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Glenda Wrenn Gord, DFAPA MSHP Health Equity in Depression T reatmentLearning Objectives By the end of this session participants will be able to: • Explain health disparities in depression treatment • Identify at least (2) strategies to promote health equity in the treatment of MDD across diverse populationsHealth (In)equity Health inequities are differences in health status or in the distribution of health resources between different population groups, arising from the social conditions in which people are born, grow, live, work and age. Health inequities are unfair and could be reduced by the right mix of government policies. Differences in treatment or access of population groups not justified by the differences in health status or preferences of the groups. The IOM definition of Clinical disparities Appropriateness and Need Patient a Preferences in health C y Difference The Operation of l r Healthcare Systems care e n and Legal and H M t Regulatory Climate Disparity o n o i N i Discrimination: Biases, a M Stereotyping, and Q Uncertainty Mental Health Disparities fall into one of three categories (public health, health systems, society) 1. Disparities between the attention given mental health CDC and that given other public health issues of comparable Definition magnitude 2. Disparities between the health of the persons with mental illness as compared with that of those without 3. Disparities between populations with respect to mental health and the quality, accessibility, and outcomes of mental health careThe Cost of Mental Health Inequity • The projected cumulative cost of mental health inequities is estimated to amount to $14 trillion by the year 2040. • The U.S. currently spends an estimated $477.5 billion annually in avoidable and unnecessary expenses related to mental health inequities. • Under the current conditions, the U.S. is estimated to spend $1.26 trillion per year by 2040 on costs related to mental health inequities. • Emergency department utilization related to mental health inequities costs an estimated $5.3 billion annually, with projections suggesting a potential rise to approximately $17.5 billion by 2040 if left unaddressed. Dawes, D, Bhatt, J, Dunlap, N, et al. The Projected Cost and Economic Impact of Mental Health Inequities in the United States. Meharry School of Global Health; 2024Depression Care Disparities in the US • Major Depression goes undiagnosed and untreated at disproportionately greater rates in majority Black and Hispanic communities • When treated, Black and Hispanic communities have lower frequency of both prescription drug treatment and counselling • The presence of mental and behavioral health providers in Black and Hispanic communities is associated with higher diagnosis rates suggesting access to care as a driver of depression care disparities BCBS Health of America Report 2022, https://www.bcbs.com/sites/default/files/file-attachments/health-of- BCBS Health of America Report 2022, https://www.bcbs.com/sites/default/files/file-attachments/health-of-america-report/Racial-Disparities-in-Diagnosis-and-Treatment-of-Major- Depression_2.pdfGlobal Disparities in DataGlobal Depression Care Disparities • The treatment coverage for major depressive disorder (MDD) is low in many parts of the world despite MDD being a major contributor to disability globally. • Mental health service use ranged from 33% (95% uncertainty interval (UI) 8, 66) in high-income countries to 8% (95% UI <1, 36) in low- and lower middle-income countries • Minimally adequate treatment (MAT) ranged from 23% (95% UI 2, 55) in high-income countries to 3% (95% UI <1, 25) in low- and lower middle-income countries. Modhurima Moitra, Damian Santomauro, Pamela Y. Collins, Theo Vos, Harvey Whiteford, Shekhar Saxena, Alize J. Ferrari. The global gap in treatment coverage for major depressive disorder in 84 countries from 2000–2019: A systematic review and Bayesian meta-regression analysis. PLOS Medicine, 2022; 19 (2): e1003901 DOI: 10.1371/journal.pmed.1003901WHO Special Initiative for Mental Health • Launched in 2019, for implementation over five years, in 12 countries at a cost of US $60 million • Designed to address this service and treatment gap and move people with these conditions towards universal health coverage - in nine countries across WHOs six Regions – Argentina, Bangladesh, Ghana, Jordan, Nepal, Paraguay, Philippines, Ukraine and Zimbabwe • Aims to ensure universal health coverage involving access to quality and affordable care for mental health, neurological and substance use conditions for 100 million more people https://www.who.int/initiatives/who-special-initiative-for-mental-healthWhat are some of the barriers? • Common barriers to accessing mental health care include costs, not knowing where to obtain care, limited provider options, and limited acceptance of insurance among providers. • People of color face increased access barriers due to a range of factors, such as the lack of a diverse mental health care workforce, the absence of culturally informed treatment options, and stereotypes and discrimination associated with poor mental health. Kaiser Family Foundation Survey of Race Discrimination and Health (2023)Promoting Depression Care Equity • Timely and Accurate Diagnosis • Use of community health workers, promatoras, peer support • Access to affordable treatment • Access to medication management and psychotherapy • Culturally Centered Care • Integrated Care • Family Engagement in CareCase Study #1 Isabel • Isabel is a 72 year old Mexican women who presents to the Heart Failure clinic after hospitalization for CHF exacerbation. She worked in agriculture for many years and currently lives with her daughter and grandchildren. She is widowed for the past 5 years and had been prescribed medication briefly after a “nervous breakdown” but did not continue. She screened positive for depression at intake, but she is not fluent in English relying on her granddaughter to assist her. • Her cardiologist makes a referral to the mental health clinic after noting that she looked detached and told them she was “waiting to die”. The granddaughter took the referral information and placed it in her bag. She did not seem that concerned.Health (In)Equity in Clinical Practice • Failure to provide culturally and linguistically appropriate services • Failure to identify social determinant of health risk/needs • Insufficient support in making mental health referral • Failure to explore potential suicide riskCase Study #2 Pamela • Pamela is a 51 year old African American women who presents to her primary care physician for annual visit. He notes that her diabetes is poorly controlled, and she cites stress after her son was murdered 8 months ago. Her PHQ-9 was 19 and she was offered a referral to the Integrated Behavioral Health Clinic. • She was initially reluctant saying “I’m not crazy, I’m just grieving” but she was glad that she could get help soon. Her doctor explains the PHQ-9 results and recommends she start an SSRI today and follow up with the behavioral health care manager with in the next 48 hours. • She was referred to a faith-based grief support group and encouraged to bring her daughter who lives with her to the next appointment to answer any questions she or her loved one may have.Health Equity in Clinical Practice • Access to collaborative care provides a low stigma treatment setting • Being prescribed an SSRI by her trusted primary care physician improved access • Use of measurement-based care ensures treatment to target • Culturally centered care helps the patient overcome self stigma and ensures her existing supports are activated • Engaging her family in treatment prevents likelihood of drop out and may improve treatment adherence https://doi.org/10.1136/gpsych-2022-100784al Health Action Plan updates to expand family and caregiver involvement in mental healthcare. General psychiatry, 35(2), e100784.“We need leaders who know enough, who care enough, who will do enough, and most importantly, who will persist until the work is done” Dth David Satcher 16 US Surgeon General Satcher Health Leadership InstituteThank you