Skip to main content
Full access
Articles
Published Online: 14 January 2020

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

Abstract

Objective:

The aim of this study was to investigate racial-ethnic differences in use of mental health services and antipsychotic medication in the year following the recent onset of a psychotic disorder and to examine the role of household income as a proxy for socioeconomic status.

Methods:

Deidentified administrative claims data from the OptumLabs Data Warehouse were used to identify 8,021 commercially insured individuals ages 14 through 30 with a recent-onset psychotic disorder (January 1, 2011, through December 31, 2015). The authors compared mental health service use among African-American (11.5%), Hispanic (11.0%), and non-Hispanic white (77.4%) individuals during the year following an index diagnosis and adjusted these analyses for household income.

Results:

The probability of any use of outpatient mental health services was lower among African-American (67.4%±1.4%) and Hispanic individuals (66.5%±1.5%) compared with non-Hispanic white patients (72.3%±0.6%; p<0.05 for each comparison). Among those who used services, African-American and Hispanic individuals had fewer mean outpatient mental health visits per year compared with non-Hispanic whites (9.7±0.7 and 10.2±0.7 versus 14.3±0.5, respectively, p<0.001 for each comparison). These racial-ethnic differences in service use remained after adjustment for household income.

Conclusions:

Among young, commercially insured individuals using outpatient services following an index diagnosis of psychotic disorder, African Americans and Hispanics received less intensive outpatient mental health care than their non-Hispanic white counterparts. Amid the upsurge of early intervention programs, special attention should be paid to increasing access to mental health services for racial-ethnic minority groups.

HIGHLIGHTS

In a commercially insured population, African-American and Hispanic individuals were less likely than the non-Hispanic white group to access outpatient mental health care during the year after a new diagnosis of psychotic disorder.
Among young persons using outpatient mental health services, African-American and Hispanic individuals received 30% fewer outpatient care visits than non-Hispanic white patients.
Differences in outpatient mental health care could not be explained by racial-ethnic differences in household income.
Given the importance of continuous treatment for the prognosis of recent-onset psychosis, these findings highlight an important public health challenge.
In the United States, significant racial-ethnic disparities exist in mental health outcomes (1). In many instances, these disparities are related to delays in treatment, different patterns of service use, and uneven quality of care. Racial-ethnic disparities have also been reported in service use among individuals with psychotic disorder. Compared with white patients, African Americans are less likely to continuously use outpatient services (2) or to be prescribed second-generation antipsychotic medication (3, 4), and they are more likely to be admitted to the emergency department (3). In the public mental health system, African-American and Hispanic patients with schizophrenia are less likely than whites with similar diagnoses to receive case management (5). Most previous findings concerning racial-ethnic differences in the treatment of serious mental illnesses rely on adult samples of chronic psychotic disorders receiving public health insurance (25). Little is known about racial-ethnic disparities in service use among commercially insured persons immediately after an initial diagnosis of psychotic disorder.
Schoenbaum and colleagues (6) found that the 1-year mortality rate was 24 times higher among commercially insured individuals with a new diagnosis of psychotic disorder compared with the general population in the United States between the ages of 16 and 30 years. The group who died within 12 months after a first diagnosis received less outpatient treatment and was more likely to use intermittent hospital and emergency care, suggesting that the early phase of a psychotic disorder is a critical period for intervention. However, the authors did not examine differences by race-ethnicity.
Racial-ethnic groups differ in sociodemographic and other contextual factors that affect mental health care use, including socioeconomic status (SES) (7). SES represents an important determinant of health care use because it reflects economic resources, vocational opportunities, health literacy, and other characteristics that affect use of mental health care (8). Additionally, race-ethnicity may affect mental health care use through several other influences, including stigma toward mental illness and treatment seeking in racial-ethnic minority communities, cultural distance between patients and service providers, and negative beliefs about and discrimination within the health care system (9, 10).
In this study, we examined patterns of use of inpatient and outpatient mental health services and antipsychotic medication in a large, racially and ethnically diverse cohort of young, commercially insured individuals during 1 year after a new diagnosis of psychotic disorder. Based on previous studies (2, 5, 11), we hypothesized that African-American and Hispanic individuals would be less likely than non-Hispanic white patients to use mental health services, especially outpatient care. We also explored whether any significant differences in service use among racial-ethnic groups were dependent on variation in household income, a proxy for SES. We anticipated that household income would not entirely account for racial-ethnic differences in service use following a new diagnosis of psychotic disorder.

Methods

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.”

Health Service Use

Mental health services included inpatient mental health days, outpatient mental health visits, and antipsychotic pharmacy fills. Inpatient mental health days were identified from inpatient admissions with a primary diagnosis related to mental health. Outpatient mental health services were identified as outpatient services with either a specialty mental health procedure code or a primary diagnosis related to mental health. Fills for antipsychotic medications were identified by using therapeutic class codes.

Study Design and Statistical Analysis

We used two-part models to analyze the number of inpatient mental health days, outpatient mental health visits, and antipsychotic pharmacy fills by race-ethnicity (1719). These models are useful in their ability to discriminate between the decision to seek out services and the amount of services received (20). Both of these processes, although distinct, can determine health service use and might be a source of disparities. We used logistic regression to estimate the probability of any use of services and negative binomial regression models to estimate the number of services conditional on some use. We selected these specific distributions on the basis of standard tests for assessing alternative transformed models (2123). We assessed goodness of fit using a modified Hosmer-Lemeshow test and a Pregibon’s link test (24, 25).
We examined mental health service use in the year following the index diagnosis by race-ethnicity, including additional covariates for age, gender, type of initial psychosis, comorbid substance use disorder, and site of index diagnosis. We then adjusted the results of service use for household income (<$50,000, $50,000–$99,000, >$99,000). We estimated the probability of any use and mean use among users. These estimates were standardized by using recycled predictions. Standard errors were calculated by using the nonparametric bootstrap, and p values were computed by using the percentile method from the empirical distributions of the results from 1,000 replicates (26). All analyses were conducted in Stata, version 14 (27).
The University of California, San Diego, Human Research Protections Program as well as the State of California Committee for the Protection of Human Subjects approved this study in accordance with the Privacy Rule of HIPAA.

Results

Sample Selection

We identified 21,003 patients between the ages of 14 and 30 years with a new diagnosis of psychotic disorder. We excluded 6,106 persons who did not have 2 years of comprehensive insurance coverage prior to the index diagnosis, 6,253 persons who did not have 365 days of coverage after the index diagnosis, 224 persons with Asian race-ethnicity, and 399 persons with unknown or other race-ethnicity.

Sample Characteristics

Study sample characteristics are shown in Table 1. Of 8,021 persons with a new diagnosis of psychotic disorder, 6,211 (77.4%) were non-Hispanic white, 921 (11.5%) were African American, and 889 (11.0%) were Hispanic.
TABLE 1. Characteristics of young individuals with a recent-onset psychotic disorder, by racial-ethnic group
 Total (N=8,021)African American (N=921; 11.5%)Hispanic (N=889; 11.0%)Non-Hispanic white (N=6,211; 77.4%)
CharacteristicN%N%N%N%
Age group, years        
 14–172,78534.729632.134538.82,14434.5
 18–244,22952.750755.141046.13,31253.3
 25–301,00712.611812.813415.175512.2
Gender        
 Male4,12851.546450.444550.13,21951.8
 Female3,89348.545749.644449.92,99248.2
Site of index diagnosis        
 Inpatient83410.4919.910511.863810.3
 Emergency department3,26240.740644.134638.92,51040.4
 Hospital outpatient department1,72221.519921.620022.51,32321.3
 Community-based outpatient visit1,89723.719220.919722.21,50824.3
 Other3063.8333.6414.62323.7
Diagnosis        
 Schizophrenia7949.911812.8859.65919.5
 Bipolar disorder with psychotic features1,52619.014615.914216.01,23819.9
 Major depressive disorder with psychotic features3,33341.635738.839644.52,58041.5
 Unspecified psychosis2,36829.530032.626629.91,80229.0
Comorbid substance use disorder        
 No6,66983.181088.075685.05,10382.2
 Yes1,35216.911112.113315.01,10817.8
Household annual income        
 Missing2,36529.526929.228031.51,81629.2
 <$50,0001,12614.026128.319221.667310.8
 $50,000–$99,0003,71546.330232.833737.93,07649.5
 >$99,00081510.2899.7809.064610.4
Compared with non-Hispanic whites, African Americans were more likely to receive their index diagnosis at the emergency department (44.1% versus 40.4%, respectively; p=0.035) and to receive a diagnosis of schizophrenia (12.8% versus 9.5%, respectively; p<0.001). Both racial-ethnic minority groups were less likely than non-Hispanic whites to receive a diagnosis of bipolar disorder with psychotic features (p<0.001). The proportion of individuals receiving a diagnosis of major depressive disorder with psychotic features was highest among Hispanics (44.5%) followed by non-Hispanic whites (41.5%) and African Americans (38.8%) (p<0.001). The proportion of individuals with a comorbid substance use disorder ranged from 12.1% among African Americans to 15.0% among Hispanics and 17.8% among non-Hispanic whites (p<0.001).
We found substantial racial-ethnic differences in household income. Larger proportions of African Americans (28.3%) and Hispanics (21.6%) were in the lower category (<$50,000 in annual income) compared with non-Hispanic whites, (10.8%) (p<0.001). The proportion of individuals with missing data on household income was similar across racial-ethnic groups, ranging from 29.2% among non-Hispanic whites and African Americans to 31.5% among Hispanics.

Mental Health Service Use

Table 2 shows standardized estimates of service use by race-ethnicity in the year after index diagnosis. Compared with non-Hispanic white individuals, Hispanics were less likely to use inpatient mental health services (32.4%±1.5% versus 36.0%±0.6%, respectively; p<0.05). Among people with inpatient use, Hispanics also had fewer inpatient days than non-Hispanic whites (10.3±0.9 versus 12.4±0.4, respectively; p<0.05).
TABLE 2. Standardized estimates of service use by young adults in the 365 days after onset of psychosis, by race-ethnicitya
 Inpatient mental health servicesOutpatient mental health servicesAntipsychotic pharmacotherapy
Race-ethnicityMSEpMSEpMSEp
Probability of use
Overall35.4.5 71.1.5 23.1.5 
African American34.21.5.25767.41.4.00123.21.4.951
Hispanic32.41.5.03066.51.5<.00122.61.4.712
Non-Hispanic white (reference)36.0.672.3.623.1.5
Services received among users
 DaysVisitsFills
Overall12.2.4 13.3.4 6.5.1 
African American13.01.3.4589.7.7<.0015.8.4.042
Hispanic10.3.9.00810.2.7<.0016.3.4.433
Non-Hispanic white (reference)12.4.414.3.56.6.2
a
Joint statistical tests show significant differences by race-ethnicity in the mean number of inpatient mental health days among users (p=.016), the probability of having an outpatient mental health visit (p<.001), and the mean number of outpatient mental health visits among users (p<.001). Standardized estimates were adjusted for age, gender, type of initial psychosis, comorbid substance use disorder, and site of index diagnosis.
The probability of having any outpatient mental health service use was lower among African-American (67.4%±1.4%) and Hispanic individuals (66.5%±1.5%) compared with non-Hispanic white patients (72.3%±0.6%, p<0.01 for each comparison). Among those using services, African Americans (9.7±0.7) and Hispanics (10.2±0.7) had fewer outpatient mental health visits compared with non-Hispanic whites (14.3±0.5, p<0.001 for each comparison).
The mean proportion of persons using antipsychotic medication was similar across racial-ethnic groups. Among those using antipsychotic medication, African Americans had a significantly lower mean number of fills compared with non-Hispanic white individuals (5.8±0.4 versus 6.6±0.2, respectively, p=0.042).
Additional analyses that included a time variable (index year) did not provide evidence that racial-ethnic differences in mental health service use changed during the study period.

Adjustment for Annual Household Income

Table 3 shows service use among racial-ethnic groups adjusted for household income. Many of the patterns in service use observed in the initial analyses were also observed when the association between mental health service use and race-ethnicity was adjusted for household income. Among users of inpatient services, the Hispanic group had a lower mean number of days compared with non-Hispanic white patients (10.4±0.9 versus 12.3±0.4, respectively; p=.014). Compared with the non-Hispanic white group, African-American and Hispanic individuals had a lower mean probability of using outpatient services (72.0%±0.6% versus 68.6%±1.4% and 67.3%±1.4%, respectively; p<0.05 for each comparison). Among those using outpatient mental health services, African Americans and Hispanics had fewer visits compared with non-Hispanic white patients (9.9±0.6 and 10.2±0.7 versus 14.2±0.4, respectively; p<0.001 for each comparison). When adjusted for household income, the mean probability of antipsychotic use and mean number of fills among users was similar across racial-ethnic groups.
TABLE 3. Standardized estimates of service use by young adults in the 365 days after onset of psychosis, by race-ethnicity and with adjustment for household incomea
 Inpatient mental health servicesOutpatient mental health servicesAntipsychotic pharmacotherapy
Race-ethnicityMSEpMSEpMSEp
Probability of use
Overall35.4.5 71.1.5 23.1.5 
African American34.81.6.51868.61.4.02723.71.5.631
Hispanic32.81.5.06767.31.4.00222.81.5.896
Non-Hispanic white (reference)35.9.6 72.0.6 23.0.5 
Services received among users
 DaysVisitsFills
Overall12.2.4 13.3.4 6.5.1 
African American13.01.2.3889.9.6<.0016.1.4.194
Hispanic10.4.9.01410.2.7<.0016.4.4.616
Non-Hispanic white (reference)12.3.4 14.2.4 6.6.2 
a
Joint statistical tests show significant differences by race-ethnicity for the mean number of mental health inpatient days among users (p=.023), the probability of having an outpatient mental health visit (p=.002), and the mean number of outpatient mental health visits among users (p<.001). Standardized estimates were also adjusted for age, gender, type of initial psychosis, comorbid substance use disorder, and site of index diagnosis.

Discussion

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.

Conclusions

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).

References

1.
Satcher D: Mental Health: Culture, Race, and Ethnicity—A Supplement to Mental Health: A Report of the Surgeon General. Rockville, MD, US Department of Health and Human Services, 2001
2.
Fontanella CA, Guada J, Phillips G, et al: Individual and contextual-level factors associated with continuity of care for adults with schizophrenia. Adm Policy Ment Health Ment Health Serv Res 2014; 41:572–587
3.
Kuno E, Rothbard AB: Racial disparities in antipsychotic prescription patterns for patients with schizophrenia. Am J Psychiatry 2002; 159:567–572
4.
Kreyenbuhl J, Zito JM, Buchanan RW, et al: Racial disparity in the pharmacological management of schizophrenia. Schizophr Bull 2003; 29:183–193
5.
Barrio C, Yamada AM, Hough RL, et al: Ethnic disparities in use of public mental health case management services among patients with schizophrenia. Psychiatr Serv 2003; 54:1264–1270
6.
Schoenbaum M, Sutherland JM, Chappel A, et al: Twelve-month health care use and mortality in commercially insured young people with incident psychosis in the United States. Schizophr Bull 2017; 43:1262–1272
7.
Jeffries N, Zaslavsky AM, Diez Roux AV, et al: Methodological approaches to understanding causes of health disparities. Am J Public Health 2019; 109(S1):S28–S33
8.
Fiscella K, Franks P, Gold MR, et al: Inequality in quality: addressing socioeconomic, racial, and ethnic disparities in health care. JAMA 2000; 283:2579–2584
9.
Wong C, Davidson L, Anglin D, et al: Stigma in families of individuals in early stages of psychotic illness: family stigma and early psychosis. Early Interv Psychiatry 2009; 3:108–115
10.
Hansen H, Braslow J, Rohrbaugh RM: From cultural to structural competency—training psychiatry residents to act on social determinants of health and institutional racism. JAMA Psychiatry 2018; 75:117–118
11.
Sohler NL, Bromet EJ, Lavelle J, et al: Are there racial differences in the way patients with psychotic disorders are treated at their first hospitalization? Psychol Med 2004; 34:705–718
12.
OptumLabs and OptumLabs Data Warehouse (OLDW) Descriptions and Citation. Cambridge, MA, OptumLabs, 2019. https://www.optumlabs.com/about
13.
Amminger GP, Harris MG, Conus P, et al: Treated incidence of first-episode psychosis in the catchment area of EPPIC between 1997 and 2000. Acta Psychiatr Scand 2006; 114:337–345
14.
Thorup A, Waltoft BL, Pedersen CB, et al: Young males have a higher risk of developing schizophrenia: a Danish register study. Psychol Med 2007; 37:479–484
15.
DeFrank JT, Michael BJ, Rimer BK, et al: Peer reviewed: triangulating differential nonresponse by race in a telephone survey. Prev Chronic Dis 2007; 4:A60
16.
Reed NS, Altan A, Deal JA, et al: Trends in health care costs and utilization associated with untreated hearing loss over 10 years. JAMA Otolaryngol Head Neck Surg 2019; 145:27–34
17.
Cameron AC, Trivedi PK: Econometric models based on count data. Comparisons and applications of some estimators and tests. J Appl Econ 1986; 1:29–53
18.
Cameron AC, Trivedi PK: Regression Analysis of Count Data. Cambridge, Cambridge University Press, 1998
19.
Mullahy J: Heterogeneity, excess zeros, and the structure of count data models. J Appl Econ 1997; 12:337–350
20.
Manning WG, Newhouse JP, Duan N, et al: Health insurance and the demand for medical care: evidence from a randomized experiment. Am Econ Rev 1987; 77:251–277
21.
Blough DK, Madden CW, Hornbrook MC: Modeling risk using generalized linear models. J Health Econ 1999; 18:153–171
22.
Manning WG, Mullahy J: Estimating log models: to transform or not to transform? J Health Econ 2001; 20:461–494
23.
Buntin MB, Zaslavsky AM: Too much ado about two-part models and transformation? Comparing methods of modeling Medicare expenditures. J Health Econ 2004; 23:525–542
24.
Hosmer DW, Lemeshow S: Applied Logistic Regression. New York, Wiley, 1989
25.
Pregibon D: Goodness of link tests for generalized linear models. Appl Stat 1980; 29:15–24
26.
Efron B: An Introduction to the Bootstrap. New York, Chapman & Hall, 1993
27.
Stata Statistical Software: Release 12. College Station, TX, StataCorp LP, 2011
28.
Simon GE, Stewart C, Yarborough BJ, et al: Mortality rates after the first diagnosis of psychotic disorder in adolescents and young adults. JAMA Psychiatry 2018; 75:254–260
29.
Anderson KK, Norman R, MacDougall A, et al: Effectiveness of early psychosis intervention: comparison of service users and nonusers in population-based health administrative data. Am J Psychiatry 2018; 175:443–452
30.
Nielsen J, le Quach P, Emborg C, et al: 10-year trends in the treatment and outcomes of patients with first-episode schizophrenia. Acta Psychiatr Scand 2010; 122:356–366
31.
Anderson KK, Flora N, Archie S, et al: A meta-analysis of ethnic differences in pathways to care at the first episode of psychosis. Acta Psychiatr Scand 2014; 130:257–268
32.
Minsky S, Vega W, Miskimen T, et al: Diagnostic patterns in Latino, African American, and European American psychiatric patients. Arch Gen Psychiatry 2003; 60:637–644
33.
Olbert CM, Nagendra A, Buck B: Meta-analysis of black vs white racial disparity in schizophrenia diagnosis in the United States: do structured assessments attenuate racial disparities? J Abnorm Psychol 2018; 127:104–115
34.
Simon GE, Coleman KJ, Yarborough BJH, et al: First presentation with psychotic symptoms in a population-based sample. Psychiatr Serv 2017; 68:456–461
35.
Tondora J, O’Connell M, Miller R, et al: A clinical trial of peer-based culturally responsive person-centered care for psychosis for African Americans and Latinos. Clin Trials 2010; 7:368–379
36.
Akinhanmi MO, Biernacka JM, Strakowski SM, et al: Racial disparities in bipolar disorder treatment and research: a call to action. Bipolar Disord 2018; 20:506–514

Information & Authors

Information

Published In

Go to Psychiatric Services
Go to Psychiatric Services
Psychiatric Services
Pages: 433 - 439
PubMed: 31931683

History

Received: 12 June 2019
Revision received: 18 October 2019
Accepted: 21 November 2019
Published online: 14 January 2020
Published in print: May 01, 2020

Keywords

  1. Psychoses
  2. Race
  3. Ethnicity
  4. First episode psychosis
  5. Early intervention
  6. Service use

Authors

Details

Els van der Ven, Ph.D. [email protected]
Mailman School of Public Health, Columbia University, New York (van der Ven, Susser); School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands (van der Ven); New York State Psychiatric Institute, New York (Susser, Dixon, Olfson); Vagelos College of Physicians and Surgeons, Columbia University, New York (Dixon, Olfson); Department of Family Medicine and Public Health, University of California, San Diego, and OptumLabs, Cambridge, Massachusetts (Gilmer).
Ezra Susser, M.D., Dr.P.H.
Mailman School of Public Health, Columbia University, New York (van der Ven, Susser); School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands (van der Ven); New York State Psychiatric Institute, New York (Susser, Dixon, Olfson); Vagelos College of Physicians and Surgeons, Columbia University, New York (Dixon, Olfson); Department of Family Medicine and Public Health, University of California, San Diego, and OptumLabs, Cambridge, Massachusetts (Gilmer).
Lisa B. Dixon, M.D., M.P.H.
Mailman School of Public Health, Columbia University, New York (van der Ven, Susser); School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands (van der Ven); New York State Psychiatric Institute, New York (Susser, Dixon, Olfson); Vagelos College of Physicians and Surgeons, Columbia University, New York (Dixon, Olfson); Department of Family Medicine and Public Health, University of California, San Diego, and OptumLabs, Cambridge, Massachusetts (Gilmer).
Mark Olfson, M.D., M.P.H.
Mailman School of Public Health, Columbia University, New York (van der Ven, Susser); School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands (van der Ven); New York State Psychiatric Institute, New York (Susser, Dixon, Olfson); Vagelos College of Physicians and Surgeons, Columbia University, New York (Dixon, Olfson); Department of Family Medicine and Public Health, University of California, San Diego, and OptumLabs, Cambridge, Massachusetts (Gilmer).
Todd P. Gilmer, Ph.D.
Mailman School of Public Health, Columbia University, New York (van der Ven, Susser); School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands (van der Ven); New York State Psychiatric Institute, New York (Susser, Dixon, Olfson); Vagelos College of Physicians and Surgeons, Columbia University, New York (Dixon, Olfson); Department of Family Medicine and Public Health, University of California, San Diego, and OptumLabs, Cambridge, Massachusetts (Gilmer).

Notes

Send correspondence to Dr. van der Ven ([email protected]).

Competing Interests

The authors report no financial relationships with commercial interests. Editor Emeritus Howard H. Goldman, M.D., Ph.D., was action editor during peer review.

Funding Information

Nederlandse Organisatie voor Wetenschappelijk Onderzoekhttp://dx.doi.org/10.13039/501100003246: Rubicon 40-45200-98-003
Dr. van der Ven was funded by a Rubicon grant from the Netherlands Organization for Scientific Research.

Metrics & Citations

Metrics

Citations

Export Citations

If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download.

For more information or tips please see 'Downloading to a citation manager' in the Help menu.

Format
Citation style
Style
Copy to clipboard

View Options

View options

PDF/EPUB

View PDF/EPUB

Login options

Already a subscriber? Access your subscription through your login credentials or your institution for full access to this article.

Personal login Institutional Login Open Athens login
Purchase Options

Purchase this article to access the full text.

PPV Articles - Psychiatric Services

PPV Articles - Psychiatric Services

Not a subscriber?

Subscribe Now / Learn More

PsychiatryOnline subscription options offer access to the DSM-5-TR® library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.

Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).

Media

Figures

Other

Tables

Share

Share

Share article link

Share