Racial And Ethnic Disparities In PTSD

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V O L U M E 3 1 / N O . 4 I S S N : 1 0 5 0 -1 8 3 5 2 0 2 0Research Quarterlyadvancing science and pr omoting unders tanding of traum atic stressPublished by:National Center for PTSDVA Medical Center (116D)215 North Main StreetWhite River JunctionVermont 05009-0001 USA(802) 296-5132FAX (802) 296-5135Email: ncptsd@va.govAll issues of the PTSD ResearchQuarterly are available online at:www.ptsd.va.govEditorial Members:Editorial DirectorMatthew J. Friedman, MD, PhDBibliographic EditorDavid Kruidenier, MLSManaging EditorHeather Smith, BA EdNational Center Divisions:ExecutiveWhite River Jct VTBehavioral ScienceBoston MADissemination and TrainingMenlo Park CAClinical NeurosciencesWest Haven CTEvaluationWest Haven CTPacific IslandsHonolulu HIWomen’s Health SciencesBoston MARacial and EthnicDisparities in PTSDHealth disparities are defined as those differences inhealth which are “unnecessary, avoidable, unfair,and unjust” (Whitehead, 1992). In a 2008 report oncauses of health disparities worldwide, the WorldHealth Organization (WHO) observed, “Withincountries there are dramatic differences in healththat are closely linked with degrees of socialdisadvantage” (WHO Commission on SocialDeterminants of Health & World Health Organization,2008). These avoidable health inequities exist“because of the circumstances in which peoplegrow, live, work, and age, and the systems put inplace to deal with illness” (WHO Commission onSocial Determinants of Health & World HealthOrganization, 2008). That is, differences in the socialdeterminants affecting everyday aspects of lifecontribute to disparities in health within and acrosspopulations. Given more recent advances ingenomic medicine, the National Institute of MinorityHealth and Disparities (NIMHD) incorporated intotheir definition biologic factors that may contributeto disparities in health (e.g., epigenomics), reframingthe social determinants of health model to that of“health determinants” (Alvidrez et al., 2019). NIMHDoperationalizes health disparities as a pattern ofdifferences among people in a demographicallydefined group in health outcomes relative to themajority of the population (i.e., in rates of diseaseincidence or prevalence, disease progression,severity, functioning, premature or excess mortality)(Alvidrez et al., 2019).In the WHO model of population health, availabilityof high quality health care is one of the socialdeterminants in one’s circumstances of living thatcontribute to health disparities across populations(WHO Commission on Social Determinants ofHealth & World Health Organization, 2008). In 2003,Michele Spoont, PhDNational Center for PTSD, Pacific Islands DivisionUniversity of Minnesota Medical SchoolCenter for Care Delivery and Outcomes ResearchJuliette McClendon, PhDNational Center for PTSD, Women’s Health Sciences DivisionVA Boston Healthcare SystemBoston University School of Medicinethe Institute of Medicine (IOM; now NationalAcademy of Medicine), published their highlyinfluential report, Unequal Treatment: ConfrontingRacial and Ethnic Disparities in Health Care. TheIOM defined racial/ethnic disparities in health careas those differences in the quality of health care notdue to differences in clinical need or patientpreferences (Smedley et al., 2003). According to theIOM report, health care disparities arise from factorsin multiple levels of health care organizations:regulatory or operational processes that selectivelydisadvantage one or more racial/ethnic groups(i.e., structural racism) and discrimination present inpatient-provider interactions (i.e., through providerconscious or unconscious biases and stereotypesabout race affecting medical decisions). The role ofhealth care systems in health disparities has sincebeen contextualized within broader societal trendsand structures. Accordingly, NIMHD has a moreexpansive view of health care disparities thatincludes, among other things, insurance coverage,ability to access appropriate care, and even patientpreferences as potential disparity drivers (Alvidrezet al., 2019).In this issue of PTSD Research Quarterly, weprovide a guide to some of the key topics in racialand ethnic disparities in PTSD and PTSD treatment,focusing on a few well-conducted studies withineach content area. Although many studies haveexamined racial or ethnic differences in PTSDincidentally or by combining minority groups into anon-white comparator, there have been relativelyfew studies specifically designed to examine theseissues. We primarily highlight studies designed toevaluate differences or disparities across racial/ethnic groups or between one underrepresentedContinued on page 2Authors’ Addresses: Michele Spoont, PhD is affiliated with the National Center for PTSD, Pacific Islands Division, Universityof Minnesota Medical School, and the Center for Care Delivery and Outcomes Research (152-9), Minneapolis VA HealthCare System, Minneapolis, MN 55417. Juliette McClendon, PhD is affiliated with the National Center for PTSD, Women’sHealth Sciences Division, VA Boston Healthcare System, and the Boston University School of Medicine. Email Addresses:spoon005@umn.edu and Juliette.Mcclendon-Iacovino@va.gov

Continued from coverracial/ethnic minority group and a White group comparator.Research to assess and evaluate potential racial and ethnicdisparities requires specific sampling, assessment, covariateselection, and statistical modeling approaches and we providesome references for those interested in learning more.Disparities in PTSD PrevalenceIn the National Vietnam Veterans Readjustment Study (NVVRS;Kulka,1990), Black and Hispanic Veterans were found to haveelevated rates of PTSD. As summarized by Dohrenwend et al. (2008),uncertainty about potential cause(s) of these rate differences (or eventheir veracity), led to a great deal of speculation: symptom overreporting, recall bias, greater trauma exposure, and differences inpre- or post-war vulnerabilities (Dohrenwend et al., 2008). Todetermine if differences in PTSD prevalence reflected genuinedisparities, Dohrenwend (2008) evaluated incident and current PTSDusing a subset of the original NVVRS sample with more detaileddiagnostic information and augmented by individual military recordsand historic accounts. With these more detailed sources, BlackVietnam Veterans were found to have greater rates of incident PTSDand Hispanic Veterans of current PTSD than White Veterans(Dohrenwend et al., 2008). The greater severity among Black andHispanic Veterans was later found to be a persistent effect(Steenkamp et al., 2017).There were two extensions of the NVVRS: the American IndianVietnam Veterans Project (AIVVP) and the Hawaii Vietnam VeteransProject (HVVP) (Beals et al., 2002; Friedman et al., 2004). In theAIVVP, Native American Veterans were found to have rates ofcurrent PTSD comparable to those that had been observed amongHispanic Vietnam Veterans and also elevated rates of lifetime PTSD(Beals et al., 2002). The HVVP examined prevalence estimatesamong two Hawaiian Veteran groups -- Native Hawaiian Veteransand Veterans of Japanese ancestry (Friedman et al., 2004).Although small sample sizes limited power to detect groupdifferences in the HVVP, Native Hawaiian Veterans had rates oflifetime PTSD comparable to Black Veterans and rates of currentPTSD equal to that of Whites; rates of both lifetime and currentPTSD among Veterans of Japanese ancestry were lower thanamong all other groups (Friedman et al., 2004; Tsai & Kong, 2012).This pattern of differential rates of PTSD across racial/ethnicgroups has likely continued into the present era as suggested byfindings from two studies: a large PTSD screening study of recentlyseparated Veterans (n 9,420) and from the National Survey ofVeterans (McClendon et al., 2019; Tsai et al., 2014).Three studies examined PTSD prevalence rates in the general U.S.population using large national samples weighted back to thepopulation. Using data from Wave 2 of the National EpidemiologicSurvey on Alcohol and Related Conditions (NESARC-II), Roberts andcolleagues (2011) examined racial/ethnic variations in populationrates of trauma exposures, lifetime prevalence and conditional risk ofPTSD among Black, Hispanic, Asian/Pacific Islander, and WhiteAmericans (Roberts et al., 2011). Both lifetime PTSD prevalence andconditional risk for PTSD were higher among Black/AfricanAmericans, lower among Asian/Pacific Islanders, and comparablefor Latinx Americans relative to Whites (Roberts et al., 2011).Although a systematic review by Alcántara and colleagues (2013)concluded Latinx Americans had greater conditional risk of PTSDPAGE 2relative to White Americans and attributed differences in prevalenceestimates across studies to variations in sampling and assessmentmethods (Alcántara et al., 2013), two studies using the integratedCollaborative Psychiatric Epidemiology Surveys (CPES) foundpatterns in PTSD prevalence rates across racial/ethnic groups similarto those reported by Roberts and colleagues (Alegría et al., 2013;McLaughlin et al., 2019; Roberts et al., 2011). Rates for lifetimePTSD were higher among White, African American, and AfroCaribbeans Americans, lower among Latinx Americans, and lowestamong those who were Asian compared to all other groups (Alegríaet al., 2013; McLaughlin et al., 2019). The pattern of 12-month PTSDwas similar (Alegría et al., 2013). Both studies reported greaterconditional risk of PTSD among Black and White Americans andlower conditional risk among Asian Americans (Alegría et al., 2013;McLaughlin et al., 2019). Conditional risk of PTSD was comparableto that of Whites among Native Americans despite higher rates oflifetime PTSD (Bassett et al., 2014; Beals et al., 2013).PTSD prevalence rates across racial/ethnic groups in the militarycohorts mirrored rates of trauma exposure – higher exposuresamong Native American, Hispanic and Black Veterans relative toWhite Veterans and lower exposure rates among Asian Veterans ofJapanese ancestry (Beals et al., 2002; Dohrenwend et al., 2008;Friedman et al., 2004). In community samples, the amount of traumaexposure did not track with PTSD prevalence estimates, but thetypes of trauma experienced were considerably more variable. Forexample, Asian/Pacific Islanders were more likely to have traumaticexperiences associated with non-combat war-related events (e.g.,those associated with being a civilian in a war zone or a refugee)(Roberts et al., 2011). White Americans reported the greatest rates oftrauma, but were more likely to experience traumas that werenon-interpersonal/non-intentional (e.g., serious accidents); NativeAmerican, Hispanic and Black Americans, in contrast, experiencedtypes of trauma more likely to lead to PTSD, such as significant childmaltreatment and, among Black and Native Americans, assaultiveviolence (Bassett et al., 2014; Beals et al., 2013; Liu et al., 2017;Roberts et al., 2011).Disparities in the Health Care SystemMental health care is an interpersonal enterprise and, as such, isvulnerable to the same biases and stereotypes operating throughoutsociety. There are numerous institutional and provider decisionpoints in health care pathways that are vulnerable to the effects ofbias; relatively few have been systematically studied. Mental healthcare at its best may help to mitigate some of the adverse effects ofdiscrimination; at its worst, it can exacerbate disparities in PTSDprevalence rates and illness severity (Alcántara et al., 2013; Alegria etal., 2016; Roberts et al., 2011).The delivery of mental health care is predicated on the ability ofindividuals to be aware of their need for treatment, ability to accessit, and to afford any attendant costs. Delays in treatment seekingmay reflect the impact of structural racism on any or all of theseprocesses. In a 15-year follow-up of mental health treatmentseeking among a registry of individuals exposed to the World TradeCenter terrorist attack (n 71,426), fewer people who were Blackor Asian received mental health care as compared to White,Hispanic, or people of other racial/ethnic groups (Jacobson et al.,2019). Of the Asian Americans who sought treatment, delays intreatment initiation were common and significantly longer thanP T S D R E S E A R C H Q U A R T E R LY

those observed among people of other racial/ethnic groups.Additionally, treatment-seeking Asian Americans were more likelyto see non-mental health specialists and Black individuals weremore likely to see non-doctoral level providers (e.g., nurses) orspiritual mentors (Jacobson et al., 2019) suggesting possibledifferential access to mental health providers.Because treatment delays may lead to worse clinical outcomes andsome racial/ethnic minorities are more likely to delay seekingtreatment for PTSD, Goldberg (2020) used NESARC-III data tocompare delays in treatment seeking by Veteran status (as anindicator of access to VA health care) across racial/ethnic groupswith PTSD, depression, and/or alcohol misuse (Goldberg et al.,2020). Among those with lifetime PTSD, community dwellingnon-Veteran racial/ethnic minorities had the longest delay in seekingmental health treatment of the four groups. Non-Veteran Whites andboth Veteran groups (White and racial/ethnic minority Veterans) hadequivalent delays, suggesting that having access to a safety nethealth care system like VA mitigated disparities in accessing mentalhealth care (Goldberg et al., 2020).Many Veterans accessing VA health care for PTSD also apply fordisability benefits (i.e., service connection, SC). Two large studiesreported that Black Veterans with PTSD are less likely to be awardedSC for PTSD than White Veterans (Murdoch et al., 2003; Redd et al.,2020). Marx and colleagues studied Black and White Veterans (n 764) who were part of a national longitudinal registry of recentlydeployed OIF/OEF Veterans who had a military-related trauma andhad also applied for VA SC for PTSD (Marx et al., 2017). Allparticipants were evaluated for current and lifetime PTSD with aStructured Clinical Interview for the fourth edition of the Diagnosticand Statistical Manual of Mental Disorders (DSM-IV; SCID). Theycompared SCID-based PTSD diagnoses with disability examinerdiagnoses and with eventual awarding of PTSD SC benefits. BlackVeterans with SCID-diagnosed PTSD were less likely to receive aPTSD diagnosis from a disability examiner (greater false negatives);White Veterans who did not meet SCID PTSD criteria were morelikely than Black Veterans to get a PTSD diagnosis from a disabilityexaminer (more false positives) (Marx et al., 2017). Differences inexaminer diagnoses resulted in more Black Veterans with PTSDbeing denied VA disability benefits regardless of SCID-baseddiagnoses and more Whites being awarded disability benefits even ifthey did not meet full criteria. Importantly, these race disparities inexaminer diagnoses occurred only when the evaluation was doneless formally — without psychometric testing (Marx et al., 2017),suggesting that disparities in examiner decision-making were likelyinfluenced by race-based heuristics.Racial/ethnic differences in mental health treatment engagement,quality, and receipt of a minimally adequate trial of care for PTSDhave been examined in a number of studies. Although severalwell-designed studies have identified racial/ethnic disparities,inconsistencies across studies in clinical contexts andmethodological issues (e.g., small sample sizes, variable samplingperiods, model adjustments for correlates of race/ethnicity prior tocomparisons- see below.), have complicated cross-studycomparisons. Larger, multisite or national studies have more oftenfound disparities between Latinx and White Veterans in receipt ofpsychotherapy, individual psychotherapy, and evidence-basedpsychotherapy (EBP) (Doran et al., 2017; Hale et al., 2019; Rosen etal., 2019; Spoont et al., 2017). There is also some evidence thatVOLUME 31/NO. 4 2020minimal trials of psychotherapy or pharmacotherapy are alsorelatively less common among racial/ethnic minorities (Doran et al.,2017; Hale et al., 2019; Spoont et al., 2015). One very large studyusing natural language processing to identify EBP appointments inthe medical records among all OIF/OEF Veterans with PTSD from2001-2015 seen in VA, found that within 3 years, Black Veterans whostarted an EBP were more likely than White Veterans to persist foreight sessions; however, improvement rates among Black Veteranswho initiated an EBP were lower than the improvement rates seenamong White Veterans (Maguen et al., 2019, 2020). Outcomedisparities have been infrequently assessed, but disparities inoutcomes among Black Veterans have been observed in otherstudies using different assessment methods and samples (Sripada etal., 2017, 2019). That single site studies and RCTs are less likely toobserve disparities (Lester et al., 2010), suggests that the impact oftreatment disparities on outcomes is likely due to variations intreatment delivery rather than differential responses to treatmentamong different racial/ethnic groups.Some Underlying Causes of Racial/Ethnic DisparitiesAccording to Williams and colleagues, racial/ethnic disparities inhealth and health care are driven by institutionalized discriminatorypractices and structures that favor the dominant group (i.e.,structural racism), discriminatory behavior by individuals, and racismembedded in American culture (e.g., race-based stereotypes) whichcreates an environment permissive to institutional and individualforms of discrimination (Williams et al., 2019). One of the ways thatdiscrimination impacts health is through differential traumaexposures — such as greater rates of exposure among militaryVeterans, more exposure to types of trauma that have lasting impacton mental health (e.g., interpersonal violence), and greatercumulative trauma exposure (Beals et al., 2013; Dohrenwend et al.,2008; McLaughlin et al., 2019; Roberts et al., 2011). Racism alsoadversely impacts mental health in ways that can compromisetrauma recovery (Williams et al., 2019). For example, a longitudinalstudy by Sibrava and colleagues (2019), found that frequency ofdiscrimination experiences predicted lower rates of recovery fromPTSD among Hispanic and Black adults 5 years later (Sibrava et al.,2019). Similarly, a study by Brooks Holliday and colleagues (2018)found that, within a predominantly African American female sample,experiences of discrimination were cross-sectionally associated withhigher PTSD symptoms, even after controlling for psychologicaldistress, perceived safety and neighborhood crime (Brooks Hollidayet al., 2018). Differential access to key resources, such as specialtymental health care (Williams, 2018), and how those resources areallocated and delivered (Doran et al., 2017; Marx et al., 2017) arealso examples of structural racism. The next issue of PTSD ResearchQuarterly will provide a more in-depth focus on the traumatic impactof racism on mental health.Research Methods in DisparitiesAlthough examining racial and ethnic group differences in secondaryanalyses can hint at potential disparities to be explored insubsequent studies, readers interested in conducting or evaluatingresearch on racial and ethnic disparities should become familiar withrecommended sampling and model designs and analytic methods toaddress the unique questions and issues in this area. For example,special considerations need to be made for subject selection,recruitment processes, and classification of subject race andPAGE 3

ethnicity (see Klein et al., 2019; Wey et al., 2018 for approaches).Health disparity populations (e.g., minority race or ethnicity) oftendiffer in numerous ways from the majority population and thesedifferences may or may not underly the health disparity in question.That is, not all differences are relevant. Factors presumed tocontribute to disparities are often intercorrelated or interrelated incomplex ways, making covariate selection and managementchallenging (Dye et al., 2019; Jeffries et al., 2019

racial/ethnic minority group and a White group comparator. Research to assess and evaluate potential racial and ethnic . disparities requires specific sampling, assessment, covariate selection, and statistical modeling approaches and we provide some references for those interested in learning more.

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