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

Center for Multicultural Mental Health Research, 120 Beacon Street, Somerville, MA 02143, USA.
Health Services Research (Impact Factor: 2.78). 03/2011; 46(4):1259-80. DOI: 10.1111/j.1475-6773.2011.01253.x
Source: PubMed


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.
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.
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.
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.
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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    • "For example, an individual with depression and a physical health comorbidity may need more mental health care because of a greater severity of illness than an individual with depression only. Another pathway by which a comorbidity might affect health care use is that comorbidities increase the likelihood and number of primary care provider visits, making the illness under study more likely to be diagnosed in primary care (Cook et al. 2011). The relationship among illnesses is reciprocal in this respect— treatment of any illness may increase the likelihood of recognition of other illnesses. "
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