care, respectively. Utilization rates for non-Hispanic Whites were 28% for primary care and 47% for specialty care, respectively. These findings affirm that underutilization is a challenge in African American communities. Furthermore, an inhibitory effect of primary care use was demonstrated regardless of respondent ethnicity, suggesting a prevalent utilization trend across both ethnic groups. Additional research is warranted to deconstruct the underlying causes of the inhibition effect in order to develop adequate care models that link patients with mental health needs to appropriate care. As such, recent initiatives to integrate mental health services into primary care settings may help bridge this gap. For example, the Primary Care–Mental Health Integration (PC-MHI) program of the Veteran Affairs health system has been shown to enhance recognition of mental health needs among primary care patients (Zivin et al., 2010). The current study should be considered an initial step towards the goal of discerning the complex help seeking patterns of individuals with mental illness, and as such has several limitations. First, the NSAL and NCS-R are cross-sectional surveys, which prevents the investigation of temporal patterns of primary care and specialty mental health care use and does not allow determinations about causality. Future longitudinal studies may help investigate the temporal sequencing of service utilization. Second, results were based on self-report data of service utilization that have not been validated against actual service utilization rates, and thus are subject to recall bias and social desirability concerns. Furthermore, because homeless and ROLE OF PRIMARY CARE IN SPECIALTY CARE USE 20 institutionalized individuals were not included, results may reflect sampling bias and the prevalence of mental illness may be higher than reported. A third limitation concerns self-reported insurance status and requirements. Responses reflect current insurance status; however, self-reported primary or specialty care use was over one’s lifetime. The analyses do not account for individuals whose insurance status may have differed in the past when reportedly utilizing care services. Additionally, and as mentioned earlier, while pharmacological treatment was accounted for in the analyses, data were not available regarding the type of provider from whom respondents had received pharmacological treatment. Finally, analyses that consider additional patient- and provider-level characteristics (e.g. patients’ stigma towards mental health professionals, providers’ cultural sensitivity training and effectiveness in identifying mental illness) were not conducted in these studies and may prove informative in future inquiries. ROLE OF PRIMARY CARE IN SPECIALTY CARE USE 21 Table 1. Demographic Characteristics and Service Use, Studies 1 and 2 Categorical Predictors NSAL NCS-R Non-Hispanic Whites African Americans n % (SE) n % (SE) n % (SE) Service use Primary care use 262 20.96 (1.48) 578 28.42 (1.10) 44 13.07 (1.35) No primary care use 990 79.04 (1.48) 1455 71.6 (1.1) 292 86.9 (1.4) Specialty care use 405 32.33 (1.56) 954 46.91 (1.30) 101 29.91 (2.99) No specialty care use 847 67.67 (1.56) 1079 53.1 (1.3) 236 70.1 (3.0) Insurance No insurance 263 21.02 (1.30) 289 13.91 (1.20) 69 20.35 (2.87) Public insurance 242 19.34 (1.65) 149 7.20 (0.79) 73 21.52 (2.88) Private insurance 747 59.64 (2.13) 1602 77.20 (1.40) 186 54.89 (3.39) Other insurance 35 1.69 (0.42) 11 3.23 (1.30) Prescription use Prescription use 221 17.75 (1.17) 688 33.20 (1.18) 60 17.63 (1.78) No prescription use 1025 82.25 (1.17) 1385 66.8 (1.2) 282 82.4 (1.8) HMO insurance plan 620 37.2 (2.4) 105 41.4 (4.4) Insurance requires referral 1035 61.9 (1.7) 141 55.3 (4.9) Education <High school diploma 310 24.79 (1.56) 223 10.76 (0.89) 66 19.26 (2.75) High school graduate 480 38.29 (1.31) 642 30.95 (2.16) 136 39.60 (3.52) Some college 322 25.67 (1.31) 650 31.35 (1.44) 101 29.63 (3.41) ≥ College graduate 141 11.25 (1.22) 559 26.94 (1.74) 39 11.51 (2.03) Employment Status Employed 880 70.29 (1.39) 1568 75.89 (1.26) 232 67.82 (3.09) Unemployed 372 29.71 (1.39) 498 24.1 (1.3) 110 32.2 (3.1) Marital Status Married/cohabiting 488 38.97 (1.20) 1226 59.10 (1.63) 102 29.71 (3.02) Divorced/separated/widowed 288 22.96 (1.27) 339 16.35 (0.82) 77 22.49 (2.16) Never married 477 38.08 (1.91) 509 24.55 (1.50) 164 47.80 (3.19) Female 734 58.58 (1.63) 1102 53.09 (1.34) 207 60.56 (2.88) Male 519 41.42 (1.63) 973 46.91 (1.34) 135 39.44 (2.88) Continuous Predictors M CI M CI M CI Age 36.21 35.28 – 37.13 39.23 38.31-40.16 35.93 34.15-37.72 Household income 35,284 31,992 – 38,575 66,357 61,524-71,191 41,793 35,746-47,841 Note: NSAL N = 1,252; NCS-R N = 2,417 (Non-Hispanic Whites = 2,075, African Americans = 342). SE = standard error of percentage for categorical variables; CI = confidence interval. ROLE OF PRIMARY CARE IN SPECIALTY CARE USE 22 Table 2. Logistic Regression Models for Specialty Mental Health Service Use, Studies 1 and 2 Predictor NSAL NCS-R Basic Model Basic Model Interaction Model Odds Ratio (95% CI) Odds Ratio (95% CI) Odds Ratio (95% CI) Service use Primary care use vs. No use 0.52 (0.35 - 0.76)* 0.21 (0.14 - 0.33)* 0.22 (0.14 - 0.34)* Insurance Public insurance vs. No insurance 0.96 (0.58 - 1.59) 6.77E-9 (8.13E-10 - 5.64E-8)* 6.70E-9 (8.03E-10 - 5.58E-8)* Private insurance vs. No insurance 0.69 (0.50 - 0.96) 3.31E-9 (4.25E-10 - 2.58E-8)* 3.26E-9 (4.18E-10 - 2.55E-8)* Other insurance vs. No insurance 3.02E-9 (3.35E-10 - 2.71E-8)* 2.92E-9 (3.25E-10 - 2.68E-8)* Prescription use vs. No use 12.56 (8.28 - 19.07)* 10.45 (7.71 - 14.16)* 10.45 (7.71 - 14.16)* HMO plan Yes vs. No 1.12 (0.90 - 1.41) 1.12 (0.90 - 1.40) Insurance requires referral Yes vs. No 1.12 (0.84 - 1.48) 1.12 (0.85 - 1.49) Age 1.00 (0.99 - 1.01) 0.99 (0.98 - 1.00) 0.99 (0.98 - 1.00) Female vs. Male 1.22 (0.89 - 1.68) 1.19 (0.93 - 1.54) 1.20 (0.93 - 1.55) Household income 1.00 (1.00 - 1.00) 1.00 (1.00 - 1.00) 1.00 (1.00 - 1.00) Marital Status Divorced/separated/widowed vs. Married/cohabiting 1.46 (1.01 - 2.11) 1.98 (1.37 - 2.85)* 1.99 (1.38 - 2.89)* Never married vs. Married/ cohabiting 1.15 (0.77 - 1.72) 0.98 (0.63 - 1.52) 0.98 (0.63 - 1.52) Education High school graduate vs. <High school diploma 0.90 (0.61 - 1.31) 0.80 (0.49 - 1.31) 0.81 (0.49 - 1.32) Some college vs. <High school diploma 1.22 (0.81 - 1.85) 1.08 (0.65 - 1.79) 1.10 (0.67 - 1.80) ≥ College graduate vs. <High school diploma 1.48 (0.86 - 2.54) 1.23 (0.71 - 2.17) 1.26 (0.73 - 2.18) Unemployed vs. Employed 1.12 (0.81 - 1.56) 1.33 (1.06 - 1.67)* 1.34 (1.07 - 1.68)* Race: African Americans vs. Whites 0.47 (0.32 - 0.67)* 0.51 (0.35 - 0.74)* Primary care use × Race 0.53 (0.23 - 1.23) Note: NSAL N = 1,252; NCS-R N = 2,417 (Non-Hispanic Whites = 2,075, African Americans = 342). 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Abstract (if available)

Abstract Racial disparities in mental health care in the United States are well documented, particularly with regard to service access, quality of treatment, and treatment outcomes (AHRQ, 2013

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Creator Jhaveri, Kinnari (Nina) (author)

Core Title The role of primary care in the use of specialty mental health services: an investigation of utilization patterns among African Americans and non-Hispanic Whites

School College of Letters, Arts and Sciences

Degree Master of Arts

Degree Program Psychology

Publication Date 04/25/2019

Defense Date 04/17/2018

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Tag ethnic disparities,Mental Health,OAI-PMH Harvest,utilization

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Advisor Huey, Stanley Jr. (committee chair), Davison, Gerald (committee member), John, Richard (committee member)

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