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Collaborative care and health disparities: A Case Example

Posted By Randi Dublin, Tuesday, April 05, 2016


A monolingual Spanish-speaking patient from Ecuador was injured on his job in the northeastern US. He was prescribed medicine for multiple physical injuries and had been previously diagnosed with depression prior to the incident. He carries shame about his history of depression and a suicide attempt before he was left unemployed, struggling financially as head of household, with physical injuries. Now the patient begins to experience mental health symptoms again; depressed mood, lethargy, low self-esteem. He begins to meet with me weekly in a pain management clinic for psychotherapy sessions. And he develops suicidal and homicidal ideation … voices telling him to hurt himself and a family member. My question to you is: how many barriers does this man face to obtaining appropriate and comprehensive, collaborative care to ease his suffering?


Let’s be sure to separate barriers to comprehensive, collaborative care that result from mental illness and barriers that result from health inequality. To address the first set of barriers, he carries shame that he is experiencing mental health symptoms which he perceives others aren’t experiencing, and self-stigma that he shouldn’t be feeling the way he is. But apart from these mental health roadblocks to comprehensive, collaborative care, this patient experiences barriers related to health inequality. He speaks a different language than I do and only with the help of a translator can we communicate effectively. He lacks funds to pay for medical services and can only see me because our visits are paid for by workers compensation. Furthermore, men from his country do not show "weakness” or a need for medical help, let alone mental health services, which are stigmatized. He doesn’t recognize that he is being denied certain medications by insurance because they are very expensive, not due to a personal flaw. The barriers posed by health inequality make it likely that this patient will not obtain comprehensive, collaborative care. A white male patient with adequate financial means may not face the same barriers.


This case example is not unique, unfortunately. Health outcomes often differ across groups, a term commonly referred to as health disparities. Factors such as poverty, economic barriers, limited access to healthcare, neighborhood problems and lack of education are just a few which lead to unequal health outcomes between groups. What about other reasons for different health outcomes? Do some individuals not seek effective healthcare because they turn to their own remedies or they don’t know what beneficial treatments might be out there? Or perhaps they don’t want someone in the Western medical establishment telling them how to get well? Or maybe the medical provider is of a different cultural background? Power dynamics between patient and provider plus history may make some groups not want to be "experimented upon.”


Recent accumulated evidence suggests that there is a longevity difference between the rich and poor in America, which is a continuing trend, attributed to economic and social inequality. When certain treatments are too expensive for some, they miss out on potentially life-saving solutions. The question ultimately is: can collaborative care, in its least restrictive definition (the integration of behavioral and physical health services and communication between care providers), help to reduce these health disparities and barriers to beneficial healthcare?


Although we lack sufficient research in this area, I propose that collaborative care can help to reduce health disparities. Collaborative care is geared towards focusing on the whole person, their biopsychosocial status, and not just on a mental health diagnosis or physical symptoms. A collaborative care team can first address whether certain biological factors predispose a patient to specific diseases or disorders. To address social factors which impact health such as poverty, unemployment, and access to healthy food, the treatment team can work together to assess nutritional needs, find financial benefit programs and unemployment resources. Collaborative care also brings the treatment to where the patient is physically located, which can ease financial burden for transportation costs. Behavioral health providers can assess for factors (i.e., depression, trauma) which may impede upon patient self-care or lead the patient to avoid health clinics for treatment. By focusing collaboratively on the whole patient, perhaps we can help reduce the health disparities that exist based upon someone’s race, education, and financial status.


We have an aging population to contend with for the next few decades. The Healthy People 2020 project is a national endeavor aimed at improving the health and longevity of Americans. Specifically, with regard to health disparities, this program aims to "achieve health equity, eliminate health disparities, and improve the health of all groups”. To meet this aim, we ultimately need to minimize barriers to healthcare for all people: economic, transportation, education, medical, and nutrition barriers. The list goes on. We need to work as a team to help the patient take care of their own health. Collaborative care is one way to break down these barriers. Let us, as the CFHA community, conduct more research to demonstrate how effective collaborative care can be in the fight to end health disparities and health inequality.

Randi Dublin, Ph.D. is a licensed clinical psychologist with particular interests in mental health advocacy and destigmatization, dissemination of evidence-based psychotherapy, integrated behavioral health & primary care, and promotion of psychological science in the community. She has worked across urban settings treating adults with psychological and health-behavior issues. Currently, she works with injured workers who are struggling with chronic pain, trauma, depression and other issues. She hopes health disparities will be addressed by collaborative care.

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