Ethnic and Cultural Considerations in the Clinical Management of Mental Illness and Substance Abuse

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Ethnic and Cultural Considerations in the
Clinical Management of Mental Illness and
Substance Abuse

• Annelle B. Primm , MD, MPH
• Medical Director
• Johns Hopkins Community Psychiatry Program

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Overview

• Population Trends
• Disparities among the 4 major racial and ethnic
  minority groups
• Barriers to treatment
• DSM-IV Cultural Formulation
• Culturally appropriate care

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Cultural Divide

• High likelihood of ethnic and cultural
  differences between health providers and patients
• Limited training about the importance of cultural
  and ethnic factors in health care

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Surgeon Generals Report on MH Race, Culture,
and Ethnicity

• Mental Illness affects all
• Striking disparities in MH Care for Minorities
• Less likely to receive services
• Poorer quality of care
• Underrepresented in MH research
• Disparities impose great disability burden on
  minorities
• Lopez, 2002

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Barriers and Mediators to Equitable Health Care
for Racial and Ethnic Groups
Barriers

• Personal/Family
• acceptability
• cultural
• language/literacy
• attitudes, beliefs
• preferences
• involvement in care
• health behavior
• education/income
• Structural
• availability
• appointments
• how organized
• transportation
• Financial
• insurance coverage
• reimbursement levels
• public support

Use of Services
Mediators
Outcomes

• Visits
• primary care
• specialty
• emergency
• Procedures
• preventive
• diagnostic
• therapeutic

• Quality of providers
• cultural competence
• communication skills
• medical knowledge
• technical skills
• bias/stereotyping
• Appropriateness of care
• Efficacy of treatment
• Patient adherence

• Health Status
• mortality
• morbidity
• well-being
• functioning
• Equity of Services
• Patient Views of Care
• experiences
• satisfaction
• effective partnership

Modified From Access to Health Care in America 10
, From Cooper LA, Hill MN, and Powe NR. JGIM
2002 477-486
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People of African DescentMental Health Care

• Underuse of community outpatient care
• Later entry into treatment
• High drop-out rate
• Fewer treatment sessions
• High rates of inpatient care
• High rates of misdiagnosis
• High rates of severe mental illness
  Cultural Competence Standards, 1997

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African Americans

• Concerns about doublestigma
• Mistrust of health professionals
• Belief that prayer alone can heal
• Belief that suffering is a part of life for Black
  people

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American Indians, Native Alaskan, Native Hawaiian
PopulationMental Health Care

• Appear to be at higher risk for mental disorders
• High prevalence of depression, anxiety, substance
  abuse, violence, suicide
• High rates of symptoms from family and
  interpersonal problems Cultural Competence
  Standards, 1997

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American Indians and Alaska Natives

• Concerns about confidentiality - small, close
  community
• Tendency to see the connection between mental
  illness and physical or spiritual illness
• Use of both traditional and Western medicine

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Asian and Pacific Islander People Mental Health
Care

• Shame stigma associated with mental illness
• High endurance of psychiatric distress
• Limited knowledge about mental health services
• Underutilization of mental health services
• Present for treatment in crisis
• High drop-out rate after initial contact
• Tendency to seek traditional healing
• Language barriers Cultural Competence
  Standards, 1997

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Asian Americans

• Symptoms are viewed as medical illness
• High prevalence of somatization symptoms
• Difficulties in developing trust
• Hesitancy in opening up
• Tendency to give limited information
• Family is a key factor in treatment
• It is acceptable to disclose the diagnosis to the
  family, but not to the patient

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Latino PopulationMental Health Care

• Early treatment drop-out
• Less access to full range of care
• Lower rates of voluntary hospitalization
• Use of crisis and other high cost services
• Language barriers Cultural Competence
  Standards, 1997

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Latinos

• Perception of mental illness as illness requiring
  medical intervention
• Use of natural support systems
• Beliefs in the supernatural and use of
  traditional healers
• Family needs prevail over individual
• Somatization of emotional states
• adapted
  from Alarcon, 2003

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Ethnic and Cultural Influences onTreatment
Outcomes

• Direct
• Cultural beliefs and preferences
• Pathoplasticity
• Ethnopsychopharmacology

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Ethnic and Cultural Influences onTreatment
Outcomes

• Indirect
• Misinterpretation of behavior and belief
• Lack of symptom recognition
• Misdiagnosis and inappropriate treatment
• Provider bias and stereotyping

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Illicit Drug Use by Race/Ethnicity-2000National
Household Survey on Drug Abuse
14.8

12.6
6.4
6.4
5.3
2.7
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DSM-IV Cultural Formulation

• Cultural identity of the individual
• Cultural explanations of the individuals illness
• Cultural factors related to psychosocial
  environment and levels of functioning
• Cultural elements of the relationship between the
  individual and the clinician
• Overall cultural assessment for diagnosis and care

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Acculturation

• Acculturation describes the degree to which
  people from a particular cultural group display
  behavior that is like the more pervasive
  cultures norms of behavior.

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Recognition of Depressive Symptoms

• Using the CES-D, 47.3 of Latino and 41.6 of
  Asian primary care patients had depressive
  symptoms indicative of psychiatric distress
• PCPs identified psychiatric distress in 43.8 of
  Latinos and 23.6 of Asian patients
• Higher acculturation status was significantly
  associated with overall diagnostic recognition as
  measured by PCP agreement with the CES-D
• H Chung, et al, Depressive Symptoms and
  Psychiatric Distress in Low Income Asian and
  Latino Primary Care Patients Prevalence and
  Recognition, Community Mental Health Journal,
  February, 2003

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Depression Related Complaints

• Complaints Culture
• nerves and headaches Latino
• weakness, tiredness, imbalance Asian
• problems of the heart Middle Eastern
• heartbroken American Indian
• anger, evil African American

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Vicious Cycle
Medical and Behavioral Problems
Poverty and Social Problems
Mental Illness
Substance Abuse
Incarceration
Violence
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Therapeutic Relationship and Milieu

• Speak, treat patients with respect, Mr., Ms.,
  honor privacy
• Show caring and empathic attitude
• Be there to intervene in crises
• Acknowledge importance of life events
• Abuse
• Loss (illness, death, loss of housing, separation
  from family)
• Achievement
• Be a part of the solution CSAT, 1999

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Cultural Competence

• A set of congruent behaviors, attitudes, and
  policies that come together in a system, agency,
  or among professionals that enable them to work
  effectively in cross-cultural situations.
• Focal Point, vol. 3 1, Fall, 1988

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Culturally Competent System of Care

• Importance of culture
• Assessment of cross-cultural relations
• Vigilance towards the dynamics that result from
  cultural differences
• Expansion of cultural knowledge
• Adaptation of services to meet culturally-unique
  needs

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Cultural Competence Techniques

• Bilingual/Bicultural providers
• Recruitment and Retention
• Training
• Coordinating with Traditional Healers
• Use of Community Health Workers
• Culturally Competent Health Promotion
• Including Family and/or Community Members
• Immersion into another Culture
• Administrative and Organizational
  Accommodations Brach Fraser, 2000

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The Broadway Center Dual Diagnosis Service

• Use of structured diagnostic interview
• Pharmacologic management if needed
• Individual and group psychotherapy
• Case management services housing, vocational
  rehabilitation, jobs, literacy programs, and
  other social services

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Key Features

• Services provided regardless of insurance status
• Availability of sample medications
• Coordination with primary care staff
• Empathic psychiatric therapist willing to do
  outreach
• Word of mouth from patient-to-patient
• Creation of a culture in which mental health is
  valued

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Culturally Appropriate Care

• Services attended by members of the specific
  ethnic groups
• Employment of appropriate ethnic staff at all
  levels
• Involvement of professional and paraprofessional
  counselors from the recovering community
  Cultural Issues in Substance Abuse
  Treatment CSAT, 1999

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Culturally Appropriate Care

• Integrated Mental Health and Substance Abuse
  Treatment
• Coordination with Systems (Corrections, Primary
  Care, Social Services)
• Continuum of services (one-stop shop)
• - case management
• - medical care
• - social services

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Culturally Appropriate Care

• Enlist people with mental illness and substance
  use disorders as advocates
• Focus on Recovery
• Outreach, Education, Prevention
• use of culturally tailored educational videotape

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Reducing Health Disparities Through the
Implementation of Cultural Competency
Source Brach and Fraser, Cultural Competency
2000
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Health Disparities and Cultural Competence
Websites

• IOM Report Unequal Treatment
• www.nap.org
• Surgeon Generals Supplement on Race Culture and
  Ethnicity
• www.surgeongeneral.gov/library/mentalhealth/cre/de
  fault.asp
• Cultural Competence Standards
• www.wiche.edu/MentalHealth/Cultural_Comp/ccstoc.ht
  m
• CLAS Standards (Culturally and Linguistically
  Appropriate Standards)
• www.omhrc.gov/clas/cultural1a.htm