Todd Gilmer|Victoria D. Ojeda|Concepción Barrio|Dahlia Fuentes|Piedad Garcia|Nicole M. Lanouette|Kelly C. Lee
Adherence to Antipsychotics Among Latinos and Asians With Schizophrenia and Limited English Proficiency
back table contents previous article next article articlefull accessadherence antipsychotics among latinos asians schizophrenia limited english proficiencytodd p gilmer phdvictoria ojeda phd mphconcepcion barrio phddahlia fuentes mph mswpiedad garcia edd lcswnicole lanouette mdkelly c lee pharmdtodd p gilmer phdsearch papers authorvictoria ojeda phd mphsearch papers authorconcepcion barrio phdsearch papers authordahlia fuentes mph mswsearch papers authorpiedad garcia edd lcswsearch papers authornicole lanouette mdsearch papers authorkelly c lee pharmdsearch papers authorpublished online13 jan 2015httpsdoiorg101176ps2009602175aboutsectionsview articlepdfview epub toolsadd favoritesdownload citationstrack citations shareshare onfacebooktwitterlinked inemail view article antipsychotic medications foundation treatment people schizophrenia despite demonstrated ability antipsychotic medications reduce symptoms relapse rates improve health outcomes nonadherence common average rates 40 50 1 2 3 4 5 6 7 poor adherence associated increased relapse psychiatric hospitalizations emergency room visits hospitalization costs 3 6 8 9 10 11 12 nonadherence also associated poor social outcomes including greater risk arrest violence victimization substance use poorer mental functioning life satisfaction 9 numerous factors influence adherence prescribed treatment plan osterberg blaschkes review 13 general medication adherence identified numerous factors may influence adherence including patientlevel factors forgetfulness priorities intentional omission doses emotional factors providerlevel factors prescription complex medication regimen failure explain side effects benefits associated medication disregard patients lifestyle economic resources poor patientprovider relationships lacro colleagues 14 identified additional patient providerlevel factors predictive nonadherence antipsychotic medication among persons schizophrenia including poor insight negative attitude negative subjective response toward medication substance abuse shorter illness duration inadequate discharge planning aftercare environment 14 patients knowledge benefits medication side effects frequency duration dosing may affected providers explanations new medications 15 patient limited language proficiency may misunderstand similarly clients level health literacy may affect processing information provided clinical visits 16 studies examined relationship adherence antipsychotic medications among adults ethnic minority groups diagnosis schizophrenia 6 17 18 diaz colleagues 17 conducted communitybased study using electronic monitoring system bottle openings assess psychotropic medication utilization behaviors among 19 african americans 44 monolingual 25 bilingual latinos 34 caucasians found african americans monolingual spanishspeaking clients less likely caucasians adherent another study used texas medicaid data found africanamerican mexicanamerican clients less adherent nonlatino whites 18 third study san diego county found latinos african americans significantly less likely adherent nonlatino whites 6 exception work diaz colleagues 17 aware study examined adherence antipsychotics language status study provides unique contribution examining relationship raceethnicity language status adherence antipsychotic medications among latino asian clients schizophrenia large public mental health system san diego county large ethnically diverse county located united statesmexico border home large ethnic minority foreignborn populations particularly latinos mexican origin asians filipino vietnamese 2007 san diego county total population approximately 31 million 29 latino 9 asian 5 african american 19 expanding prior research objectives study analyze relationship raceethnicity english proficiency adherence antipsychotic medications among persons diagnosis schizophrenia analyze relationships raceethnicity english proficiency adherence psychiatric nonpsychiatric hospitalization costsmethodsa conceptual model language adherence service use propose expanded model adherence considers roles language family support predicting adherence antipsychotic medication use mental health services studies reviewed found patient provider factors interact affect adherence language proficiency affects exchange information patient provider however clients level english proficiency may also proxy migration history culture family social support ramirez garcia colleagues 20 found familial support predicted better medication adherence among mexican americans schizophrenia although client low english proficiency may experience difficulty communicating provider client may also benefit engagement family members treatment process thus clients low english proficiency may result increased participation care family members barriers communication adherence may reduced family members effectively serve linguistic social translators patient provider 21 adherence antipsychotic medications associated fewer inpatient admissions 3 6 8 9 10 11 12 propose additional link english proficiency service use 22 23 expect set cultural social factors associated english proficiency independent effect hospitalizations costs beyond effects medication adherence sample independent variablesdata san diego county adult older adult mental health services aoamhs encounterbased management information system mis merged data californias department health care services identify medical californias medicaid program beneficiaries schizophrenia living community receiving psychiatric services filled prescriptions oral antipsychotic medications 19992004 n31560 personyears mis includes demographic informationage gender selfreported race ethnicity selfreported preferred language mental health services previous research used clients preferred service language proxy limited english proficiency status 22 23 clients report preferred language receiving services admission service california language highly correlated foreignborn status analyzed data california health interview survey found among latino adults san diego homes spanish spoken 73 born mexico among asians homes chinese vietnamese spoken 86 born asia pacific islands 24 sample study reported limited latinos preferred language spanish english asians preferred asian language example vietnamese tagalog english nonlatino whites hereafter whites preferred language english among 460 asian clients sample 44 n201 filipino 17 n78 vietnamese 8 n36 japanese 7 n32 chinese 25 n113 asian groups clients also report living situation admission service classified clients commonly reported living situation included persons living independently residents assisted living facilities also known boardandcare facilities homeless adults adults unknown living situations excluded persons residing primarily jails longterm institutional care facilities also excluded persons insurance data medication use payment health services costs unavailable conservatorship status ascertained mis medicare eligibility identified medical data diagnosis substance use disorder identified across systems medical strict requirements verify residency status thus clients included study either us citizens documented immigrants used icd9 diagnosis codes medical claims assess comorbid illness severity chronic illness disability payment system cdps 25 cdps diagnostic classification system commonly used medicaid programs assess illness severity make healthbased capitated payments health plans enroll medicaid beneficiaries cdps software assigns diagnostic codes obtained claims 56 diagnostic categories within 18 major diagnostic groups corresponding major body systems example cardiovascular type disease example diabetes cdps scores assigned basis age gender presence diagnostic categories scores reflect illness severity basis predicted future expenditures score permits comparison average expenditure across medicaid beneficiaries example 40yearold male schizophrenia general medical comorbidity would risk score 12 therefore would expected 20 greater medicaid costs average beneficiary additional information cdps public use software available cdpsucsdedu dependent variablesadherence prescribed regimens determined examining medical claims means medication refill records adherence measured annual medication possession ratio mpr computed person calendar year mpr calculated dividing number days medications available consumption number days adults eligible medical example person eligible medical entire year received total 240 days supply prescribed antipsychotic medication would mpr 66 quetiapine commonly used sleeping aid thus excluded prescribed low daily dosage 200 mg less conjunction another antipsychotic also excluded individuals prescribed depot antipsychotics pharmacokinetic profiles depot antipsychotic medications oral medications vary considerably users depot medications typically nonadherent medication regimens frequent users inpatient services categorized adherence personyear ordinal scale derived mpr using following designations nonadherent mpr49 partially adherent mpr5079 adherent mpr80110 fillers excess medication mpr110 reasons excess filling medications include overuse loss theft medicationswe used medical claims determine whether someone hospitalized given year acute psychiatric facility psychiatric ward community hospital medicalsurgical ward acute care hospital calculated total amount paid medical health services inpatient outpatient psychiatric general medical care laboratory radiological services noninpatient acute care amount paid pharmaceuticals total amount paid acute care costs reported 2004 dollars merged mismedical database previously used examine utilization mental health services language status costs associated nonadherence antipsychotic medications 6 23 university california san diego institutional review board san diego county mental health services research committee approved use data study accordance privacy rule health insurance portability accountability act 1996 statistical analyses used multinomial logistic regression estimate probability nonadherent partially adherent adherent excess filler function raceethnicity preferred language controlling age gender conservatorship status medicare coverage living situation type antipsychotic medication cdps score diagnosis comorbid substance use disorder resulting parameter estimates used calculate estimates adherence raceethnicity language status standardized underlying population characteristics example calculated probability adherent among latinos limited english proficiency mean probability adherent across persons limited english proficiency standard errors estimated using nonparametric bootstrap method 1000 replications p values computed estimated distributions 26 account potential individualcorrelated errors data bootstrap analysis sampled individual rather observation used logistic regression estimate probability psychiatric admission nonpsychiatric admission inpatient admission calculate standardized estimates adherence category raceethnicity language status using methods described similarly controlling additional demographic clinical characteristics finally used generalized linear regression assuming gamma distribution log link function estimate health services costs pharmaceutical costs total costs provide standardized estimates costs raceethnicity language status using methods described 27 28 resultstable 1 provides information english proficiency status selected characteristics adults treated schizophrenia antipsychotic medications data include 7784 unique medical beneficiaries including 5695 nonlatino whites 1196 englishproficient latinos 523 latinos limited english proficiency 298 englishproficient asians 162 asians limited english proficiency latinos asians limited proficiency older englishproficient latinos asians roughly age whites latinos limited proficiency likely englishproficient latinos female 52 compared 42 asian clients limited proficiency less likely englishproficient asians dual medicaremedical coverage 24 31 table 1 characteristics nonlatino white latino asian patients treated schizophrenia antipsychotic medication language proficiency n31560 personyearstable 1 characteristics nonlatino white latino asian patients treated schizophrenia antipsychotic medication language proficiency n31560 personyearsenlarge tableacross language racialethnic groups majority adults 50 treated schizophrenia resided independently notably threequarters latinos asians limited english proficiency resided independently 78 proportions higher englishproficient latinos asians 65 69 respectively mean cdps score exceeded 3 group indicating sample expected health care costs least three times high average medicaid beneficiary fewer adults limited proficiency comorbid substance use disorders compared englishproficient adults example 52 englishproficient latinos substance use disorder diagnosis compared 29 latinos limited proficiency among asians differences language status less pronounced nevertheless significant 39 24 respectively probability hospitalization level adherence shown table 2 clients adherent medications least likely experience psychiatric admission 15 nonpsychiatric admission 18 admission 28 overall nearly half 48 nonadherent adults hospitalized results support validity mpr measure adherence table 2 probability annual inpatient admission medication adherence category among patients treated schizophrenia antipsychotic medicationtable 2 probability annual inpatient admission medication adherence category among patients treated schizophrenia antipsychotic medicationenlarge table adherence antipsychotic medications raceethnicity english proficiency shown table 3 notably greater proportion latinos limited proficiency adherent compared englishproficient latinos 41 36 p002 contrast smaller proportion asians limited proficiency adherent compared englishproficient counterparts 40 45 p034 latino asian adults limited proficiency less likely englishproficient peers excess fillers antipsychotic medication example 15 latinos limited proficiency met criteria excess medication filling compared 20 englishproficient latinos p001 similarly 13 asians limited proficiency excess fillers compared 17 englishproficient asians p002 notably latinos higher rate adherence among limited proficiency entirely attributable less likely excess fillers nonlatino whites likely excess fillers 22 table 3 probability adherence antipsychotic medication language proficiency among patients treated schizophrenia antipsychotic medicationtable 3 probability adherence antipsychotic medication language proficiency among patients treated schizophrenia antipsychotic medicationenlarge tableseveral controlling variables also related adherence overall sample probability adherent increased age 25 among aged 24 younger 37 among aged 25 59 43 among aged 60 older clients resided assisted living facilities highly likely adherent 47 excess fillers 34 clients homeless highly likely nonadherent 49 clients diagnosis substance use disorder less likely adherent without diagnosis 32 44 probability inpatient hospitalization raceethnicity language status shown table 4 analysis controlled level adherence latinos limited proficiency less likely englishproficient latinos experience psychiatric admissions 17 21 p001 nonpsychiatric admissions 20 22 p014 rate overall inpatient admissions also lower 33 38 p001 overall admissions lower among asians limited proficiency compared englishproficient asians although effect reach significance 33 38 p070 table 4 probability annual inpatient admission language proficiency among patients treated schizophrenia antipsychotic medication adjusted medication adherencetable 4 probability annual inpatient admission language proficiency among patients treated schizophrenia antipsychotic medication adjusted medication adherenceenlarge table costs health services pharmacy costs raceethnicity language status shown table 5 analysis controlled level adherence latinos asians limited proficiency lowest overall costs 15883 15138 respectively compared groups outcome resulted lower health services pharmacy costs among adults limited proficiency compared englishproficient counterparts table 5 annual health care pharmaceutical costs language proficiency among patients treated schizophrenia antipsychotic medication adjusted medication adherencetable 5 annual health care pharmaceutical costs language proficiency among patients treated schizophrenia antipsychotic medication adjusted medication adherenceenlarge tablediscussion although several studies examined adherence psychiatric medications addressed relationship antipsychotic adherence raceethnicity know one small study examined adherence among monolingual bilingual spanishspeaking latino clients 17 study know examined adherence among asian clients united states language status study presented addressed gaps examining experiences large public mental health system providing care ethnically linguistically diverse community given nations growing immigrant population 29 critical understand factors influence mental health outcomes ethnically linguistically diverse adults serious mental illness study found latinos limited english proficiency likely englishproficient latinos adherent antipsychotic medications difference adherence among two latino groups entirely attributable differences excess filling prescriptions excess filling also indicator poor medication management study individuals excess fillers likely adherent hospitalized excess fillers shown higher costs resulting higher rates hospitalizations increased pharmaceutical costs 6 analyses controlled adherence comorbidity latinos limited english proficiency less likely hospitalized lower pharmaceutical total costs contrast asians limited proficiency less likely englishproficient asians adherent although also less likely hospitalized lower costs one explanation higher rate adherence lower rate hospitalization among latinos limited english proficiency may benefit higher level familial social support cultural variation within groups may lead differential adherence outcomes associated raceethnicity english proficiency family social support may serve cultural buffer family involvement clients life treatment plan may improve medication adherence independently affect service utilization barrio colleagues 21 found monolingual spanishspeaking latino clients often accompanied medical visits englishspeaking relatives example adult children spouses siblings advocated behalf providers ramirez garcia colleagues 20 found family instrumental taskoriented support predicted higher medication adherence among mexican americans schizophrenia living family members contrast kopelowicz colleagues 30 find improved medication adherence among latino clients received skills training however hypothesis greater family support inconsistent finding lower adherence lower probability hospitalization among asians limited english proficiency may familial social support operates differently among asians perceived susceptibility disease perceived benefits western medication perceived benefits cultural traditional medication stigma associated psychiatric medication may serve reduce adherence among asians limited english proficiency 31 32 culturally appropriate medication management services may prove effective improving adherence among asian clients unfortunately unable test explicitly independent effects language proficiency social support language status measure potentially correlated several aspects clients life experiences including heritage culture acculturation physiology genetics preferences future data collection efforts may address limitations including specific measures permit us fully explore mechanisms drive differences adherence service utilization results limited use administrative data lack dimensions needed fully study issues related antipsychotic medication adherence among racialethnic minority populations time large sample size may resulted findings statistically significant clinically insignificant used medication refill records claims data assess adherence although approach limited inability directly monitor medication administration claims data represent objective unobtrusive measure adherence lacked clients selfreported english proficiency status data language commonly spoken home measures employed research examining impacts language health service use 33 patients use alternative treatments unknown study use alternative practitioners asian patients common may resulted lower rates adherence service use 34 35 sample size limitations asians classified single group despite wide heterogeneity cultural backgrounds language family dynamics reasons findings replicated larger sample disaggregate data asian subgroup future investigations may examine role various levels social support provided families example instrumental support compared emotional support medication adherence service utilization across asian subgroups finally high rate excess prescription filling among residents assisted living facilities warrants investigation medication therapy management pharmacistled review clients pharmacotherapy includes consideration therapeutic goals interactions side effects adherence would provide deeper understanding causes excess filling setting may provide vehicle intervention excess filling inconsistent clients treatment goals conclusions found adherence antipsychotic medication among latinos asians schizophrenia varied english language proficiency systematic examination clinical outcomes language status needed order assess whether health disparities may emerging among certain patient subgroups health care organizations continue prioritize use professional translation services patients limited english proficiency rather relying family friends order ensure patients confidentiality accurate conveyance health information 36 also critical medical schools allied health professional programs nursing physician assistant programs continue promote ethnically diverse linguistically adept health care workforce 37 patients providers may communicate timely manner without intermediaries acknowledgments disclosuresfinancial support provided grant p30mh066248 national institute mental health grant 3r01da019829s2 national institute drug abuse authors gratefully acknowledge county san diego health human services agency adult older adult mental health services access management information systemthe authors report competing interestsdr gilmer dr ojeda affiliated department family preventive medicine university california san diego ucsd 9500 gilman dr la jolla ca 920930622 email email protected dr barrio ms fuentes school social work university southern california los angeles dr garcia san diego county adult older adult mental health services dr lanouette 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