EDITORIAL

Health Disparities Research in Geriatric Mental Health: Commentary from the National Institute of Mental Health Jovier D. Evans, Ph.D., Denise Juliano-Bult, M.S.W., Su Yeon Lee, Ph.D.

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he expanding cohort of older Americans is rapidly becoming more ethnically and culturally diverse.1,2 In fact, between 2000 and 2011, the number of racial and ethnic minority adults over age 65 increased significantly, from 16.3% of older adults (5.7 million) to 21% (8.5 million).3 Between 2012 and 2030, non-Hispanic white older adults are projected to increase by 54%, whereas older adults from racial and ethnic minority groups are expected to grow by 125% over that same period.3 By 2030, the United States is projected to have 20.2 million racial and ethnic minority older adults (28% of the elderly population).3 These factors create an increased public health demand to understand and reduce the burden of all types of mental disorders on older Americans, particularly among people from underserved populations. The U.S. Department of Health and Human Services defines health disparities as differences in the incidence, prevalence, mortality, and burden of disease and other adverse health conditions that exist among specific groups in United States.4 Such differences can be broadly classified as disparities in health status (resulting from obstacles posed by race or ethnicity, geographic location, socioeconomic status, sex and/or gender identity, age, etc.)5 or in healthcare (resulting from differences in access to and quality of healthcare not due to needs or preferences). Bias, discrimination, and stereotypes held by the patient and provider, institution, and health

system are factors that contribute to healthcare disparities.6 The National Institute of Mental Health (NIMH) has emphasized mental health disparities as a crosscutting theme among its strategic research objectives (see the draft of the NIMH strategic plan),7 which is intended to foster scientific discoveries that improve outcomes for people with mental illnesses. An approach that potentially impacts conducting disparities reduction research involves, first, theoretical or empirical identification of root causes of disparities, followed by efforts to develop and test the effectiveness of strategies targeted to intervene on the root causes. Interventions of this sort proven effective can then be disseminated and implemented broadly to reduce mental health disparities. Clinical trials funded by NIMH are shifting toward an “experimental therapeutics approach,” which rigorously assesses the intervention’s mechanisms of altering brain function or other factors hypothesized to lead to improvement in symptoms or other desired outcomes.8 Studies that assess how successfully an intervention alters such intermediate factors, referred to as the interventional “targets”—en route to achieving improved symptomatic, behavioral, and functional outcomes—can serve as probes to understand mechanisms underlying a disorder or a pattern of health service use as much as they inform potential treatment development.9 (More information on NIMH’s general approach to intervention development can be found at

Received January 22, 2015; accepted January 31, 2015. From the Division of Translational Research (JDE), Division of Services and Interventions Research (DJ-B), and Office for Research on Disparities and Global Mental Health (SYL), National Institute of Mental Health, Rockville, MD. Send correspondence and reprint requests to Jovier D. Evans, Ph.D., Division of Translational Research, National Institute of Mental Health, 6001 Executive Boulevard, MSC 9634, Room 7217, Rockville, MD 20852. e-mail: [email protected] Published by Elsevier Inc. on behalf of the American Association for Geriatric Psychiatry http://dx.doi.org/10.1016/j.jagp.2015.01.006

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Editorial http://www.nimh.nih.gov/funding/opportunitiesannouncements/clinical-trials-foas/index.shtml.) This new approach can be applied fruitfully to interventions that attempt to reduce disparities in racial and ethnic minority treatment outcomes. The Geriatrics and Aging Processes Branch at NIMH oversees a research portfolio that spans from clinical neuroscience/translational spectrum to efficacy and effectiveness research. The branch is particularly interested in fostering both basic and early translational studies to facilitate the understanding of biologic mechanisms of disease and potential avenues for biomarker development and refinement. For these efforts to be meaningful, they must represent the full diverse spectrum of the geriatric population. More efforts to diversify the populations under study are essential in achieving these goals. There is also a need to have larger samples in these studies to examine both biologic and phenotypic variations in both the pathophysiology and maintenance of psychiatric disease. Do geneeenvironment interactions and risk profile look the same across different ethnic groups? Are there differences in risk and resilience profiles among different ethnic minority elders that may point to novel targets for intervention? Can new treatments be developed or augmented to personalize treatments to improve their benefit? To answer some of these questions, concerted efforts must be conducted to gather large diverse samples while also asking focused questions concerning efforts to tailor and personalize treatments for elders, who have not been traditional participants in research. In the realm of intervention research, more work needs to examine mechanisms of both disease pathophysiology and intervention action to improve the reach and usefulness of these interventions. Once these mechanisms are identified, understanding the cultural and/or ethnic variations will help to personalize treatment approaches beyond just populations but to treatment settings and environments. It is important to develop disparity reduction interventions, with attention to their further dissemination and implementation in real-world settings. For this to happen, investigators must work outside of traditional academicemedical settings and pay attention to the resources and settings where these interventions may be delivered.

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NIMH priorities in geriatric services research fall into two main categories: (1) improving the efficiency, effectiveness, availability, quality, and use of existing evidence-based mental health practices and (2) development and testing of innovative new service delivery models to improve access and outcomes of mental healthcare. Outcomes of interest include reduction of psychiatric symptoms and associated functional disability and overall reduction in disparities in mental health services for older adults with mental disorders. Strategies to accomplish this may involve service interventions delivered at the individual, family, provider, payer, clinic, or systems levels, in both public and private healthcare systems. Studies that use existing, realworld data collection systems or that focus on optimizing healthcare financing models for older adults are also of interest, as are empirical tests of strategies for broad implementation of geriatric mental health evidence-based practices in diverse communities and for continuous quality improvement of mental health interventions and services for older adults. In addition, studies on the use of technology, delivery of services via nontraditional mental healthcare settings, and coordinated medical decision-making to integrate care across settings for older people with multiple chronic conditions are also of interest. The individual and institutional training mechanisms supported by NIMH can be used to foster the development of the next generation of geriatric mental health researchers. There is an urgent need to expand the geriatric expertise available in both general medicine and other allied health professionals to deal with the growing segment of the older adult population.10 In addition, NIMH is also continuously developing and supporting a cadre of racially and ethnically diverse researchers who will tackle some of these issues in their careers. Beyond expanding the pool of researchers available, we must also ensure that all geriatric mental health professionals are equipped to serve a multicultural community of elders. Training programs that focus on evidencebased practices and dissemination and implementation strategies for diverse communities are one strategy to address this issue. Collectively, the articles in this issue speak to outreach efforts to increase the diversity of older

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Evans et al. adult research samples to improve their representation of the elderly population. These articles also highlight successful research efforts with “hard to reach” populations and provide interesting results regarding the experience and interpretation of mental illness among racial and ethnic minority elders. The article by Samus et al.11 speaks to the need to improve outreach efforts in clinical research and how to deal with complex and structural barriers to participation. What is clear from this article is that several approaches and strategies are needed to effectively recruit and retain a diverse sample of community-dwelling elders for participation in research studies. Jang et al.12 and Kim et al.13 describe interesting research that attempts to bridge gaps in both the understanding and the assessment of both clinical and cognitive domains among elder racial and ethnic minority populations. In addition to discussing the prevalence and perception of affective symptoms in these populations, both reports note high levels of problems and unmet service utilization

in these groups due to both structural and individual differences in the perception of mental health distress and in willingness to seek treatment from traditional mental health sources. Vahia et al.14 examine the usefulness and reliability of telepsychiatry for a rural Latino community for the assessment of cognitive status, and Fitzpatrick et al.15 discuss the validity and usefulness of a cognitive screening measure in a large multiethnic cohort of older adults who have cardiovascular problems. All articles presented in this issue address the need to further research efforts among diverse elders to not only to expand knowledge about how best to provide evidence-based care but to develop innovative and creative solutions to meet the treatment gaps seen for this rapidly growing segment of the population. The NIMH is interested in supporting more work that seeks a basic understanding of the individual and structural factors that may be used to improve engagement and access to both mental health services and research that would ultimately improve care.

References 1. Woodward AT, Taylor RJ, Bullard KM, et al: Prevalence of lifetime DSM-IV affective disorders among older African Americans, Black Caribbeans, Latinos, Asians and Non-Hispanic White people. Int J Geriatr Psychiatry 2012; 27:816e827 2. Vincent GK, Velkoff VA: The next four decades: the older population in the United States: 2010 to 2050. [Population Estimates and Projects.] December 11, 2010. Available at: http://www. census.gov/prod/2010pubs/p25-1138.pdf. Accessed 2014 3. Administration on Aging: A profile of older Americans: 2012. Available at: http://www.aoa.gov/Aging_Statistics/Profile/2012/ docs/2012profile.pdf 4. U.S. Department of Health and Human Services: HHS action plan to reduce racial and ethnic health disparities: a nation free of disparities in health and health care; May 7, 2011. Available at: http://minorityhealth.hhs.gov/npa/files/Plans/HHS/HHS_Plan_ complete.pdf. Accessed 2013 5. Office of Minority Health: National Stakeholder Strategy for Achieving Health Equity. Rockville, MD, U.S. Department of Health and Human Services, 2011 6. Smedley BD, Stith AY, Nelson AR, et al: Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC, National Academy Press, 2003 7. Office of Science Policy, Planning, and Communications: Public draft of National Institute of Mental Health strategic plan, December 1, 2014. Available at: http://www.nimh.nih.gov/about/strategic-plann ing-reports/Strategic_Plan_2015_public_comment_148461.pdf 8. Insel T: A new approach to clinical trials [director’s blog]. March 4, 2014. Available at: http://www.nimh.nih.gov/about/director/ 2014/a-new-approach-to-clinical-trials.shtml

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9. National Institute of Mental Health: NIMH clinical trials funding opportunity announcements—applicant FAQs, January 2, 2014. Available at: http://www.nimh.nih.gov/funding/ opportunities-announcements/clinical-trials-foas/changing-nimhclinical-trials-efficiency-transparency-and-reporting.shtml. Accessed 2015 10. Institute of Medicine, Committee on Mental Health Workforce for Geriatric PopulationsEden J: The Mental Health and Substance Use Workforce for Older Adults. In: Whose Hands? Washington, DC, National Academies Press, 2012 11. Samus QM, Amjad H, Johnston D, et al: A multipronged, adaptive approach for the recruitment of diverse community-residing elders with memory impairment: the MIND at Home experience. Am J Geriatr Psychiatry 2015; 23:698e708 12. Jang Y, Yoon H, Chiriboga DA, et al: Bridging the gap between common mental disorders and service use: the role of self-rated mental health among African Americans. Am J Geriatr Psychiatry 2015; 23:658e665 13. Kim MT, Kim KB, Han HR, et al: Prevalence and predictors of depression in Korean American elderly: findings from the memory and aging study of Koreans (MASK). Am J Geriatr Psychiatry 2015; 23:671e683 14. Vahia IV, Ng B, Camacho A, et al: Telepsychiatry for neurocognitive testing in older rural Latino adults. Am J Geriatr Psychiatry 2015; 23: 666e670 15. Fitzpatrick AL, Rapp SR, Luchsinger J, et al: Sociodemographic correlates of cognition in the multi-ethnic study of atherosclerosis (MESA). Am J Geriatr Psychiatry 2015; 23: 684e697

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Health Disparities Research in Geriatric Mental Health: Commentary from the National Institute of Mental Health.

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