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Adults with serious mental illness (SMI) often experience gaps in access to needed health care compared with other populations. Such disparities may be even more pronounced between certain groups of patients with SMI, differing by race, ethnicity, gender, economic disadvantage (including housing stability) and socioeconomic status, and geographic location (chiefly, rural versus urban residence); disparities arise as well for individuals identifying as lesbian, gay, bisexual, and transgender (LGBT) and those who have difficulty communicating in English (because it is a second language).
The primary goal of this Technical Brief is to describe and review the effectiveness of interventions that address disparities among adult patients with SMI in these important groups.
We reviewed the published and gray literature and interviewed Key Informants (KIs) to address four Guiding Questions (GQs). The four refined GQs for this Technical Brief focus on the critical areas of concern in relation to mental health treatment disparities—access to health insurance with appropriate coverage for these SMI conditions, accurate diagnostic evaluations, receipt of necessary and appropriate therapeutic services, quality of the health services, adherence to treatment over the long term, and various outcomes of care. The principal focus for the first three GQs is a description of the interventions (GQ 1), the context in which they are implemented (GQ 2), and a description of the evidence about the effectiveness of the interventions (GQ 3); GQ 4 presents conclusions, examines the gaps in the knowledge base, and identifies high-priority needs for future research. We include interventions addressing diagnosis, access to, and quality of treatment and support services among disparity groups of adults with SMI.
We identified 42 descriptive articles meeting inclusion criteria for GQs 1, 2, and 4, plus 37 articles measuring intervention effectiveness reporting on 26 unique studies (GQ 3). For GQ 1, the goals of each intervention were related to the specific diagnosis and disparity group that the intervention was targeting. Increased service use and treatment adherence were the most common intervention goals. For GQ 2, settings involved primarily mental health specialists being colocated in nonpsychiatric locations. These were usually primary care, but sometimes they were obstetrics-gynecology clinics, perinatal health care settings, and community mental health entities.
For GQ 3, most interventions tested adding enhanced services to usual available care, including culturally adapted collaborative care or other therapies, integrated services, case management and telemedicine. We found no studies of interventions for individuals identifying as LGBT or focusing only on English as a second language, addressing access to health care coverage, or addressing diagnostic accuracy. We found one study of the elderly, a group that can be predicted to have a larger number of physical comorbidities and difficulties obtaining necessary care because of their SMI.
Future research should identify interventions that are effective in reducing disparities all along the health care continuum and determine whether such interventions are equally effective for particular groups within the SMI population. Many promising interventions focused on disadvantaged individuals, including homeless individuals and racial or ethnic minority disparity groups. Future research can include comparative findings between minority and majority group patients and subgroup analyses to evaluate effectiveness among different disparity groups.
Most interventions targeted depressive and psychotic disorders. The use of collaborative care, intensive case management approaches, such as the Critical Time Intervention (CTI) and Assertive Community Treatment (ACT), and specific culturally adapted therapies, including those involving families of individuals with SMI, were the most noticeable modifications to interventions, but were not widely applied across groups. Gaps persist both in terms of the diversity of disparity groups included in studies (particularly individuals who identify as LGBT and the elderly) and approaches considered.