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Crowd-out and Exposure Effects of Physical Comorbidities on Mental Health Care Use: Implications for Racial–Ethnic Disparities in Access

Authors

  • Benjamin Lê Cook,

    1. Center for Multicultural Mental Health Research, 120 Beacon St., 4th Floor, Somerville, MA 02143
    2. Department of Psychiatry, Harvard Medical School, Boston, MA
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    • Address correspondence to Benjamin Lê Cook, Ph.D., M.P.H., Senior Scientist, Center for Multicultural Mental Health Research, 120 Beacon St., 4th Floor, Somerville, MA 02143; e-mail: bcook@charesearch.org. Benjamin Lê Cook, Ph.D., M.P.H., Instructor, is with the Department of Psychiatry, Harvard Medical School, Boston, MA. Thomas G. McGuire, Ph.D., Professor of Health Economics and Sharon-Lise Normand, Ph.D., Professor of Health Care Policy (Biostatistics), are with the Department of Health Care Policy, Harvard Medical School, Boston, MA. Margarita Alegría, Ph.D., Director, is with the Center for Multicultural Mental Health Research, Somerville, MA and Professor of Psychology, with the Department of Psychiatry, Harvard Medical School, Boston, MA.

  • Thomas G. McGuire,

    1. Department of Health Care Policy, Harvard Medical School, Boston, MA
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  • Margarita Alegría,

    1. Department of Psychiatry, Harvard Medical School, Boston, MA
    2. Center for Multicultural Mental Health Research, Somerville, MA
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  • Sharon-Lise Normand

    1. Department of Health Care Policy, Harvard Medical School, Boston, MA
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Abstract

Objectives. In disparities models, researchers adjust for differences in “clinical need,” including indicators of comorbidities. We reconsider this practice, assessing (1) if and how having a comorbidity changes the likelihood of recognition and treatment of mental illness; and (2) differences in mental health care disparities estimates with and without adjustment for comorbidities.

Data. Longitudinal data from 2000 to 2007 Medical Expenditure Panel Survey (n=11,083) split into pre and postperiods for white, Latino, and black adults with probable need for mental health care.

Study Design. First, we tested a crowd-out effect (comorbidities decrease initiation of mental health care after a primary care provider [PCP] visit) using logistic regression models and an exposure effect (comorbidities cause more PCP visits, increasing initiation of mental health care) using instrumental variable methods. Second, we assessed the impact of adjustment for comorbidities on disparity estimates.

Principal Findings. We found no evidence of a crowd-out effect but strong evidence for an exposure effect. Number of postperiod visits positively predicted initiation of mental health care. Adjusting for racial/ethnic differences in comorbidities increased black–white disparities and decreased Latino–white disparities.

Conclusions. Positive exposure findings suggest that intensive follow-up programs shown to reduce disparities in chronic-care management may have additional indirect effects on reducing mental health care disparities.

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