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Original Investigation
December 23, 2020

Association Between Race/Ethnicity and Disparities in Health Care Use Before First-Episode Psychosis Among Privately Insured Young Patients

Author Affiliations
  • 1Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
  • 2Sol Price School of Public Policy, University of Southern California, Los Angeles
  • 3Department of Emergency Medicine, Keck School of Medicine, University of Southern California, Los Angeles
  • 4Department of Emergency Medicine, David Geffen School of Medicine, University of California Los Angeles
  • 5LAC+USC Medical Center, Los Angeles, California
  • 6University of Southern California, Los Angeles
  • 7Department of Pharmaceutical and Health Economics, School of Pharmacy, University of Southern California, Los Angeles
JAMA Psychiatry. 2021;78(3):311-319. doi:10.1001/jamapsychiatry.2020.3995
Key Points

Question  To what extent are racial and ethnic disparities in health care use present in the year before diagnosis of the first episode of psychosis?

Findings  In this cohort study of 3017 privately insured patients aged 10 to 21 years, Black and Hispanic patients were less likely than White patients to receive behavioral health diagnoses and treatment before the diagnosis of first-episode psychosis. Racial/ethnic disparities persisted after controlling for socioeconomic variables.

Meaning  Racial/ethnic disparities in diagnoses and treatment appeared to be visible before the first diagnosis of psychosis, even in this relatively homogeneous sample of individuals with continuous private health insurance; lower rates of outpatient behavioral health care use in the year before the first episode of psychosis may result in increased duration of untreated psychosis and worse long-term outcomes.


Importance  Racial/ethnic disparities in health care use and clinical outcomes for behavioral health disorders, including psychosis, are well documented, but less is known about these disparities during the period leading up to first-episode psychosis (FEP).

Objective  To describe the racial/ethnic disparities in behavioral health care use and prescription drug use of children and young adults before the diagnosis of FEP.

Design, Setting, and Participants  An observational cohort study was conducted using medical and prescription drug claims from January 1, 2007, to September 30, 2015, obtained from Optum’s deidentified Clinformatics Data Mart Database, a commercial claims database augmented with race/ethnicity and socioeconomic variables. Data analysis was performed from February 6, 2018, to October 10, 2020. First-episode psychosis was determined by the presence of psychosis diagnoses on claims for at least 1 hospitalization or 2 outpatient events, with a continuous enrollment requirement of at least 2 years before the first diagnosis. Participants included 3017 Black, Hispanic, or White patients who were continually enrolled in commercial insurance plans and received an FEP diagnosis between the ages of 10 and 21 years.

Main Outcomes and Measures  Race/ethnicity was determined from a commercial claims database. Rates of inpatient admission, emergency department presentation, and outpatient visits (including psychotherapy), behavioral health disorder diagnoses, and antipsychotic/antidepressant prescription fills were determined for the year before FEP. Race/ethnicity was also obtained from Optum’s claims database. With use of multivariable logistic regression, results were adjusted for covariates including estimated household income, age, sex, and geographic division in the US.

Results  Of the 3017 patients with FEP, 643 Black or Hispanic patients (343 [53.3%] Black, 300 [46.7%] Hispanic, 324 [50.4%] male, mean [SD] age, 17.2 [2.76] years) were less likely than 2374 White patients (1210 [51.0%] male, mean age, 17.0 [2.72] years) to receive comorbid behavioral health disorder diagnoses in the year before the diagnosis of FEP (410 [63.8%] vs 1806 [76.1%], χ2 = 39.3; P < .001). Except for emergency care, behavioral health care use rates were lower in Black and Hispanic patients vs White patients (424 [65.9%] vs 1868 [78.7%]; χ2 = 45.0; P < .001), particularly for outpatient visits with behavioral health care professionals (232 [36.1%] vs 1236 [52.1%]; χ2 = 51.7; P < .001). After adjustment for socioeconomic covariates, behavioral health care use rates (68.9% vs 79.2%; P < .001), outpatient visits with behavioral health professionals (37.7% vs 51.2%; P < .001), and other outcomes remained significantly lower for Black and Hispanic patients vs White patients.

Conclusions and Relevance  The results of this study extend existing research findings of well-known racial/ethnic disparities in the population of patients who are diagnosed with FEP. These differences were apparent in young patients with continuous commercial health insurance and after controlling for household income. Providing equal access to preventive outpatient behavioral health care may increase opportunities for timely detection of psychotic symptoms and early intervention and improve differential outcomes after FEP.

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