Provider Contributions to Disparities in Mental Health Care

Abstract

Objective: Disparities in diagnosis of mental health problems and in access to treatment among racial-ethnic groups are apparent across different behavioral conditions, particularly in the quality of treatment for depression. This study aimed to determine how much disparities differ across providers.

Methods: Bayesian mixed-effects models were used to estimate whether disparities in patient adherence to antidepressant medication (N=331,776) or psychotherapy (N=275,095) were associated with specific providers. Models also tested whether providers who achieved greater adherence to treatment, on average, among non-Hispanic white patients than among patients from racial-ethnic minority groups attained lower disparities and whether the percentage of patients from racial-ethnic minority groups in a provider caseload was associated with disparities.

Results: Disparities in adherence to both antidepressant medication and psychotherapy were associated with the provider. Provider performance with non-Hispanic white patients was negatively correlated with provider-specific disparities in adherence to psychotherapy but not to antidepressants. A higher proportion of patients from racial-ethnic minority groups in a provider's caseload was associated with lower adherence among non-Hispanic white patients, lower disparities in adherence to psychotherapy, and greater disparities in adherence to antidepressant medication.

Conclusions: Adherence to depression treatment among a provider's patients from racial-ethnic minority groups was related to adherence among that provider's non-Hispanic white patients, but evidence also suggested provider-specific disparities. Efforts among providers to decrease disparities might focus on improving the general skill of providers who treat more patients from racial-ethnic minority groups as well as offering culturally based training to providers with notable disparities.

Keywords: Bayesian multilevel modeling; adherence; cross-cultural issues; cultural competence; provider effects; racial-ethnic mental health disparities; treatment adherence.

Figure 1.. Distribution of the Difference in the Probability of non-Hispanic White and racial-ethnic minority Return Rates.

This figure illustrates the model derived provider-specific disparities (e.g., random effects) in psychotherapy and medication (based on randomly selected 5% of the provider sample to increase readability of plot). Each circle is a provider. Circles above zero indicate non-Hispanic white patients had a greater probability of adhering to the treatment. Differences between plot and model results in the narrative are due to using a subsample of the providers in the plot.

Figure 2.. Effect of the Proportion of racial-ethnic minority Patients in Provider Caseload Adherence Rates.

The effects of the proportion for ADM and psychotherapy. For ADM, adherence among non-Hispanic white and racial-ethnic minority patients diverged when the percentage of racial-ethnic minority patients was larger. For psychotherapy it was the opposite, adherence rates converged when the percentage of racial-ethnic minority patients was larger.