Treatment Pathways for Psychosis Vary by Race

A new study, published in JAMA Psychiatry, examines ethnoracial disparities in pathways to treatment in youth experiencing first-episode psychosis.

Researchers found differences between ethnoracial groups experiencing psychotic symptoms regarding how quickly they received care and where (emergency department, law enforcement, mental health, etc.) they gained access to treatment. They conclude by offering suggestions about addressing these disparities at both organizational and systemic levels.

The authors, led by Els van der Van of Vrije Universiteit Amsterdam write:

“Disparities in pathways to care, typically characterized by source of referral and type of first mental health contact, have been found between majority White individuals and under-served racialized and ethnic (hereafter, ethnoracial) groups. Studies from Europe and Canada have demonstrated that Black Caribbean and Black African individuals with psychosis experience more negative pathways to care, including high rates of compulsory admissions and police involvement compared with majority White groups.”

Previous studies on ethnoracial disparities in treatment pathways have centered on differences between marginalized ethnoracial groups and non-Latinx White individuals, which operates from the assumption that White persons are the norm that other groups deviate from.

In the current study, van der Van and colleagues use a cultural variant model, which takes into consideration how the different intersections of an individual’s sociodemographic background, including race and ethnicity (in this study, Latinx, Asian Black, White, multiracial, and other/unknown) as well as gender, sexual orientation, living situation, type of health insurance, and so on, determine how individuals are influenced by disadvantage/privilege.

To explore ethnoracial differences in time-to-treatment access, researchers analyzed data from OnTrackNY, comprised of a network of coordinated specialty care (CSC) programs across New York State that provide: “recovery-oriented, evidence-based psychosocial interventions and medications to young people experiencing early psychosis.”

Using OnTrackNY data, researchers created different “clusters” of individuals based on their first contact with mental health treatment and social position. The first cluster of individuals was the largest at 34.6%. It consisted of predominantly minority ethnoracial groups (except for 1 White individual) who were hospitalized and experienced positive symptoms, including hallucinations, delusions, and paranoia. They also tended to exhibit violent behavior. Most persons in the first cluster were referred to treatment by their family (78%) or had first contact with mental health treatment via psychiatric hospitalization (75.9%).

The second cluster of persons included mostly White, more economically advantaged individuals who tended to report a mix of symptoms and be treated at sites outside of the city. Most individuals in this group had private insurance (67%) and were psychiatrically hospitalized for their first contact (60%). However, this group was the largest proportion of individuals whose first contact was with OnTrackNY at 4.3%.

The third grouping of participants was the most entho-racially diverse and consisted of younger individuals (most under 21), the highest percentage of sexual minorities (29%), and women (8.5%). Individuals in this group were most likely to be referred to care through their schools and were typically treated in the emergency department and were not admitted to inpatient hospitalization. Most persons in this group received outpatient or primary care as their first contact (28%). There were no particular symptoms that stood out for this group.

The fourth cluster consisted of persons who were predominantly Asian (18%) and Latinx (49%), non-English speakers, and all had symptoms of depression (100%) as well as the highest rates of suicidality (42%), hallucinations (79%), and paranoia (86%). Most individuals in this group were treated at sites located in the city (81%) and were referred to care by a mental health professional.

The fifth group included primarily Black (63%) and older persons. Individuals in this cluster had the highest rates of public insurance. In addition, 49% of persons in this grouping were homeless, and 40% lived alone. They were the most likely of any group to have their first contact to care occur via law enforcement (11%), most often to be referred from emergency services (25%), and were more likely to be referred by the criminal justice system (4%). This group had low rates of depression and high rates of violent behavior in comparison to other groups.

When comparing these groups, researchers found that the group consisting of primarily White individuals differed the most from other groups. They discovered that ethnoracial minorities, including Black, Asian, Latinx, and multicultural individuals, had more extended periods between first contact for services (36-44 days for BIPOC individuals; 17 days for White individuals) but a relatively short first contact to CSC pathways when compared to White individuals.

Similar patterns were found when comparing groups of predominantly Asian and Latinx individuals with the White, privately insured cluster–they had longer onset for first contact and shorter onset for contact to CSC.

When comparing overall symptom onset to access to CSC pathways, rates varied inconsistently among marginalized ethnoracial groups – the first group, which consisted of individuals of predominantly minority ethnoracial backgrounds, had a median of 140 days from symptom onset to CSC, while the fifth cluster, which included primarily Black persons, had a median of 201 days.

The researchers offer a few explanations for these differences in access and pathways to care:

“A possible explanation is that marginalized groups have shorter and perhaps more challenging first contact to CSC pathways that include police contact and emergency services, whereas White patients may be more likely to receive outpatient mental health care and ultimately get referred to CSC. However, it is also possible that the relatively short care pathway to OnTrackNY for disadvantaged individuals is due to a lack of involvement of other mental health services or to the accessibility of and engagement strategies practiced by CSC services, which are designed to limit barriers to services.”

Delays in receiving care can significantly negatively impact the individual in need. For example, delaying treatment even by three weeks has been shown to lead to an increase in more severe symptoms by more than 20%.

However, Van der Van and colleagues’ findings differ from other studies across the UK, Canada, and the US, which found shorter periods of untreated psychosis in Black individuals. However, the authors point out that only examining untreated psychosis as opposed to looking at different stages along the process of pathways of care may not reveal ethnoracial disparities across the care continuum.

Further, they emphasize that quick access to treatment could be the result of negative pathways to care, such as lower tolerance of perceived deviant behavior in minority groups, as evidenced by research elsewhere that highlights how youth from marginalized racial groups are more likely to be hospitalized against their will, and that Black individuals with first-episode psychosis are at higher risk of coercive treatment. On the other hand, receiving treatment quickly could result from positive pathways, such as fast access to specialized care.

Limitations of the study include that due to the nature of the OnTrackNY data, which clinicians generated, it could be influenced by clinician bias, and researchers were unable to conduct validity and reliability assessments. Also, the study had limited measures of socioeconomic status and is grounded in the context of the US healthcare system.

Lastly, issues like stigma and potential misrecognition of symptoms were unaddressed, which is critical given that Black persons are almost twice as likely to be diagnosed with schizophrenia than White individuals, which may be due to clinician bias and misdiagnosis.

The researchers conclude by emphasizing the need to include service users in research, examine why youth may mistrust or not want to engage in CSC services, and increase access to mental health care in schools.

At the systemic level, the school-to-prison pipeline for Black and Latinx youth and the disparities in the handling of behavioral and mental health crises need to be examined. Elsewhere, research has shown that White children’s problem behaviors tend to be medicalized, whereas Black children’s problem behavior is criminalized.

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van der Ven, E., Jones, N., Bareis, N., Scodes, J. M., Dambreville, R., Ngo, H., Mathai, C. M., Bello, I., Martínez-Alés, G., Mascayano, F., Lee, R. J., Veling, W., Anglin, D. M., Lewis-Fernandez, R., Susser, E. S., Compton, M. T., Dixon, L. B., Wall, M. M. (2022). An intersectional approach to ethnoracial disparities in pathways to care among individuals with psychosis in coordinated specialty care. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2022.1640 (Link)