Conversation: Applying What We Know: Mark K. Hartzenbuehler, Assistant Professor of Sociomedical Sciences - Columbia College

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  • Sexual orientation related disparities in mental health are well-documented. These data come from a paper that my colleagues and I published using data from the NESARC, a nationally representative survey of US adults age 18 and over. The results indicated that 55% of LGB adults met criteria for any Axis I psychiatric disorder in the past 12 months, compared to only 35% of heterosexuals. This pattern of disparities persisted across multiple subclasses of mental disorders, including mood, anxiety, and substance disorders, as well as psychiatric comorbidity, which is defined as the presence of 2 or more co-occurring disorders. These findings have been replicated in other probability-based surveys of US adults.
  • --Stigma is the most frequently hypothesized risk factor that may explain these disparities. As this figure demonstrates stigma is conceptualized as a multi-level construct. --Most research has focused on stigma at the individual level, including perceptions of stigmatized individuals and stereotyping and labeling. Some research has also examined interpersonal forms of stigma, such as micro-level interactions, discrimination and status loss . --More recently, researchers have introduced the idea of structural stigma, which refers to societal-level conditions that constrain stigmatized individuals’ opportunities, resources, and wellbeing, which in turn may compromise the mental health of the stigmatized. Importantly, structural stigma can disadvantage someone even in the absence of stigma at the individual level. For example, a lesbian living in the Castro district of SF may not experience any discrimination from neighbors or work colleagues, and yet she resides in a state where she is unable to marry her same-sex partner. -My work has focused on this structural level of analysis because it’s an understudied area in the literature despite the fact that the processes involved in structural stigma are likely major contributors to unequal health outcomes.
  • --One of the measures of structural stigma that I have used is social policies that differentially target gays and lesbians in the United States. --Today I am going to present data from 4 studies we’ve been conducting showing that social policies exert a demonstrable impact on the mental health of LGB populations. --The first study that I’ll be presenting examined associations between state policies and psychiatric disorders in a national sample of LGB adults.
  • --In this study, we considered two state-level policies targeting LGBs: Absence of hate crimes statutes protecting LGBs No protections against employment discrimination based on sexual orientation --We coded each state on the presence or absence of these policies and created a dichotomous variable, comparing states with no protective policies vs. states that had at least one protective policy. --Hopefully you’ll forgive my perpetuating the red state/blue state distinction, but I’ve depicted in red the states with no protective policies and in blue the states with at least one protective policy.
  • --In order to examine associations between these policies and psychiatric disorders, we used data from the NESARC. --Probability-based, nationally representative study of U.S. adults aged 18 and over. --Used structured diagnostic interviews to generate DSM-IV diagnoses of psychiatric disorders --We knew the state of residence for all participants in the NESARC so we can link the state policy data to individual health outcomes of the participants. --2% of the sample identified as LGB which is comparable to rates seen in other nationally representative surveys
  • --Y axis = the Odds Ratios which indicate the likelihood that LGB individuals have a psychiatric disorder, relative to heterosexuals --X axis = disorders where we found a significant interaction between LGB status and state-level policy. --Example: dysthymia (mood disorder that is less severe but more chronic than MDE): LGB respondents living in states with protective policies were no more likely to have dysthymia than heterosexuals. In contrast, LGB respondents living in states with no protective policies were 2.5 times more likely to have dysthymia compared to heterosexuals. --GAD (characterized by chronic tension and worry): LGB respondents living in states with protective policies were only 1.86 times more likely to have GAD than heterosexuals. In contrast, LGB respondents living in states with no protective policies were nearly 3.5 times more likely to have GAD compared to heterosexuals. --These results were also found for PTSD and psychiatric comorbidity. --Important to note that, with the exception of dysthymia, where disparities were eliminated, LGB respondents are still at risk for psychiatric disorders in states with protective policies, but they are at significantly greater risk in states without these protective policies --In sum, differences in disorder prevalence are significantly weaker among those in states that extend protections to LGBs.
  • --This was one of the first studies to establish an association between social policies and the mental health of LGB populations, but the data were cross-sectional. --A stronger test of the impact of social policies on health is to have a longitudinal design where we examine changes in health outcomes following a change in social policies. --The next study addressed this limitation through using longitudinal data.
  • --During the elections in 2004, 16 states passed constitutional amendments banning gay marriage. --It just so happened that these events occurred in between the two data collection periods of the NESARC, which was the dataset I used in the previous study. Respondents were first interviewed in 2001 and then the same respondents were reinterviewed again in 2005, following the passage of the constitutional amendments. This created a “natural experiment” of sorts that enabled us to examine changes in prevalence of psychiatric disorders among LGB respondents assessed prospectively before and after the amendments were passed.
  • --For sake of time, just be presenting results on mood disorders, which includes major depression and dysthymia. --First set of analyses were conducted only among LGB respondents. --Y axis = percentage of people meeting criteria for mood disorders; X axis = state of residence (left = bans, right = no ban) 22.7--> 31.0 (36.6% increase) 22.5--> 17.2 (23.6% decrease) We then conducted within-group logistic regressions to estimate the odds of a mood disorder. The OR’s indicated that this was a statistically significant increase in mood disorders for LGB individuals living in states that passed the amendments. But this was not a significant difference between Waves 1 and 2 for LGB respondents living in states that did NOT pass the amendments.
  • --Second set of analyses compared LGBs to heterosexuals in order to determine the specificity of these results. --We examined the changes in prevalence of mood disorders between Wave 1 and Wave 2 comparing LGB and heterosexual respondents both living in states where gay marriage bans were adopted. 22.7--> 31.0 (36.6% increase) 10.9--> 11.2 (2.6% increase) The OR’s indicated that this was a statistically significant increase in mood disorders for LGB respondents living in states that passed gay marriage bans. But not for heterosexual respondents living in these same states.
  • --In this previous study, we’ve examined some of the negative health consequences of living in states that ban same-sex marriage. In the present study, which we recently published in AJPH, we were interested in the flip side of this question: Are there health benefits associated with reducing structural stigma through enacting same-sex marriage laws? And, relatedly, would these benefits translate into reduced health care use and costs?
  • -- In the analyses I’m presenting, we restricted the sample to individuals who had data at both time points (i.e., used services at least once in the 12 months before and after the marriage law). This permitted a within-subjects approach, which provides a stronger test than a between-subjects design, particularly because individuals serve as their own controls, and also controlled for some potential confounds (e.g., sicker patients dropped out of treatment).
  • --Y axis=mean # of mental health care visits; X axis=time; left is 12 months before the legalization of marriage, and the right is 12 months after. --In the 12 months before the legalization of gay marriage, sexual minority men had an average of 25 mental health visits, compared to only 22 visits in the 12 months following the legalization of gay marriage, and this was a statistically significant decrease. -We find similar results for medical care as well.
  • --The average cost of mental health care visits in the 12 months before the law was about $2400, compared to about $2100 in the 12 months after. This was a 13% decrease and was statistically significant.
  • -In ecologic studies like this, there is the potential for unmeasured confounding – e.g., changes in other health care policies in MA during this time could have been responsible for the results. I want to briefly mention a couple of things that reduce this possibility: MA instituted a comprehensive health care reform law that required all residents to purchase health insurance, but this went into effect in 2006, well outside the study period. Data from the Center for Medicare and Medicaid Services showed that trends in health care costs in MA increased during the study period, whereas we find evidence for decreased expenditures. In 2004, MA implemented significant cuts to their MassHealth insurance program for individuals with disabilities or living in poverty. Although cuts to MassHealth may have prevented some individuals from using health care, only 3% of the clinic sample had this form of insurance, and removing them from the analyses did not change the direction or magnitude of the results.
  • --These previous studies have all focused on the mental health consequences of social policies for LGB adults. --In the final study we examined whether policies are also social determinants of mental health among LGB youths
  • --The policy we focused on in this study was anti-bullying policies in school districts. --In the past year, the topic of suicide attempts among gay youth has received increased media attention following several suicides among gay youth who had reportedly been bullied in school, including Tyler Clementi. In the wake of these events, there has been a national conversation around what can be done to reduce suicide attempts among gay youth, including improving school climates. --In this last study, we examined whether the presence of anti-bullying policies that include sexual orientation as a protected class status protect gay and lesbian youth from attempting suicide.
  • --To address this question, we examined the proportion of school districts that had inclusive anti-bullying policies in 34 Oregon counties. --We obtained this information on anti-bullying policies from the Oregon Department of Education. We carefully went through the student handbooks in the 197 school districts and coded whether sexual orientation was included as a protected class status in the bullying policy. -- Because information on location of residence for the participants in our study was only available at the county level, the measures of anti-bullying policies were aggregated from the district to the county level. So each county received a score based on the proportion of school districts in the county that included sexual orientation as a protected class status in their anti-bullying policies.
  • -We then linked data on policies to individual health outcomes among lesbian and gay youth, using population-based data from the Oregon Healthy Teens study. -Modeled on Youth Risk Behavior Surveillance Survey designed by the CDC to measure the prevalence of behaviors and risk factors associated with the leading causes of morbidity and mortality in youth. -I chose Oregon because it was the only state that both assessed sexual orientation and also released data at the county level. -I pooled data from 2006 (first year sexual orientation was assessed) to 2008 (most recent available data) to increase sample size.
  • --The inclusive anti-bullying policies were divided into tertiles, ranging from least inclusive (i.e., counties with the smallest proportion of school districts with inclusive policies) to most inclusive (i.e., counties with the largest proportion of school districts with inclusive policies). We then examined the prevalence of suicide attempts within each tertile. --The results indicated that 31% of lesbian and gay youth living in the least inclusive counties attempted suicide in the past year, compared to only 16% of lesbian and gay youth living in the most inclusive counties. (The proportion of gay and lesbian respondents attempting past-year suicide within the tertiles was as follows: most inclusive (16.67%); medium (19.05%); and least inclusive (31.08%).) --Lesbian and gay youths living in the least inclusive counties were 2.25 times more likely to have attempted suicide in the past year compared to those in the most inclusive counties.
  • --In the next set of analyses, we found that inclusive anti-bullying policies were associated with reduced risk for suicide attempts among lesbian and gay youths over and above individual risk factors for suicide attempts, including sociodemographic characteristics and peer victimization. --Peer victimization of all youth was also less likely to occur in counties with inclusive anti-bullying policies. These results not only suggest one potential mechanism linking inclusive anti-bullying policies to reduced risk of suicide attempts in lesbian/gay youth but also demonstrate that policies protecting sexual minority adolescents may confer benefits for heterosexual youths as well
  • --In conclusion, the research that I presented today suggests that reducing structural forms of stigma through social policies may have beneficial health consequences for LGB populations. --Based on this research and other studies I’ve conducted, I’ve been involved in efforts to connect this social science research with public policies. --The MA Attorney General’s Office cited a few of these studies for their amicus brief in Perry vs. Schwarzenegger, the litigation aimed at overturning Proposition 8 in CA, the referendum denying same-sex couples the right to marry.
  • --We were interested in determining whether stress was a potential mechanism that may explain these results. --Previous qualitative research has indicated that LGB adults experience multiple stigma-related stressors in states that have enacted anti-marriage policies, including exclusion and marginalization. --Conversely, as this picture demonstrates, LGB individuals view the passage of same-sex marriage laws as granting much more than simply the right to marry – they experience these laws as a demonstration of their full humanity in the eyes of society.
  • --Consequently, we hypothesized that sexual minority men would experience fewer stressors when structural forms of stigma are eliminated. --Given established links between stress and health, we anticipated that this reduction in stress would translate into fewer health problems. --To evaluate that hypothesis, we identified the 3 most frequently billed diagnostic codes that medical and mental health care providers charged after each visit. --If these diagnostic codes were known to be associated with stress, and were reduced in the 12 months following the legalization of same-sex marriage, we would have some initial support for a stress pathway.
  • --In support of this hypothesis, we found a reduction in mental and medical health diagnoses associated with stress. On the Y axis is the percent reduction. --In the 12 months following the legalization of same-sex marriage in MA, there was a 14% reduction in depressive disorders, a 16% reduction in adjustment disorders, and an 18% reduction in hypertension. --These results are consistent with the the hypothesis that stress may be an intervening pathway linking structural stigma to health.
  • --We obtained data on LGBT hate crimes from the Boston Police Department Community Disorders Unit and linked this information to individual-level data on bullying and sexual orientation from a representative sample of Boston youth. --The LGBT assault hate crime rate for sexual minority youths who reported electronic bullying was 26.73 per 100,000, compared to a rate of 13.29 per 100,000 for sexual minority youths who reported no electronic bullying ( p =0.0313). --Sexual minority youths who reported relational bullying had a LGBT assault hate crime rate of 21.58 per 100,000 vs. 11.95 per 100,000 for sexual minority youths who reported no relational bullying ( p =0.0047). --In contrast, there was no association between LGBT assault hate crimes and bullying among heterosexual youths ( p> 0.05). Additionally, no relationships were observed between sexual minority bullying and area-level violent and property crimes ( p> 0.05), providing evidence for specificity of the results.
  • Conversation: Applying What We Know: Mark K. Hartzenbuehler, Assistant Professor of Sociomedical Sciences - Columbia College

    1. 1. Social Determinants of Mental Health Disparities in Lesbian, Gay, and Bisexual Populations Mark L. Hatzenbuehler, PhD Assistant Professor Department of Sociomedical Sciences Mailman School of Public Health Columbia University September 20, 2012
    2. 2. Sexual Orientation Disparities in Psychiatric Morbidity Hatzenbuehler et al., (2009). Am J Public Health
    3. 3. Stigma:A Multi-Level Construct StructuralState Policies, Institutional Practices Interpersonal Status Loss, Discrimination Individual Labeling, Stereotyping Level 1 Level 2 Level 3
    4. 4. Study 1
    5. 5. State-level policies (1) Hate Crimes (2) Employment Discrimination • Red = States with no protective policies • Blue = States with at least one protective policy
    6. 6. National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) • Wave 2 (N=34,653) • Household and group residents • Face-to-face interviews • Response rate: 81% • Oversampling of Blacks, Hispanics, young adults (18-24 yrs) • DSM-IV diagnoses • Sexual orientation (1.67% LGB-identified [1.86% men, 1.52% women])
    7. 7. LGB individuals have higher rates of psychiatric disorders in states with no protective policiesCovariates: sex, age, race/ethnicity, SES, marital status Hatzenbuehler et al (2009), Am J Public Health
    8. 8. Study 2
    9. 9. Constitutional Amendments Banning Same-Sex Marriage (2004) • Red = States passing constitutional amendments • Blue = States not passing constitutional amendments NESARC (2001-2005)
    10. 10. Results: Any Mood Disorder among LGB Respondents 36.6% increase 23.6% decreaseOR = 1.67 (95% C.I. 1.01,2.77) OR = 0.69 (95% C.I., 0.47,1.01)
    11. 11. Results:Any Mood Disorder in States with Constitutional Amendments 36.6% increase 2.6% increaseOR = 1.67 (95% C.I. 1.01,2.77) OR = 1.03 (95% C.I. 0.93,1.15)
    12. 12. Study 3• Are there health benefits associated with reducing structural stigma?• Do these benefits translate into reduced health care use and costs?
    13. 13. Methods• In 2003, Massachusetts became the first state to legalize same-sex marriage (Goodridge vs. Department of Public Health)• Community-based health clinic (N=1,211 gay and bisexual men)• Extracted health information in outpatient billing records from 2002- 2004• Examined changes in medical and mental health care utilization and expenditures in the 12 months before and after same-sex marriage legalized• Analyses restricted to individuals with data at both time points (i.e., used services at least once in the 12 months before and after the law)
    14. 14. 13% Reduction in Mental Health Care Utilization in the 12 Months Following Same-Sex Marriage F(1,147)=4.60, p=.03, Cohen’s d=0.35
    15. 15. 14% Reduction in Mental Health Care Costs in the 12 Months Following Same-Sex MarriageCosts(in $) F(1, 147)=6.32, p<.01, Cohen’s d=0.41
    16. 16. Addressing Confounding: Health Care in Massachusetts (2002-2004)• Instituted comprehensive health care reform law in 2006• Trends in health care costs increased during study period (CMS, 2007)• Cuts to MassHealth insurance program (disabilities, poverty) in 2004
    17. 17. Study 4• Studies 1-3 focused on LGB adults• Are policies also social determinants of mental health among LGB youth?
    18. 18. Suicides Put Light on Pressures of Gay Teenagers Tyler Clementi, September 29, 2010
    19. 19. Oregon CountiesProportion of school districts with anti-bullying policies inclusive of sexual orientation in 34 Oregon counties
    20. 20. Oregon Healthy Teens (OHT) Study• Linked ecologic data on inclusive anti-bullying policies at the county level to individual health outcomes among lesbian and gay youth living in these counties• Health and sexual orientation data from OHT study • Annual surveys to over 1/3 of Oregon’s 11th grade public school students • Modeled on Youth Risk Behavior Surveillance studies from CDC • N=31,852 11th grade students (2006-2008) • N=301 lesbian and gay respondents • Outcome measure: any suicide attempt in the past year (Brener et al., 1995; 2002)
    21. 21. Highest Risk of Suicide Attempts in Counties with Lowest Proportion of School Districts with Inclusive Anti-Bullying Policies (Lesbian and Gay Youth)OR=2.25, 95%CI=1.13, 4.49 Hatzenbuehler & Keyes, (in press), J Adolesc
    22. 22. Inclusive Anti-Bullying Policies Associated with Reduced Risk for Suicide Attempts Independent of Individual- Level Risk Factors (Lesbian and Gay Youth) Parameters Odds Ratio 95% Confidence Interval Inclusive Anti- 0.18 0.03 - 0.92 Bullying Policies Sex (Female) 1.95 1.01 – 3.79 Race/Ethnicity 2.55 1.21 – 5.38 (White) Peer Victimization 7.72 3.12 – 19.13 Hatzenbuehler & Keyes (in press), J Adolesc Health
    23. 23. Connecting Social Science Research with Public Policy
    24. 24. AcknowledgmentsFunders• National Institute of Mental Health (MH834012)• American Public Health Association (Walter J. Lear Award, Kenneth Lutterman Award)• American Psychological Association (Maylon-Smith Dissertation Award)• Williams Institute at UCLA School of Law• Robert Wood Johnson Foundation• Center for Population Research In LGBT HealthCollaborators• Deborah Hasin, Katherine Keyes (Columbia)• Kate McLaughlin (Harvard)• Steve Safren, Ken Mayer, Judy Bradford, Conall O’Cleirigh (Fenway)
    25. 25. Extra Slides
    26. 26. Future Directions:Mechanisms Linking Structural Stigma and Health Structural Stigma Stress Biological Psychosocial Mechanisms Mechanisms Mechanisms Health
    27. 27. Potential Mechanism:Reduction in Stress Associated with Equality, Inclusion
    28. 28. Stress as a Potential Mechanism• Hypothesis: • Sexual minority men would experience fewer stressors when structural forms of stigma were reduced • Given established links between stress and health, we anticipated that this reduction in stress would translate into fewer health problems• Test of hypothesis: • Identified the 3 most frequently billed health problems (by ICD-9 diagnostic code) charged by providers• Support for hypothesis: • If the 3 health problems were known to be associated with stress and were reduced in 12 months following same-sex marriage
    29. 29. Percent Reduction in Stress-Related Health Problems (by International Classification of Diseases-9 codes)
    30. 30. Future Directions:Mechanisms Linking Structural Stigma and Health Structural Stigma Stress Biological Psychosocial Mechanisms Mechanisms Mechanisms Health
    31. 31. Bullying of sexual minority youths is more likely to occur in neighborhoods with greater prevalence of LGBT assault hate crimes (obtained from police records) Hatzenbuehler & Duncan (under review)

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