Racial-Ethnic Differences in Service Use Patterns Among Young, Commercially Insured Individuals With Recent-Onset Psychosis

This study involved a retrospective analysis of deidentified administrative claims data from the OptumLabs Data Warehouse (OLDW), including medical claims and eligibility information, from more than 200 million enrollees of a population representing a diverse mixture of ages, ethnicities and geographical regions across the United States (12). The claims are dated January 1, 2009, to December 31, 2016. The household income distribution of commercial enrollees included in this study was similar to that of the commercially insured population in the entire country, although the U.S. commercially insured population includes a slightly lower proportion of patients in the highest income bracket and a slightly higher proportion in the lowest income bracket (12). Every individual in the OLDW is assigned a unique, lifetime, and encrypted identifier to ensure that counts are unduplicated. The OLDW extract includes individuals ages 14 to 30 with comprehensive commercial insurance coverage for hospital, physician, behavioral health, and prescription drug services. We selected this age range because it coincides with the onset of a large proportion of psychotic disorders and corresponds to the age selection for many early intervention programs for first-episode psychosis (13, 14).

Individuals with a new diagnosis of psychotic disorder were identified through their claims histories from January 1, 2011, through December 31, 2015. An initial diagnosis of psychosis was identified hierarchically by using the following ICD-9-CM and ICD-10-CM diagnosis codes: schizophrenia and schizophreniform disorder (295, F20, or F25), bipolar disorder with psychotic features (296.04, 296.14, 296.44, 296.54, 296.64, F30.2, F31.2, F31.5, and F31.64), major depressive disorder with psychotic features (296.24, 296.34, F32.3, and F33.3), and other psychotic disorders (297.1, 297.3, 298.8, 298.9, F22, F23, F24, F28, and F29). Diagnosis codes were also used to identify comorbid substance use disorder. In order to increase the likelihood of identifying the first episode of psychosis, we limited the sample to persons who had at least 2 years of continuous insurance coverage prior to the index diagnosis. We selected a 2-year cutoff to maximize the likelihood of capturing the first diagnosis while maintaining sufficient power to generate meaningful results. To support the analyses described below, we also limited the sample to persons with 1 year of full insurance coverage following the index diagnosis, because this permitted tracking of mental health care service use for the entire year.

Information on age, gender, and race-ethnicity was extracted from health insurance enrollment data. A supplier of consumer marketing data provided information on race-ethnicity derived from public and predictive data. These data were generated on the basis of a structured, rule-based system that combines analysis of first names, middle names, surnames, and surname prefixes and suffixes, with, in case of doubt, geographic reference files (15). The supplier used imputation methods for race-ethnicity that had moderate sensitivity (48%), high specificity (97%), and moderate positive predictive value (71%) for identifying race-ethnicity (16).

Values were categorized in the OLDW to comply with data deidentification requirements. In OLDW, race and ethnicity are defined as African American, Hispanic, Asian, or non-Hispanic white. We did not include the Asian group because of its relatively small sample (N=224) and because the socioeconomic indicators of the Asian group more closely resembled those of the non-Hispanic white group than those of other racial-ethnic minority groups. We also excluded individuals with other or unknown race-ethnicity. Place-of-service codes, procedure codes, and revenue codes were used to identify the site of index diagnosis, according to the following hierarchy: inpatient, emergency department, hospital-based outpatient department, community-based outpatient visit, or other. For example, if a person had an inpatient and an outpatient hospital claim on the same day that he or she received an index diagnosis of psychosis, the site of the index diagnosis would be identified as inpatient. The rationale was to assign the most intensive treatment setting.

Data on annual household income, a proxy for SES, was provided by OLDW and was measured by using data from both public and private consumer information (credit card statements, loan amounts, and loan payments). This variable was assigned at the household level, and a household was defined as individuals with the same surname living at the same street address. Categories included an annual household income of less than $50,000, $50,000–$99,000, more than $99,000, or “missing.”

This study examined patterns in use of mental health services by race-ethnicity following a new diagnosis of psychotic disorder among young individuals with commercial insurance. Among patients using outpatient services, African Americans and Hispanics received about 30% fewer outpatient visits compared with the non-Hispanic white group, also following adjustment for household income. Previously reported deficiencies in the quality of care for young people with early psychosis in the United States, therefore, appear to be a particular concern for members of racial-ethnic minority groups (6, 28). Notably, higher intensity of outpatient treatment has previously been associated with fewer hospitalizations and lower all-cause mortality rates in the years following the onset of a psychotic disorder (6, 29, 30). Despite this marked disparity, other differences between racial-ethnic groups in mental health service use were relatively small. As such, we found limited support for our hypothesis that compared with non-Hispanic white patients, young African Americans and Hispanics are less likely to use various types of mental health services following the onset of a psychotic disorder.

Racial-ethnic patterns of inpatient mental health care and antipsychotic medication use were inconsistent. Hispanics had a lower probability of an inpatient admission and fewer inpatient days among users of inpatient mental health services but average rates of antipsychotic medication use. African Americans had average rates of inpatient service use but a lower number of mean fills of antipsychotic medication use, a finding that dissolved when adjusted for household income. Overall, during the year after index diagnosis, only a very small proportion—less than one-fourth of individuals—used antipsychotic medication and less than three-fourths used outpatient services, indicating that there is a treatment gap in pharmacological management in this population, irrespective of racial-ethnic background.

Compared with non-Hispanic white individuals, a higher proportion of African-American, but not Hispanic individuals received their index diagnosis in the emergency department, which may be a marker of a more adverse pathway to care. Previous studies from the United Kingdom and Canada showed that there was more police involvement and fewer primary care providers in the pathway to care of black individuals with first-episode psychosis compared with the white majority group (31). Another finding that is in line with previous work pertains to racial-ethnic differences in diagnosis. African Americans were more likely than non-Hispanic whites to receive a diagnosis on the schizophrenia spectrum as their index diagnosis and less likely to receive a diagnosis of mood disorder with psychotic features. Similar ethnic differences in diagnostic patterns of psychotic disorders, especially higher rates of schizophrenia among African Americans, have been reported in previous studies (32, 33). As this study shows, this divergence is already present at initial diagnosis within a large, commercially insured sample.

Aspects of the social environment influence help seeking for a psychotic disorder. A few of these factors include health care affordability, mental health literacy, health beliefs, racial concordance between physician and patient, patient attitudes, and provider bias (8). Even among this commercially insured group, we observed striking racial-ethnic differences in SES, as measured by household income. However, adjusting the analyses for household income did not have substantial effects on the association between race-ethnicity and patterns of mental health service use.

This study had several limitations. First, the classification of racial-ethnic groups masks large within-group heterogeneity, and we were unable to capture the full racial-ethnic experience of African-American, Hispanic, or non-Hispanic white individuals on the basis of available data. Second, individuals with a newly diagnosed psychotic disorder were identified by using diagnoses from claims data, and we were not able to verify these diagnoses using medical record review. Thus diagnoses were based on clinical judgments and were not subject to expert validation. However, previous work has found that claims data have high specificity in identifying psychosis among young individuals in inpatient, emergency, and outpatient settings (34).

Third, it was not possible to determine mental health service use or diagnoses prior to the 2-year look-back period. As a result, some of the patients in our cohort may have had an earlier clinical diagnosis of psychotic disorder. Moreover, the selection of a 2-year cutoff was arbitrary. Fourth, data on household income was missing for about one-third of individuals (29.4%). We therefore chose to enter household income as a covariate in the model, which may diminish the total effect of race-ethnicity. Future studies should employ mediation analyses to assess the potentially mediating role of socioeconomic indicators in the relationship between race-ethnicity and mental health service use.

Fifth, the data used for defining race-ethnicity had imperfect sensitivity and moderate positive predictive value, suggesting possible misclassification. Sixth, the large sample size may lead to spurious findings of statistical significance but limited clinical significance. Finally, a substantial proportion of the cohort was excluded because of a lack of continuous insurance coverage. A more economically unstable group may, therefore, have been excluded from analyses, which likely diminished observed disparities in service use among this group.

This large-scale study examined use of mental health services among commercially insured individuals in the year after a new diagnosis of psychotic disorder. The most salient finding was a lower intensity of outpatient mental health use among African Americans and Hispanics compared with non-Hispanic whites. Given the serious implications of the onset of psychotic illness among young people and the importance of continuous treatment to key outcomes, our findings highlight an important public health challenge. Future studies should investigate the efficacy of interventions aimed at improving racial-ethnic equity in the provision of continuous and intensive mental health care for people with early psychosis.

The effect of household income on mental health service use among racial-ethnic minority groups was limited, suggesting that policies aimed only at lowering financial barriers to care might be insufficient to narrow racial-ethnic disparities in outpatient mental health service use. Specialized mental health services—especially those tailored to young people, such as early intervention programs for psychosis—may facilitate access to treatment for racial-ethnic minority groups, among others, by incorporating culturally competent care (35). Last, this work supports the importance of including racial-ethnic minority groups in clinical and services research on psychotic disorder so that cultural factors can be better understood and access to services improved (36).