NYAPRS Note: The following comes from Andel Nicasio who writes “Please enjoy the fourteenth edition of Cultural Competence Matters - a report from the New York State Center of Excellence for Cultural Competence at the New York State Psychiatric Institute (CECC). This issue introduces a new article on the risk of multiple chronic medical conditions (MCMC) for persons with psychiatric disorders and racial/ethnic minority status. The article “Do race, ethnicity and psychiatric diagnoses matter in the prevalence of multiple chronic medical conditions?” will be published in the Journal Medical Care in June 2013. Additionally, this issue lists some of the initiatives undertaken by the New York State Office of Mental Health (OMH) to improve the health of persons with psychiatric disorders living in New York State.
Cultural Competence Matters
Racial and Ethnic Disparities among Persons With Psychiatric Disorders and Multiple Chronic Medical Conditions
June 2013 Issue 14
Center of Excellence for Cultural Competence
New York State Psychiatric Institute
Problem: The proportion of people in the United States with multiple chronic medical conditions (MCMC; for example, diabetes and hypertension) is increasing and creating a serious burden on our healthcare system. Chronic medical conditions are defined as those that limit a person’s functioning, last a year or more, and require ongoing medical care1. MCMC are associated with adverse health outcomes, including impaired functioning, unnecessary hospitalizations, adverse drug effects, duplicative tests, and higher mortality2. MCMC are also costly, with average health care spending per capita increasing exponentially with the number of medical conditions a person faces.
Persons with psychiatric disorders are at greater risk for MCMC3-5, as are persons from underserved racial/ethnic groups6. Providing effective care for persons with MCMC is thus a priority for the NYS Office of Mental Health (OMH), as it administers the state’s public mental health system, which serves a population with serious mental illness who are also often members of racial/ethnic minority groups7. OMH has undertaken numerous efforts to improve the quality of care for high-risk and high-cost clients, including the promotion of integrated care and health homes8. As part of this effort, it is essential to understand whether the risk of MCMC increases when a person is subject to two risk factors simultaneously: psychiatric conditions and racial/ethnic minority status. Researchers from the New York State Center of Excellence for Cultural Competence at the New York State Psychiatric Institute (CECC-NYSPI) have examined these issues in a new article coming out in June, 2013 in the journal Medical Care9.
Findings: The study examined a representative sample of the US population to detect the risk of MCMC separately for race/ethnicity and psychiatric status, and then for the combination of the two risk factors. In terms of race/ethnicity, Hispanics had lower odds and African Americans had higher odds than non-Hispanic Whites of MCMC, after taking into account the effect of sociodemographic characteristics (e.g., age, education), body mass index, and health-related quality of life.
Turning to psychiatric status, having a psychiatric disorder was associated with higher odds of MCMC. However, when the two risk factors were examined together, complicated results emerged. African Americans with a psychiatric disorder had higher odds of MCMC than Whites with a psychiatric disorder. This suggests a synergistic effect, in which being in both groups at once is worse than either effect alone. However, this did not hold true for Hispanics. Hispanics with psychiatric disorders still faced greater odds of MCMC than Hispanics without psychiatric disorders, but no combined effect of being Hispanic and having a psychiatric disorder was observed.
Taken together, the findings suggest that race/ethnicity and psychiatric conditions do matter in the prevalence of MCMC and that their combination may at times result in a greater burden than would be seen with either condition alone. Yet, the effect of this combination of risk factors can vary across racial/ethnic groups, with one finding for African Americans and another for Hispanics. As the rates of MCMC continue to rise in the U.S., it is essential to identify which populations are at increased risk in order to direct integrated health and mental health services to address their needs and improve the quality of their lives.
Innovations: New York State is undertaking a number of initiatives to improve the health of persons with psychiatric disorders. The Center for Practice Innovation (CPI) has developed a Wellness Self-Management curriculum to help adults with serious mental illnesses to understand the connection between their physical and mental health10. In addition, Leopoldo Cabassa, PhD, of the CECC-NYSPI and the Columbia University School of Social Work has received funding from the National Institutes of Mental Health (NIMH) to adapt a healthcare manager intervention to the Latino community in northern Manhattan11. These are just two examples of the innovations that New York State is supporting to provide integrated physical and mental health care for vulnerable populations.
- US Department of Health and Human Services. Mutiple Chronic Conditions: A Strategic Framework: Optimum Health and Quality of Life for Individuals with Multiple Chronic Conditions. Washington, D. C.; 2010.
- Parekh AK, Barton MB. The challenge of multiple comorbidity for the US health care system. Jama 2010;303:1303-4.
- Musselman DL, Betan E, Larsen H, Phillips LS. Relationship of depression to diabetes types 1 and 2: epidemiology, biology, and treatment. Biol Psychiatry 2003;54:317-29.
- Newcomer JW, Hennekens CH. Severe mental illness and risk of cardiovascular disease. JAMA. 2007;298:1794-6.
- Saha S, Chant D, McGrath J. A systematic review of mortality in schizophrenia: is the differential mortality gap worsening over time? Arch Gen Psychiatry. 2007;64:1123-31.
- Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington DC; 2003.
- Siegel C, Wanderling J, Haugland G, Laska E, Case B. Access to and use of non-inpatient services in the NYS public mental health system by racial/ethnic groups. In Unmet Needs Assessment Report: Statewide
Assessment of Treatment Gaps for Racial/Ethnic Groups in Need of Mental Health Services. New York State Office of Mental Health (eds). Albany, NY: 2011.
- New York State Office of Mental Health. Targeted Case Management to Health Homes Information. Available at http://www.omh.ny.gov/omhweb/adults/health_homes/. Accessed June 6, 2013.
- Cabassa LJ, Humensky J, Druss B, et al. Do race, ethnicity and psychiatric diagnoses matter in the prevalence of multiple chronic medical conditions? Medical Care 2013; 51(6):540-547.
- The Center for Practice Innovations. Wellness Self-Management. Available at http://practiceinnovations.org/CPIInitiatives/WellnessSelfManagementWSM/tabid/189/Default.aspx. Accessed June 6, 2013.
- Cabassa LJ, Druss B, Wang Y, Lewis-Fernandez R. Collaborative planning approach to inform the implementation of a healthcare manager intervention for Hispanics with serious mental illness: a study protocol.
Implementation Science 2011; 6:80. Available at http://www.implementationscience.com/content/6/1/80.