THE RACIAL AND ETHNIC DISPARITIES IN PATHWAY TO MAJOR DEPRESSIVE DISORDER (MDD) AND ITS IMPACT ON THE RECEIPT OF MDD TREATMENT
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Major Depressive Disorder (MDD) is the third leading cause of death in the US and has long-term negative impact on adolescents such as failure at school, substance abuse, and adult depression [1-4]. It affects approximately 8% of adolescents every year [5, 6]. Early identification and receipt of quality treatment are paramount for prognosis. However, 50% of pediatric MDD patients are not identified before they reach adulthood, and most children and adolescents with MDD do not receive treatment [7-9]. Racial/ethnic disparity in access to mental health care has been well-documented [10-12]. Studies using both national and regional samples found that white children were at least two times more likely to receive needed mental health services (including specialty care), and 35-85% more likely to receive a prescription compared to minorities [13-17]. The literature also suggested that minority children and adolescents were less likely to receive adequate mental health treatment than their white counterparts. In a randomized control trial of Cognitive Behavioral Therapy (CBT), only 72% of the 111 adolescents continued treatment for 12 weeks . Among children and adolescents receiving pharmacotherapy, more than 60% discontinued antidepressant medication before reaching 12 weeks,[7-9] and only 15% had a follow-up visit during the first three months of the antidepressant treatment . Research attention has gradually shifted towards understanding how racial/ethnic disparities emerge in structure and process of care. An earlier study reported that not having a usual source of care explained a significant portion of disparity . Another study using an adult sample reported that the type of provider who first identified cancer patients determined the course of care and the subsequent treatment patients received . Primary Care Providers (PCP), Social Workers/Psychologists (SWP) and Psychiatrists (PSY) are the health care providers who primarily identify and treat MDD in children and adolescents. It remains unknown whether the type of provider who identifies youth with MDD has any impact on the subsequent care steps and whether it contributes to the racial and ethnic disparities in receiving adequate quality of MDD care. Therefore, we aimed to investigate the racial/ethnic disparity in access and quality of MDD treatment and how access to certain type of provider impacts this disparity. Specifically, the objectives for each manuscript were: MANUSCRIPT I) 1) To characterize the cascade of the delivery steps children and adolescents went through from a new MDD diagnosis to the treatment initiation; and 2) To examine whether the racial and ethnic disparities in receiving follow up care and MDD treatment could be explained by the type of provider who first identified the MDD cases. MANUSCRIPT II) 1) To quantify the racial disparity in quality of pediatric MDD treatment; and 2) To examine the contribution of mental health specialist access to the disparities. Hispanics and Blacks were less likely to receive any MDD treatment as compared to Whites (OR: 0.80, 95%CI: 0.70-0.90, and 0.81, 0.70-0.90, respectively). Patients identified by PCPs [PCP-OR(95%CI):0.54 (0.4-0.7)] and SWP [PCP-OR(95%CI):0.17 (0.1-0.2)] were less likely to receive treatment compared to PSY-identified patients. However, identifying provider did not have an impact on racial/ethnic disparity of receiving any MDD treatment. In contrast, disparity in receiving psycho-pharmacotherapy is affected by the type of identifying provider. Hispanics were less likely to receive prescription treatment than Whites when identified by PCP (OR: 0.53, 95%CI: 0.40-0.80) or SWP (OR: 0.73, 95%CI: 0.60-0.80). The same disparity was not found in PSY identified youth. Similar to access to treatment, there was also racial/ethnic disparity in receipt of quality treatment. Hispanics and Blacks were less likely to receive adequate treatment as compared to Whites (OR: 0.67, 95%CI: 0.60-0.80, and 0.66, 95%CI: 0.60-0.80), but adequate monitoring was not statistically significantly different between racial/ethnic groups. Although type of identification of provider did not impact the racial/ethnic disparity in treatment completion, it was associated with improved medication related monitoring. Youth identified by PCP were 39% less likely to receive adequate monitoring compared to PSY identified patients [OR (95%CI): 0.61 (0.5-0.8)]. This study is the first that reports the positive association between access to child and adolescent psychiatrists and the access to pediatric MDD treatment. Although improved access to mental health specialists did not prevent racial/ethnic disparities in access and completion of treatment, it improved the overall treated rates, and was found to be associated with reduction in racial/ethnic disparities in accessing and monitoring of psycho-pharmacotherapy.