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Commentary   |    
Mental Health in the Context of Health Disparities
Jeanne Miranda, Ph.D.; Thomas G. McGuire, Ph.D.; David R. Williams, M.P.H., Ph.D.; Philip Wang, M.D., Dr.P.H.
Am J Psychiatry 2008;165:1102-1108. doi:10.1176/appi.ajp.2008.08030333

A  longstanding theme of mental health policy has been the tension between the integration of mental health into general health policy and exceptionalism. Integration is represented by policies such as parity in health insurance coverage, and exceptionalism by “carve-outs” of mental health care to behavioral health care organizations. Frank and Glied (1) have argued that policies based on exceptionalism in mental health are waning and that integration has had salutary effects on persons with mental illness through mainstreaming into general social and health programs (notably Medicaid).

Mental health status and mental health care disparities can also be framed within the exceptionalism/integration debate, in both a traditional and new sense. In the traditional sense, one may question whether policies promoting general purpose interventions to reduce health status or health care disparities will also address disparities in mental health. In the new sense, one may question whether policies should differ when poor health status or poor health care is correlated with certain racial groups. Should we take an integrationist perspective and address poor health status and low quality of care in general or take an exceptionalist perspective and promote policies focused on disparities? From a health policy perspective, disparities in health status or health care may not deserve special focus over and above the problems of poor health status and poor quality of care in general. Concern for social justice, however, argues for a focus on disparity. For example, the goal of equal opportunity is to provide a social environment in which no one is excluded from the activities of society, such as education, employment, or health care, on the basis of immutable traits.

No consensus exists for defining and measuring health status disparities (2). The definition we use in this article is that any inequality in health due to social factors or allocation of resources is unjust and, therefore, constitutes a disparity. Included as part of the definition of a health disparity between races are health status differences due to higher rates of poverty, such as poor nutrition.

Similarly, no consensus exists about what constitutes a health care disparity. We agree with the Institute of Medicine’s report, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care” (3), which defines disparity as any difference in health care quality not due to differences in health care needs or preferences. As such, disparities can be caused by a range of social factors, including inequalities in access to good providers, differences in insurance coverage, or discrimination by professionals in the clinical encounter.

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Brief Review of Disparities

Health and mental health disparities are embedded within persistent socioeconomic differences. Large differences among the major racial groups exist in terms of income, and even more so in terms of wealth. In 2004, minorities’ incomes were about 56% of that of their white counterparts; however, their net worth (assets minus debts) was only 27% of that of their white counterparts (4). Not surprisingly, large differences in access to health care also exist among these groups. All minority groups are less likely to be covered by health insurance than their white counterparts. Broad patterns of socioeconomic disparities by race exist in many levels of American life.

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Disparities in health status

Despite the well-known unreliability of ethnic designations noted on death certificates, the most meaningful summary measure of health status disparities is life expectancy, driven by differential mortality among ethnic groups. Table 1 shows disparities in age-adjusted and age-specific death rates for white and minority populations. Black and American Indian/Alaskan Native populations have elevated rates of mortality compared with white Americans. On the other hand, Asian Americans have significantly lower mortality rates. Finally, Hispanic Americans have advantages early and late in life but are at a disadvantage from ages 15 to 34 (5).

Future health disparities are likely to be driven in part by the differential rates of obesity currently found among young minorities because of the associated health risks, including heart disease, type 2 diabetes, high blood pressure, stroke, arthritis-related disabilities, sleep disorders, and cancers of the breast, prostate, and colon. Although 30% of men across racial groups are obese, African American and Latina women have rates of obesity of 51.6% and 40.3%, respectively, compared with a rate of 31.5% for white women (6).

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Disparities in health care

The quality of health care in the United States for all ethnic groups is far from ideal. A major gap exists between recommended care and what is delivered. Nationally, medical patients receive only 54.9% of recommended care (7). Evidence of racial and ethnic disparities in health care is almost uniformly consistent across a range of illnesses and health care services (for an exception, see reference 8). Disparities have been clearly documented in cardiovascular care (9–12); cancer diagnostic tests (13) and treatments (14); HIV antiretroviral therapy (15), prophylaxis for pneumocystic pneumonia, and protease inhibitors (16); diabetes care (17); and end-stage renal disease and kidney transplantation (18, 19). Over time, disparities appear to have diminished slowly for black Americans, but the majority of disparities for quality and access have widened for Hispanic Americans (20).

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Disparities in mental health status

Mental health status disparities exhibit a decidedly different pattern than do health disparities. The findings in Table 2 all derive from the Collaborative Psychiatric Epidemiology Survey program funded by the National Institute of Mental Health (NIMH), which used common core questions and unified sampling weights (21). Hispanic Americans (with the exception of those from Puerto Rico), Asian Americans, and black Americans have fewer mental disorders than do white Americans (22–24). For Mexican, African, and Caribbean immigrants, rates of disorders increase with time spent in the United States (25, 26). Similarly, compared with a nationally representative sample of the U.S. population, American Indians are at heightened risk for posttraumatic stress and alcohol dependence, but at lower risk for depression (27). However, more black Americans may have schizophrenia, a rare but very serious condition, than white Americans (28–31). While substantial evidence exists to suggest that clinicians overdiagnose schizophrenia and underdiagnose mood disorders in African Americans (32), clinical decisions do not account for all of the observed differences.

Although minorities have fewer psychiatric disorders than do white Americans, both black and Hispanic Americans are more likely to be persistently ill (33). Similarly, depression is more likely to be chronic, severe, disabling, and untreated among black Americans compared with white Americans (34).

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Disparities in mental health care

Most research comparing mental health care across ethnic groups finds evidence of disparities in access, use, and quality of care. As documented in “Mental Health: A Report of the Surgeon General” (35) and its supplement, “Mental Health: Culture, Race, and Ethnicity” (36), members of racial and ethnic minority groups have less access to mental health services than do their white counterparts, are less likely to receive needed care, and are more likely to receive poor quality of care when treated. Minorities in the United States are more likely than white Americans to delay or fail to seek mental health treatment (37–40). Two studies examining trends in mental health care, using the Institute of Medicine definition of disparities (41, 42), found no progress toward eliminating disparities in mental health care provided in either primary care or psychiatric settings.

Health and mental health care disparities are highly associated with access in general and lack of insurance in minority communities (43). In addition, both geographic and provider-level differences are major sources of disparity (44). Minorities are often overrepresented in inner cities with poor access and quality of care. Disparities may also occur at the provider level, with minorities overrepresented in practices providing low-quality care.

Health and mental health care may differ in the impact of providers on disparities. Specifically, physicians tend to hold a prior belief about the likelihood of a patient having a condition and update this belief according to the strength of information received in the clinical encounter. Because the prevalence of mental disorders may be slightly lower in minorities, underlying assumptions about the distribution of disease or communication problems between the physician and patient can lead to discrimination. This provider discrimination has been documented in two studies of mental health care (45, 46), in which clinicians responded with less alacrity to variation in severity of depression among minority patients than white patients, implying that clinicians are less able to “read” severity among minorities. Disparities arising within the clinical encounter may be more important in mental health care than in health care.

Low treatment rates in minority populations are likely related to poor minority representation in the health care workforce. Ethnic minorities are even more poorly represented in mental health care than in health care in general (Table 3). Because of the greater need for cultural sensitivity in dealing with mental health issues, extensive issues of trust, and the increasing language barrier between provider and patients, disparities in the workforce may account for more disparities in mental health than general health care. Disparities in mental health professionals also likely contributes to the inadequate representation of minorities in research, including in important clinical trials.

We now turn to the question of whether mainstream policy can reduce mental health status and health care disparities.

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Policies to Address Disparities

To eliminate health status disparities, progress against social disparities (e.g., education, housing, job opportunities, etc.) is likely to be most important (47). Mental health, in which health status disparities are not evident, presents an interesting paradox in this respect. While addressing social disparities may be important in its own right and in terms of reducing general health disparities, emphasizing social factors as a means to deal with mental health disparities seems less indicated. In contrast to general health, focus on mental health care appears to be more important for addressing disparities. For example, black Americans have lower rates of lifetime depression than their white counterparts living in similar areas, but rates of depression in the past year only are similar, and black Americans are more likely to rate their depression as severe and disabling (34). Quality mental health care could potentially eliminate these disparities.

In the case of mental health care, policy approaches share features with general health care policy. In fact, the major recommendations for eliminating health care disparities from the Institute of Medicine’s report (3) appear equally applicable to mental health care, including taking steps to improve access to care and providing economic incentives for improving patient-provider communication and trust, as well as rewarding appropriate screening, preventive, and evidence-based clinical care. Further, policies to increase minority participation in the health care workforce would most likely improve disparities in mental health care, as provider-patient communication and common language is particularly important and in which the minority workforce is particularly lacking.

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Policies Designed to Improve the Quality of Care

Should quality improvement efforts be focused on low quality or, since quality is lower for minorities, should care for minorities get special attention? Two studies have looked at interventions designed to improve quality of mental health care and examined minority outcomes. These studies were conducted in primary care settings, where ethnic minorities are most likely to receive mental health care. In a large trial of quality improvement for depression in older patients, a collaborative care intervention similarly improved the quality of care provided to African American, Hispanic, and white patients (48). A similar study of two quality improvement interventions for depression in managed care settings found that clinical outcomes at 1 year were better for Latino and African American patients than for white patients (49). Five years later, the interventions were found to improve disparities by improving health status outcomes and unmet need for care more among minorities than white patients (50). General mental health care improvements may help to decrease disparities, especially if efforts are made to make the quality improvement interventions appropriate for ethnic minorities.

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Research to Decrease Disparities

A major priority for research is finding solutions to eliminate mental health care disparities. Public awareness campaigns and direct-to-consumer advertising may do little to improve disparities. On the other hand, quality improvement interventions have been shown to decrease disparities in depression care for some minority groups initially experiencing lower quality of care. Determining the effectiveness of such interventions in other mental disorders (e.g., bipolar disorder, anxiety, and schizophrenia), other populations (e.g., Asian American and American Indian/Alaskan Native), and other care settings (e.g., mental health specialty) will be important. If this finding is robust, public policy emphasizing general quality improvement interventions could help reduce disparities.

Racial minorities have equal or better mental health than do white Americans, despite lower socioeconomic status and higher levels of social problems. Research to understand the protective role of cultural factors could benefit everyone. Understanding how culture protects mental health but not physical health in the presence of poverty, particularly for African Americans, could help answer fundamental questions about the impact of culture on health. Similarly, monitoring the patterns of worsening mental health status for minorities according to time spent in the United States could be important to understanding negative environmental influences on mental health in the United States.

Improving the representation of minorities in the health and mental health care system is needed. Evaluation of innovative programs to increase interest in health and mental health care among minorities would be an important step toward eliminating disparities. Similarly, understanding the impact of minority-focused mental health clinics on access and quality of care for minority populations will be important for building an appropriate policy to overcome mental health care disparities.

1.Frank RG, Glied SA: Better But Not Well: Mental Health Policy in the United States Since 1950. Baltimore, Johns Hopkins University Press, 2006
 
2.Carter-Pokras O, Baquet C: What is a “health disparity”? Public Health Rep 2002; 117:426–434
 
3.Smedley BD, Stith AY, Nelson AR (eds); Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, Board on Health Sciences Policy, Institute of Medicine: Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC, National Academies Press, 2003
 
4.Bernstein J; Economic Policy Institute: Minority wealth gap: net worth gap twice that of income, in Economic Snapshots, Mar 15, 2006 (www.epi.org/content.cfm/webfeatures_snapshots_20060315)
 
5.Williams DR: The health of U.S. racial and ethnic populations. J Gerontol B Psychol Sci Soc Sci 2005; 60:53–62
 
6.National Center for Health Statistics: Health, United States, 2006: Chartbook on Trends in the Health of Americans. Hyattsville, Md, U.S. Department of Health and Human Services, 2006
 
7.McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA: The quality of health care delivered to adults in the United States. N Engl J Med 2003; 348:2635–2645
 
8.Asch SM, Kerr EA, Keesey J, Adams JL, Setodji CM, Malik S, McGlynn EA: Who is at greatest risk for receiving poor-quality health care? N Engl J Med 2006; 354:1147–1156
 
9.Ayanian JZ, Udvarhelyi IS, Gatsonis CA, Pashos CL, Epstein AM: Racial differences in the use of revascularization procedures after coronary angiography. JAMA 1993; 269:2642–2646
 
10.Allison JJ, Kiefe CI, Centor RM, Box JB, Farmer RM: Racial differences in the medical treatment of elderly Medicare patients with acute myocardial infarction. J Gen Intern Med 1996; 11:736–743
 
11.Weitzman S, Cooper L, Chambless L, Rosamond W, Clegg L, Marcucci G, Romm F, White A: Gender, racial, and geographic differences in the performance of cardiac diagnostic and therapeutic procedures for hospitalized acute myocardial infarction in four states. Am J Cardiol 1997; 79:722–726
 
12.Schneider EC, Leape LL, Weissman JS, Piana RN, Gatsonis C, Epstein AM: Racial differences in cardiac revascularization rates: does “overuse” explain higher rates among white patients? Ann Intern Med 2001; 135:328–337
 
13.McMahon LF Jr, Wolfe RA, Huang S, Tedeschi P, Manning W Jr, Edlund MJ: Racial and gender variation in use of diagnostic colonic procedures in the Michigan Medicare population. Med Care 1999; 37:712–717
 
14.Imperato PJ, Nenner RP, Will TO: Radical prostatectomy: lower rates among African-American men. J Natl Med Assoc 1996; 88:589–594
 
15.Moore RD, Stanton D, Gopalan R, Chaisson RE: Racial differences in the use of drug therapy for HIV disease in an urban community. N Engl J Med 1994; 330:763–768
 
16.Shapiro MF, Morton SC, McCaffrey DF, Senterfitt JW, Fleishman JA, Perlman JF, Athey LA, Keesey JW, Goldman DP, Berry SH: Variations in the care of HIV-infected adults in the United States: results from the HIV Cost and Services Utilization Study. JAMA 1999; 281:2305–2315
 
17.Chin MH, Zhang JX, Merrell K: Diabetes in the African-American Medicare population: morbidity, quality of care, and resource utilization. Diabetes Care 1998; 21:1090–1095
 
18.Ayanian JZ, Weissman JS, Chasan-Taber S, Epstein A: Quality of care by race and gender for congestive heart failure and pneumonia. Med Care 1999; 37:1260–1269
 
19.Epstein AM, Ayanian JZ, Keogh JH, Noonan SJ, Armistead N, Cleary PD, Weissman JS, David-Kasdan JA, Carlson D, Fuller J: Racial disparities in access to renal transplantation—clinically appropriate or due to underuse or overuse? N Engl J Med 2000; 343:1537–1544
 
20.Agency for Healthcare Research and Quality: National Healthcare Disparities Report, 2006. Rockville, Md, Department of Health and Human Services, 2006
 
21.Heeringa SG, Wagner J, Torres M, Duan N, Adams T, Berglund P: Sample designs and sampling methods for the Collaborative Psychiatric Epidemiology Studies (CPES). Int J Methods Psychiatr Res 2004; 13:221–240
 
22.Alegría M, Mulvaney-Day N, Woo M, Torres M, Gao S, Oddo V: Correlates of past-year mental health service use among Latinos: results from the National Latino and Asian American Study. Am J Public Health 2007; 97:76–83
 
23.Takeuchi DT, Zane N, Hong S, Chae DH, Gong F, Gee GC, Walton E, Sue S, Alegría M: Immigration-related factors and mental disorders among Asian Americans. Am J Public Health 2007; 97:84–90
 
24.Williams DR, Haile R, González HM, Neighbors H, Baser R, Jackson JS: The mental health of black Caribbean immigrants: results from the National Survey of American Life. Am J Public Health 2007; 97:52–59
 
25.Vega WA, Kolody B, Aguilar-Gaxiola S, Alderete E, Catalano R, Caraveo-Anduaga J: Lifetime prevalence of DSM-III-R psychiatric disorders among urban and rural Mexican Americans in California. Arch Gen Psychiatry 1998; 55:771–778
 
26.Miranda J, Siddique J, Belin TR, Kohn-Wood LP: Depression prevalence in disadvantaged young black women-African and Caribbean immigrants compared to US-born African Americans. Soc Psychiatry Psychiatr Epidemiol 2005; 40:253–258
 
27.Beals J, Manson SM, Whitesell NR, Spicer P, Novins DK, Mitchell CM: Prevalence of DSM-IV disorders and attendant help-seeking in two American Indian reservation populations. Arch Gen Psychiatry 2005; 62:99–108
 
28.Robins LN, Regier DA (eds): Psychiatric Disorders in America: The Epidemiologic Catchment Area Study. New York, Free Press, 1991
 
29.Kendler KS, Gallagher TJ, Abelson JM, Kessler RC: Lifetime prevalence, demographic risk factors, and diagnostic validity of nonaffective psychosis as assessed in a US community sample: the National Comorbidity Survey. Arch Gen Psychiatry 1996; 53:1022–1031
 
30.Kessler RC, Chiu WT, Demler O, Walters EE: Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005; 62:617–627
 
31.Bresnahan M, Begg MD, Brown A, Schaefer C, Sohler N, Insel B, Vella L, Susser E: Race and risk of schizophrenia in a US birth cohort: another example of health disparity? Int J Epidemiol 2007; 36:751–758
 
32.Strakowski SM, McElroy SL, Keck PE, West SA: Racial influence on diagnosis in psychotic mania. J Affect Disord 1996; 39:157–162
 
33.Breslau J, Kendler KS, Su M, Gaxiola-Aguilar S, Kessler RC: Lifetime risk and persistence of psychiatric disorders across ethnic groups in the United Status. Psychol Med 2005; 35:317–327
 
34.Williams DR, González HM, Neighbors H, Nesse R, Abelson JM, Sweetman J, Jackson JS: Prevalence and distribution of major depressive disorder in African Americans, Caribbean blacks, and non-Hispanic whites: results from the National Survey of American Life. Arch Gen Psychiatry 2007; 64:305–315
 
35.U.S. Department of Health and Human Services: Mental Health: A Report of the Surgeon General. Rockville, Md, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, NIMH, NIH, 1999
 
36.U.S. Department of Health and Human Services: Mental Health: Culture, Race, and Ethnicity, Supplement to Mental Health: A Report of the Surgeon General. Rockville, Md, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, NIMH, NIH, 2001
 
37.Sussman LK, Robins LN, Earls F: Treatment-seeking for depression by black and white Americans. Soc Sci Med 1987; 24:187–196
 
38.Zhang AY, Snowden LR, Sue S: Differences between Asian and white Americans’ help seeking and utilization patterns in the Los Angeles area. J Community Psychol 1998; 26:317–326
 
39.Abe-Kim J, Takeuchi DT, Hong S, Zane N, Sue S, Spencer MS, Appel H, Nicdao E, Alegría M: Use of mental health-related services among immigrant and US-born Asian Americans: results from the National Latino and Asian American Study. Am J Public Health 2007; 97:91–98
 
40.Jackson JS, Neighbors HW, Torres M, Martin LA, Williams DR, Baser R: Use of mental health services and subjective satisfaction with treatment among Black Caribbean immigrants: results from the National Survey of American Life. Am J Public Health 2007; 97:60–67
 
41.Cook BL, McGuire T, Miranda J: Measuring trends in mental health care disparities, 2000–2004. Psychiatr Serv 2007; 58:1533–1540
 
42.Stockdale SE, Lagomasino IT, Siddique J, McGuire T, Miranda J: Racial and ethnic disparities in detection and treatment of depression and anxiety among psychiatric and primary health care visits, 1995–2005. Med Care 2008; 46:668–677
 
43.Alegría M, Cao Z, McGuire TG, Ojeda VD, Sribney B, Woo M, Takeuchi D: Health insurance coverage for vulnerable populations: contrasting Asian Americans and Latinos in the United States. Inquiry 2006; 43:231–254
 
44.Baicker K, Chandra A, Skinner JS: Geographic variation in health care and the problem of measuring racial disparities. Perspect Biol Med 2005; 48(Suppl 1):S42–S53
 
45.Balsa AI, McGuire TG, Meredith LS: Testing for statistical discrimination in health care. Health Serv Res 2005; 40:227–252
 
46.McGuire TG, Ayanian JZ, Ford DE, Henke RE, Rost KM, Zaslavsky AM: Testing for statistical discrimination by race/ethnicity in panel data for depression treatment in primary care. Health Serv Res 2008; 43:531–551
 
47.Williams DR: Socioeconomic differentials in health: a review and redirection. Soc Psychol Q 1990; 53:81–99
 
48.Areán PA, Ayalon L, Hunkeler E, Lin EH, Tang L, Harpole L, Hendrie H, Williams JW Jr, Unützer J; IMPACT Investigators: Improving depression care for older, minority patients in primary care. Med Care 2005; 43:381–390
 
49.Miranda J, Duan N, Sherbourne C, Schoenbaum M, Lagomasino I, Jackson-Triche M, Wells KB: Improving care for minorities: can quality improvement interventions improve care and outcomes for depressed minorities? results of a randomized, controlled trial. Health Serv Res 2003; 38:613–630
 
50.Wells K, Sherbourne C, Schoenbaum M, Ettner S, Duan N, Miranda J, Unützer J, Rubenstein L: Five-year impact of quality improvement for depression: results of a group-level randomized controlled trial. Arch Gen Psychiatry 2004; 61:378–386
 

+Received March 3, 2008; revised May 3, 2008; accepted May 12, 2008 (doi: 10.1176/appi.ajp.2008.08030333). From the Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles; Department of Health Care Policy, Harvard Medical School, Boston; Department of Society, Human Development, and Health, School of Public Health, Harvard University, Boston; and the Division of Services and Intervention Research, NIMH, Bethesda, Md. Address correspondence and reprint requests to Dr. Miranda, Department of Psychiatry and Biobehavioral Sciences, 10920 Wilshire Blvd., Ste. 300, Los Angeles, CA 90095; mirandaj@ucla.edu (e-mail).

+The authors report no competing interests.

+The views and opinions expressed in this commentary are those of the authors and should not be construed to represent the views of any sponsoring organization, agency, or the U.S. government.

+

References

1.Frank RG, Glied SA: Better But Not Well: Mental Health Policy in the United States Since 1950. Baltimore, Johns Hopkins University Press, 2006
 
2.Carter-Pokras O, Baquet C: What is a “health disparity”? Public Health Rep 2002; 117:426–434
 
3.Smedley BD, Stith AY, Nelson AR (eds); Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, Board on Health Sciences Policy, Institute of Medicine: Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC, National Academies Press, 2003
 
4.Bernstein J; Economic Policy Institute: Minority wealth gap: net worth gap twice that of income, in Economic Snapshots, Mar 15, 2006 (www.epi.org/content.cfm/webfeatures_snapshots_20060315)
 
5.Williams DR: The health of U.S. racial and ethnic populations. J Gerontol B Psychol Sci Soc Sci 2005; 60:53–62
 
6.National Center for Health Statistics: Health, United States, 2006: Chartbook on Trends in the Health of Americans. Hyattsville, Md, U.S. Department of Health and Human Services, 2006
 
7.McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA: The quality of health care delivered to adults in the United States. N Engl J Med 2003; 348:2635–2645
 
8.Asch SM, Kerr EA, Keesey J, Adams JL, Setodji CM, Malik S, McGlynn EA: Who is at greatest risk for receiving poor-quality health care? N Engl J Med 2006; 354:1147–1156
 
9.Ayanian JZ, Udvarhelyi IS, Gatsonis CA, Pashos CL, Epstein AM: Racial differences in the use of revascularization procedures after coronary angiography. JAMA 1993; 269:2642–2646
 
10.Allison JJ, Kiefe CI, Centor RM, Box JB, Farmer RM: Racial differences in the medical treatment of elderly Medicare patients with acute myocardial infarction. J Gen Intern Med 1996; 11:736–743
 
11.Weitzman S, Cooper L, Chambless L, Rosamond W, Clegg L, Marcucci G, Romm F, White A: Gender, racial, and geographic differences in the performance of cardiac diagnostic and therapeutic procedures for hospitalized acute myocardial infarction in four states. Am J Cardiol 1997; 79:722–726
 
12.Schneider EC, Leape LL, Weissman JS, Piana RN, Gatsonis C, Epstein AM: Racial differences in cardiac revascularization rates: does “overuse” explain higher rates among white patients? Ann Intern Med 2001; 135:328–337
 
13.McMahon LF Jr, Wolfe RA, Huang S, Tedeschi P, Manning W Jr, Edlund MJ: Racial and gender variation in use of diagnostic colonic procedures in the Michigan Medicare population. Med Care 1999; 37:712–717
 
14.Imperato PJ, Nenner RP, Will TO: Radical prostatectomy: lower rates among African-American men. J Natl Med Assoc 1996; 88:589–594
 
15.Moore RD, Stanton D, Gopalan R, Chaisson RE: Racial differences in the use of drug therapy for HIV disease in an urban community. N Engl J Med 1994; 330:763–768
 
16.Shapiro MF, Morton SC, McCaffrey DF, Senterfitt JW, Fleishman JA, Perlman JF, Athey LA, Keesey JW, Goldman DP, Berry SH: Variations in the care of HIV-infected adults in the United States: results from the HIV Cost and Services Utilization Study. JAMA 1999; 281:2305–2315
 
17.Chin MH, Zhang JX, Merrell K: Diabetes in the African-American Medicare population: morbidity, quality of care, and resource utilization. Diabetes Care 1998; 21:1090–1095
 
18.Ayanian JZ, Weissman JS, Chasan-Taber S, Epstein A: Quality of care by race and gender for congestive heart failure and pneumonia. Med Care 1999; 37:1260–1269
 
19.Epstein AM, Ayanian JZ, Keogh JH, Noonan SJ, Armistead N, Cleary PD, Weissman JS, David-Kasdan JA, Carlson D, Fuller J: Racial disparities in access to renal transplantation—clinically appropriate or due to underuse or overuse? N Engl J Med 2000; 343:1537–1544
 
20.Agency for Healthcare Research and Quality: National Healthcare Disparities Report, 2006. Rockville, Md, Department of Health and Human Services, 2006
 
21.Heeringa SG, Wagner J, Torres M, Duan N, Adams T, Berglund P: Sample designs and sampling methods for the Collaborative Psychiatric Epidemiology Studies (CPES). Int J Methods Psychiatr Res 2004; 13:221–240
 
22.Alegría M, Mulvaney-Day N, Woo M, Torres M, Gao S, Oddo V: Correlates of past-year mental health service use among Latinos: results from the National Latino and Asian American Study. Am J Public Health 2007; 97:76–83
 
23.Takeuchi DT, Zane N, Hong S, Chae DH, Gong F, Gee GC, Walton E, Sue S, Alegría M: Immigration-related factors and mental disorders among Asian Americans. Am J Public Health 2007; 97:84–90
 
24.Williams DR, Haile R, González HM, Neighbors H, Baser R, Jackson JS: The mental health of black Caribbean immigrants: results from the National Survey of American Life. Am J Public Health 2007; 97:52–59
 
25.Vega WA, Kolody B, Aguilar-Gaxiola S, Alderete E, Catalano R, Caraveo-Anduaga J: Lifetime prevalence of DSM-III-R psychiatric disorders among urban and rural Mexican Americans in California. Arch Gen Psychiatry 1998; 55:771–778
 
26.Miranda J, Siddique J, Belin TR, Kohn-Wood LP: Depression prevalence in disadvantaged young black women-African and Caribbean immigrants compared to US-born African Americans. Soc Psychiatry Psychiatr Epidemiol 2005; 40:253–258
 
27.Beals J, Manson SM, Whitesell NR, Spicer P, Novins DK, Mitchell CM: Prevalence of DSM-IV disorders and attendant help-seeking in two American Indian reservation populations. Arch Gen Psychiatry 2005; 62:99–108
 
28.Robins LN, Regier DA (eds): Psychiatric Disorders in America: The Epidemiologic Catchment Area Study. New York, Free Press, 1991
 
29.Kendler KS, Gallagher TJ, Abelson JM, Kessler RC: Lifetime prevalence, demographic risk factors, and diagnostic validity of nonaffective psychosis as assessed in a US community sample: the National Comorbidity Survey. Arch Gen Psychiatry 1996; 53:1022–1031
 
30.Kessler RC, Chiu WT, Demler O, Walters EE: Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005; 62:617–627
 
31.Bresnahan M, Begg MD, Brown A, Schaefer C, Sohler N, Insel B, Vella L, Susser E: Race and risk of schizophrenia in a US birth cohort: another example of health disparity? Int J Epidemiol 2007; 36:751–758
 
32.Strakowski SM, McElroy SL, Keck PE, West SA: Racial influence on diagnosis in psychotic mania. J Affect Disord 1996; 39:157–162
 
33.Breslau J, Kendler KS, Su M, Gaxiola-Aguilar S, Kessler RC: Lifetime risk and persistence of psychiatric disorders across ethnic groups in the United Status. Psychol Med 2005; 35:317–327
 
34.Williams DR, González HM, Neighbors H, Nesse R, Abelson JM, Sweetman J, Jackson JS: Prevalence and distribution of major depressive disorder in African Americans, Caribbean blacks, and non-Hispanic whites: results from the National Survey of American Life. Arch Gen Psychiatry 2007; 64:305–315
 
35.U.S. Department of Health and Human Services: Mental Health: A Report of the Surgeon General. Rockville, Md, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, NIMH, NIH, 1999
 
36.U.S. Department of Health and Human Services: Mental Health: Culture, Race, and Ethnicity, Supplement to Mental Health: A Report of the Surgeon General. Rockville, Md, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, NIMH, NIH, 2001
 
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