The 2002 Institute of Medicine report Unequal Treatment: Confronting Racial and Ethnic Disparities affirms in its first finding that “racial and ethnic disparities in healthcare exist and, because they are associated with worse outcomes in many cases, are unacceptable.” The mechanisms that generate racial/ethnic disparities in health care operate at two levels: the health care system, and the clinical encounter. Although important gaps in knowledge necessary to formulate policy remain, research has demonstrated the role of health care system factors, such as insurance coverage, in disparities. Research has also demonstrated, however, that even when system factors are controlled for through matching or other statistical methods, disparities persist. In other words, when a clinician encounters African-American or Latino patients with insurance access and clinical characteristics similar to those of Caucasian patients, the minority patients sometimes receive less or inferior care. This has been shown to be true with both mental and physical disorders.

The second source of disparities, the clinical encounter, was the subject of investigation of the IOM Unequal Treatment report. Unfortunately, while the mechanisms operating within the encounter can be identified conceptually, the empirical research necessary to inform policy is missing. This critical research gap is the motivation for this project.

This research will focus on the mechanisms within the clinical encounter that lead to disparities, which can roughly be defined as unjustified differences in use of health care services across groups. Recent theoretical and conceptual research provides the framework for empirical analysis, which this study will use for the purposes of informing policy about effective actions to combat disparities. A multidisciplinary team will conduct empirical and policy studies using previously collected data. The research capitalizes on NIMH investments in data with large numbers of members of racial and ethnic minorities to make progress on understanding and reducing mental health care disparities. Specifically, the study aims to:

• investigate provider-side mechanisms explaining discrimination in the clinical encounter using data from the Quality Improvement for Depression (QID) projects and test whether “statistical discrimination” can account for some of the racial/ethnic differences in diagnosis and treatment recommendations for African-American and Latino populations; and

• using the same data, test for evidence that patient reaction to provider discrimination leads to lower adherence rates and worse outcomes for these minorities.