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Further Reflections on Race, Psychiatric Diagnosis, and Mental Health Care Utilization in Older Persons
COMMENTARY Further Reflections on Race, Psychiatric Diagnosis, and Mental Health Care Utilization in Older Persons F. M. Baker, M.D., M.P.H., F.A.P.A.
Copyright 䉷 2000 American Association for Geriatric Psychiatry
Am J Geriatr Psychiatry 8:4, Fall 2000
I
n this issue of The American Journal of Geriatric Psychiatry, Kales and co-authors present data from an analysis of the Veterans Administration (VA) Patient Treatment File. This Treatment File is a national computerized database containing information on all VA medical centers’ discharge records containing information on dates of admission and discharge, discharge diagnoses, and demographic characteristics (age, sex, race) of the veterans treated. Data on outpatient utilization in the VA Outpatient Clinic File of all VA facilities were also reviewed, providing information on the utilization of psychiatric services by these veterans for the 2-year period following their index inpatient discharge. These authors report on one of the largest sample of minority elderly patients who have received psychiatric treatment. Their study provides an important benchmark in our knowledge of psychiatric service utilization by older African American, Caucasian, and Hispanic American veterans. Knowledge concerning the presence of psychiatric illness in older persons of color in the United States before the 1980s has been limited. Studies of cognitive impairment and affective illness have looked primarily at small samples of older African Americans.1–6 The Epidemiologic Catchment Area (ECA) Survey oversampled older persons in two U.S. cities, New Haven, Connecticut, and Baltimore, Maryland.7,8 The National Co-Morbidity Survey, the most recent epidemiologic study that interviewed a representative sample of the U.S. population, limited its sampling to persons age 18– 54.9 Studies of the prevalence of dementia in Copiah County, Mississippi, and Baltimore, Maryland, were based on a universal sample of one county and a probability sample of one city, respectively.1,10 Neither of these samples contained more than a few hundred older African American patients. Thus, studies with more than a few hundred persons age 60-and-older who were ethnic minorities (African American, American Indian and Alaskan Natives, Asian American and Pacific Islanders, or Hispanic Americans) were few. Several authors have addressed issues of misdiagnosis and clinical bias over the past 27 years.11–15 Elderly patients with a diagnosis of schizophrenia made in their 20s in the 1950s would be in their 60s in the 1990s. A few studies found that the use of structured clinical interviews to establish diagnosis resulted in equal rates of schizophrenia in African American and Caucasian patients admitted to state psychiatric hospitals11 and clarified misdiagnosis or underdiagnosis of psychiatric disorders of older patients in treatment at a community mental health center.3 Kales et al., in the article that follows, review this literature and acknowledge this finding as a factor in potential bias in their study of older veterans, who may have had their psychiatric diagnosis made before their index admission in 1993 or 1994, at a time of less diagnostic rigor in American psychiatry. The increased mortality of older people of color has been documented in the literature.16,17 Hypertension, diabetes, stroke, and
297
Editorial Commentary cardiovascular disease result in early mortality for African American and Hispanic American men (mainly Mexican American men).17 The study of Kales and colleagues is an important contribution to the literature because it provides data about older, mentally ill African American and Hispanic American men who have not been studied extensively to date. Furthermore, the VA database enabled these investigators to address both psychiatric and physical morbidity. Using data from October 1st, 1993, to September 30th, 1994 (the 1994 federal fiscal year), a total of 23,718 veterans age 50 and older were admitted to VA psychiatric units. Some 3,529 were African American; 19,330 were Caucasian; and 859 were Hispanic American. Diagnoses were grouped into the categories of cognitive disorders, mood disorders, psychotic disorders, substance abuse disorders, anxiety disorders, and all other disorders. The authors assessed comorbid conditions. The percentage of African American veterans who had both depression and anxiety disorders was less than the percentage of Hispanic American veterans and Caucasian veterans who were comorbid for these conditions. This is of interest because the ECA data found that the rates of anxiety disorder among elderly patients were only slightly lower than the rate for persons age 18–54.7 Although the rate of phobic disorder was higher among African Americans age 65 and older in the ECA data,7,8 specific rates for the various anxiety disorders were not included in this study. When older veterans with depression and substance abuse were compared by race, African Americans had a higher rate of these comorbid conditions and had a higher utilization rate of outpatient visits than the other two groups. These authors found no difference in inpatient utilization between races. Only in rates of outpatient utilization did the comparison of race, diagnosis, and comorbidity demonstrate a difference. The results of these investigators suggest that older African American veterans who have had an inpatient psychiatric hospitalization will utilize outpatient services. The authors acknowledge that it is unclear whether these veterans are engaged in treatment or only making multiple contacts without effectively engaging in treatment. Clarification of the service utilization pattern would be an important future study. Also of interest would be clarification of whether the index hospitalization was the first psychiatric admission for the veteran or whether the veteran had a previous psychiatric history. How many of these older veterans developed a comorbid condition in their later years? How many of these older veterans with a previous psychiatric history had their diagnoses changed during the course of their treatment in the VA? How many older veterans’ psychiatric illness began with a diagnosis of substance abuse as the initial contact with psychiatric services? What are the rates of substance-induced dementia in this population? These are a few of the questions for future research raised by this study.
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Am J Geriatr Psychiatry 8:4, Fall 2000
Baker This unique sample of older, predominantly male, veterans requires caution in generalizing the results to other populations, such as ethnic elderly patients admitted to psychiatric units of general hospitals or those seen in medical clinics. The authors acknowledge these concerns. These data do enable geriatric psychiatrists to appreciate that older ethnic elderly patients can be engaged in treatment and that, at least in the VA system, do return for outpatient services. We hope this study will encourage other investigators who have access to data-sets of patient contacts to explore their databases to establish the patterns of service utilization by elderly ethnic patients by diagnosis and by race. An analysis of treatment history from other data-sets would be of interest to compare with this VA sample. By 2030, 15.3% of persons age 65 and older in the United States will be people of color, and by 2030, the combined group of ethnic elderly persons will comprise 21.3% of the U.S. population.18 An appreciation of the types of psychiatric services that they will need should enable geriatric psychiatrists to prepare to serve this expanding population in their practices. Kales and co-authors have provided important beginning answers about treatment and, we hope, will stimulate other studies in this area. F.M. Baker, M.D., M.P.H., F.A.P.A. Department of Psychiatry University of Maryland Medical School Medical Director, Lower Shore Clinic Salisbury, MD References 1. Schoenberg BS, Anderson DW, Haerer AF: Severe dementia: prevalence and clinical features in a biracial U.S. population. Arch Neurology 1985; 42:74–743 2. Folstein M, Anthony JC, Parhard J, et al: The meaning of cognitive impairment in the elderly. J Am Geriatr Soc 1985; 33:228–233 3. Baker FM: Misdiagnosis of older psychiatric patients. J Natl Med Assoc 1995; 87:872–876 4. Baker FM, Parker DL, Wiley C, et al: Depressive symptoms in African American medical patients. Int J Geriatr Psychiatry 1995; 10:9–14 5. Baker FM, Okwumabua J, Philipose V, et al: Screening African American elderly for the presence of depressive symptoms: a preliminary investigation. J Geriatr Psychiatry Neurol 1996; 9:127–132 6. Blazer DG, Hughes DC, George LK: The epidemiology of depression in an elderly community population. Gerontologist 1987; 27:281–287 7. Thompson JW: National databases on minority elders, in Ethnic Minority Elderly: A Task Force Report of the American Psychiatric Association. Washington, DC, American Psychiatric Association, 1993, pp 13–19 8. Sakauye K: Ethnocultural aspects, in Comprehensive Review of Geriatric Psychiatry, 2nd Edition. Edited by Sadavoy J, Lazarus LW, Jarvik LF, et al. Washington, DC, American Psychiatric Press, 1996, pp 197–221 9. Blazer DG, Kessler RC, McGonagle KA: The prevalence and distribution of major depression in a national community sample: the National Co-morbidity Survey. Am J Psychiatry 1994; 151:979–986 10. Folstein MF, Bassett SS, Anthony JL, et al: Dementia: case ascertainment in a community survey. J Gerontol 1991; 46:M132–M138 11. Simon RJ, Fleiss JL, Gurland BJ, et al: Depression and schizophrenia in hospitalized black and white mental patients. Arch Gen Psychiatry 1973; 28:509– 512
Am J Geriatr Psychiatry 8:4, Fall 2000
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Editorial Commentary 12. Bell CC, Mehta H: The misdiagnosis of black patient with manic-depressive illness: second in a series. J Natl Med Assoc 1981; 73:101–107 13. Adebimpe VR: Overview: white norms and psychiatric diagnosis of black patients. Am J Psychiatry 1981; 138:279–285 14. Jones BE, Gray BA, Parson EB: Manic-depressive illness among poor urban blacks. Am J Psychiatry 1981; 185:654–657 15. Coleman D, Baker FM: Misdiagnosis of schizophrenia among older, black veterans. J Nerv Ment Dis 1994; 182:527–528 16. Baker FM, Lavizzo-Mourey R, Jones BE: Acute care of the African American elder. J Geriatr Psychiatry Neurol 1993; 6:66–71 17. U.S. Department of Health and Human Services: Report of the Secretary’s Task Force on Black and Minority Health (Vol. 1: Executive Summary). Washington, DC, U.S. Government Printing Office, 1985 18. Angel JL, Hogan DP: The demography of minority aging populations, in Minority Elders: Longevity, Economics, and Health — Building a Public Policy Base. Edited by Harootyan LK. Washington, DC, Gerontological Society of America, 1991, pp 1–13
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Am J Geriatr Psychiatry 8:4, Fall 2000
Copyright 䉷 2000 American Association for Geriatric Psychiatry
Am J Geriatr Psychiatry 8:4, Fall 2000
I
n this issue of The American Journal of Geriatric Psychiatry, Kales and co-authors present data from an analysis of the Veterans Administration (VA) Patient Treatment File. This Treatment File is a national computerized database containing information on all VA medical centers’ discharge records containing information on dates of admission and discharge, discharge diagnoses, and demographic characteristics (age, sex, race) of the veterans treated. Data on outpatient utilization in the VA Outpatient Clinic File of all VA facilities were also reviewed, providing information on the utilization of psychiatric services by these veterans for the 2-year period following their index inpatient discharge. These authors report on one of the largest sample of minority elderly patients who have received psychiatric treatment. Their study provides an important benchmark in our knowledge of psychiatric service utilization by older African American, Caucasian, and Hispanic American veterans. Knowledge concerning the presence of psychiatric illness in older persons of color in the United States before the 1980s has been limited. Studies of cognitive impairment and affective illness have looked primarily at small samples of older African Americans.1–6 The Epidemiologic Catchment Area (ECA) Survey oversampled older persons in two U.S. cities, New Haven, Connecticut, and Baltimore, Maryland.7,8 The National Co-Morbidity Survey, the most recent epidemiologic study that interviewed a representative sample of the U.S. population, limited its sampling to persons age 18– 54.9 Studies of the prevalence of dementia in Copiah County, Mississippi, and Baltimore, Maryland, were based on a universal sample of one county and a probability sample of one city, respectively.1,10 Neither of these samples contained more than a few hundred older African American patients. Thus, studies with more than a few hundred persons age 60-and-older who were ethnic minorities (African American, American Indian and Alaskan Natives, Asian American and Pacific Islanders, or Hispanic Americans) were few. Several authors have addressed issues of misdiagnosis and clinical bias over the past 27 years.11–15 Elderly patients with a diagnosis of schizophrenia made in their 20s in the 1950s would be in their 60s in the 1990s. A few studies found that the use of structured clinical interviews to establish diagnosis resulted in equal rates of schizophrenia in African American and Caucasian patients admitted to state psychiatric hospitals11 and clarified misdiagnosis or underdiagnosis of psychiatric disorders of older patients in treatment at a community mental health center.3 Kales et al., in the article that follows, review this literature and acknowledge this finding as a factor in potential bias in their study of older veterans, who may have had their psychiatric diagnosis made before their index admission in 1993 or 1994, at a time of less diagnostic rigor in American psychiatry. The increased mortality of older people of color has been documented in the literature.16,17 Hypertension, diabetes, stroke, and
297
Editorial Commentary cardiovascular disease result in early mortality for African American and Hispanic American men (mainly Mexican American men).17 The study of Kales and colleagues is an important contribution to the literature because it provides data about older, mentally ill African American and Hispanic American men who have not been studied extensively to date. Furthermore, the VA database enabled these investigators to address both psychiatric and physical morbidity. Using data from October 1st, 1993, to September 30th, 1994 (the 1994 federal fiscal year), a total of 23,718 veterans age 50 and older were admitted to VA psychiatric units. Some 3,529 were African American; 19,330 were Caucasian; and 859 were Hispanic American. Diagnoses were grouped into the categories of cognitive disorders, mood disorders, psychotic disorders, substance abuse disorders, anxiety disorders, and all other disorders. The authors assessed comorbid conditions. The percentage of African American veterans who had both depression and anxiety disorders was less than the percentage of Hispanic American veterans and Caucasian veterans who were comorbid for these conditions. This is of interest because the ECA data found that the rates of anxiety disorder among elderly patients were only slightly lower than the rate for persons age 18–54.7 Although the rate of phobic disorder was higher among African Americans age 65 and older in the ECA data,7,8 specific rates for the various anxiety disorders were not included in this study. When older veterans with depression and substance abuse were compared by race, African Americans had a higher rate of these comorbid conditions and had a higher utilization rate of outpatient visits than the other two groups. These authors found no difference in inpatient utilization between races. Only in rates of outpatient utilization did the comparison of race, diagnosis, and comorbidity demonstrate a difference. The results of these investigators suggest that older African American veterans who have had an inpatient psychiatric hospitalization will utilize outpatient services. The authors acknowledge that it is unclear whether these veterans are engaged in treatment or only making multiple contacts without effectively engaging in treatment. Clarification of the service utilization pattern would be an important future study. Also of interest would be clarification of whether the index hospitalization was the first psychiatric admission for the veteran or whether the veteran had a previous psychiatric history. How many of these older veterans developed a comorbid condition in their later years? How many of these older veterans with a previous psychiatric history had their diagnoses changed during the course of their treatment in the VA? How many older veterans’ psychiatric illness began with a diagnosis of substance abuse as the initial contact with psychiatric services? What are the rates of substance-induced dementia in this population? These are a few of the questions for future research raised by this study.
298
Am J Geriatr Psychiatry 8:4, Fall 2000
Baker This unique sample of older, predominantly male, veterans requires caution in generalizing the results to other populations, such as ethnic elderly patients admitted to psychiatric units of general hospitals or those seen in medical clinics. The authors acknowledge these concerns. These data do enable geriatric psychiatrists to appreciate that older ethnic elderly patients can be engaged in treatment and that, at least in the VA system, do return for outpatient services. We hope this study will encourage other investigators who have access to data-sets of patient contacts to explore their databases to establish the patterns of service utilization by elderly ethnic patients by diagnosis and by race. An analysis of treatment history from other data-sets would be of interest to compare with this VA sample. By 2030, 15.3% of persons age 65 and older in the United States will be people of color, and by 2030, the combined group of ethnic elderly persons will comprise 21.3% of the U.S. population.18 An appreciation of the types of psychiatric services that they will need should enable geriatric psychiatrists to prepare to serve this expanding population in their practices. Kales and co-authors have provided important beginning answers about treatment and, we hope, will stimulate other studies in this area. F.M. Baker, M.D., M.P.H., F.A.P.A. Department of Psychiatry University of Maryland Medical School Medical Director, Lower Shore Clinic Salisbury, MD References 1. Schoenberg BS, Anderson DW, Haerer AF: Severe dementia: prevalence and clinical features in a biracial U.S. population. Arch Neurology 1985; 42:74–743 2. Folstein M, Anthony JC, Parhard J, et al: The meaning of cognitive impairment in the elderly. J Am Geriatr Soc 1985; 33:228–233 3. Baker FM: Misdiagnosis of older psychiatric patients. J Natl Med Assoc 1995; 87:872–876 4. Baker FM, Parker DL, Wiley C, et al: Depressive symptoms in African American medical patients. Int J Geriatr Psychiatry 1995; 10:9–14 5. Baker FM, Okwumabua J, Philipose V, et al: Screening African American elderly for the presence of depressive symptoms: a preliminary investigation. J Geriatr Psychiatry Neurol 1996; 9:127–132 6. Blazer DG, Hughes DC, George LK: The epidemiology of depression in an elderly community population. Gerontologist 1987; 27:281–287 7. Thompson JW: National databases on minority elders, in Ethnic Minority Elderly: A Task Force Report of the American Psychiatric Association. Washington, DC, American Psychiatric Association, 1993, pp 13–19 8. Sakauye K: Ethnocultural aspects, in Comprehensive Review of Geriatric Psychiatry, 2nd Edition. Edited by Sadavoy J, Lazarus LW, Jarvik LF, et al. Washington, DC, American Psychiatric Press, 1996, pp 197–221 9. Blazer DG, Kessler RC, McGonagle KA: The prevalence and distribution of major depression in a national community sample: the National Co-morbidity Survey. Am J Psychiatry 1994; 151:979–986 10. Folstein MF, Bassett SS, Anthony JL, et al: Dementia: case ascertainment in a community survey. J Gerontol 1991; 46:M132–M138 11. Simon RJ, Fleiss JL, Gurland BJ, et al: Depression and schizophrenia in hospitalized black and white mental patients. Arch Gen Psychiatry 1973; 28:509– 512
Am J Geriatr Psychiatry 8:4, Fall 2000
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Editorial Commentary 12. Bell CC, Mehta H: The misdiagnosis of black patient with manic-depressive illness: second in a series. J Natl Med Assoc 1981; 73:101–107 13. Adebimpe VR: Overview: white norms and psychiatric diagnosis of black patients. Am J Psychiatry 1981; 138:279–285 14. Jones BE, Gray BA, Parson EB: Manic-depressive illness among poor urban blacks. Am J Psychiatry 1981; 185:654–657 15. Coleman D, Baker FM: Misdiagnosis of schizophrenia among older, black veterans. J Nerv Ment Dis 1994; 182:527–528 16. Baker FM, Lavizzo-Mourey R, Jones BE: Acute care of the African American elder. J Geriatr Psychiatry Neurol 1993; 6:66–71 17. U.S. Department of Health and Human Services: Report of the Secretary’s Task Force on Black and Minority Health (Vol. 1: Executive Summary). Washington, DC, U.S. Government Printing Office, 1985 18. Angel JL, Hogan DP: The demography of minority aging populations, in Minority Elders: Longevity, Economics, and Health — Building a Public Policy Base. Edited by Harootyan LK. Washington, DC, Gerontological Society of America, 1991, pp 1–13
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Am J Geriatr Psychiatry 8:4, Fall 2000