National data indicate that patients treated with buprenorphine for opiate use disorders are more likely to be White, highly educated, and to have greater incomes than those receiving methadone, but patterns of buprenorphine dissemination across demographic areas have not been documented in major metropolitan areas where poverty, minority populations and injection heroin use are concentrated. Rates of buprenorphine and methadone treatment are compared among areas of New York City defined by their income and ethnic/racial composition. Residential social areas (hereinafter called social areas) were defined as aggregations of ZIP codes with similar race/ethnicity and income characteristics, and were formed based on clustering techniques. Treatment rates were obtained for each New York City ZIP code: buprenorphine treatment rates were based on the annual number of buprenorphine prescriptions written, and the methadone treatment rate on the number of methadone clinic visits for persons in each ZIP code. Treatment rates were correlated univariately with ethnicity and income characteristics of ZIP codes. Social area treatment rates were compared using individual ANOVA models for each rate. Buprenorphine and methadone treatment rates were significantly correlated with the ethnicity and income characteristics of ZIP codes, and treatment rates differed significantly across the social areas. Buprenorphine treatment rates were highest in the social area with the highest income and lowest percentage of Black and Hispanic residents. Conversely, the methadone treatment rate was highest in the social area with the highest percentage of low income and Hispanic residents. The uneven dissemination of 0pioid maintenance treatment in New York City may be reflective of the limited public health impact of buprenorphine in ethnic minority and low income areas. Specific policy and educational interventions to providers are needed to promote the use of buprenorphine for opiate use disorders in diverse populations.

Background Falling duration of psychiatric inpatient stays over the past two decades and recent recommendations to tighten federal regulation of electroconvulsive therapy (ECT) devices have focused attention on trends in ECT use, but current national data have been unavailable. Methods We calculated the annual number of inpatient stays involving ECT and proportion of general hospitals conducting the procedure at least once in the calendar year using a national sample of discharges from 1993–2009. We estimated adjusted probabilities that inpatients with severe recurrent major depression (N=465,646) were treated in a hospital which conducts ECT and, if so, received the procedure. Results The annual number of stays involving ECT fell from 12.6 to 7.2 per 100,000 adult US residents, driven by dramatic declines among the elderly, while the percentage of hospitals conducting ECT decreased from 14.8% to 10.6%. The percentage of stays for severe recurrent major depression in hospitals which conducted ECT fell from 70.5% to 44.7%, while receipt of ECT where conducted declined from 12.9% to 10.5%. For depressed inpatients, the adjusted probability that the treating hospital conducts ECT fell 34%, while probability of receiving ECT was unchanged for patients treated in facilities which conducted the procedure. Adjusted declines were greatest for the elderly. Throughout the period inpatients from poorer neighborhoods or who were publicly- or un-insured were less likely receive care from hospitals conducting ECT. Conclusions ECT use for severely depressed inpatients has fallen markedly, driven exclusively by a decline in the probability that their hospital conducts ECT.

Objective This paper tests the validity of a simple and easy to use scale, the Modified Mini Screen (MMS) to identify people with mental health problems in the treatment ecology for chemical dependency, including specialty sector substance abuse treatment settings, and shelters, jails and street community outreach programs. Methods Four hundred and seventy-six individuals in chemical dependency treatment and in jails, shelters and outreach settings completed a set of 22 items to screen for mental disorders-the MMS-and a validation interview-the Structured Clinical Interview for Diagnosis (SCID). ROC curve analysis was used to (1) determine the optimal range of cut points for identifying mental health problems in this culturally heterogeneous sample and wide range of treatment and community settings, and (2) calculate overall accuracy, sensitivity, specificity, and positive and negative predictive values for the MMS. Results Forty three percent of the sample met criteria for a DSM-IV diagnosis of anxiety, mood or psychotic disorder. At cut points of 6-9, the sensitivity of the MMS ranged from 0.63-0.82, its specificity ranged from 0.61-0.83, and its overall accuracy ranged from 70-75%. At these cut points, the MMS screen performed equally well for men and women, and for African Americans and Caucasians, and is comparable to the performance of other screens validated for less compromised populations. A decision tool has been developed based on these results that is available from the authors.

Background Black Americans with depression were less likely to receive electroconvulsive therapy (ECT) than whites during the 1970’s and 80’s. This pattern was commonly attributed to treatment of blacks in lower quality hospitals where ECT was unavailable. We investigated whether a racial difference in receiving ECT persists, and, if so, whether it arises from lesser ECT availability or from lesser ECT use within hospitals conducting the procedure. Methods Black or white inpatient stays for recurrent major depression from 1993-2007 (N=419,686) were drawn from an annual sample of US community hospital discharges. The marginal disparity ratio estimated adjusted racial differences in the probabilities of (1) admission to a hospital capable of conducting ECT (availability), and (2) ECT utilization if treated where ECT is conducted (use). Results Across all hospitals, the probability of receiving ECT for depressed white inpatients (7.0%) greatly exceeded that for blacks (2.0%). Probability of ECT availability was slightly greater for whites than blacks (62.0% versus 57.8%), while probability of use was markedly greater (11.8% versus 3.9%). The white versus black marginal disparity ratio for ECT availability was 1.07 (95% confidence interval 1.06-1.07) and stable over the period, while the ratio for use fell from 3.2 (3.1-3.4) to 2.5 (2.4-2.7). Limitations Depressed persons treated in outpatient settings or who receive no care are excluded from analyses. Conclusions Depressed black inpatients continue to be far less likely than whites to receive ECT. The difference arises almost entirely from lesser use of ECT within hospitals where it is available.

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