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National African American Drug Policy Coalition Health Care Disparities and Barriers to Treatment

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Title: National African American Drug Policy Coalition Health Care Disparities and Barriers to Treatment


1
National African American Drug Policy
Coalition Health Care Disparities and Barriers
to Treatment
  • Gail C. Christopher, D.N.
  • Vice President
  • Office of Health, Women and Families
  • Joint Center for Political and Economic Studies

2
Mental Health
  • The prevalence of mental disorders in the US is
    about 21 of adults and children. (DHHS, 1999)
  • The prevalence of mental disorders for racial and
    ethnic minorities in the US is similar to that
    for whites.
  • This general finding does not apply to those
    individuals in vulnerable, high-need subgroups
    (i.e., individuals who are homeless,
    incarcerated, or institutionalized). It only
    applies to minorities living in the communities.
    If those in high-need groups are counted, higher
    rates of mental illness among minorities might be
    detected.
  • African Americans were less likely to be
    depressed and more likely to suffer from phobia
    than whites. (Zhang Snowden, 1999)
  • (Mental Health Culture, Race, and Ethnicity
    (Supplement), DHHS, US Public Health Services,
    Aug. 27, 2001)

3
Mental Health
  • Substance abuse is a common reason for Alaskan
    native men and women to seek mental health care.
    (Aoun Gregory, 1998)
  • According to a study of Alaska Natives seen in a
    community mental health center 85 of the men
    and 65 of the women seen at this center.
  • Higher rates of substance abuse or dependence
    were found in American Indian children as
    compared to white children. (Costello et al,
    1997)
  • The difference in substance abuse is almost
    totally accounted for by alcohol use among 13
    year old American Indian children. (Based on The
    Great Smoky Mountain Study of 431 youths ages
    9-13.)
  • Suicide rate for Alaska Natives was 1.5 times the
    national rate.
  • Suicide rate is particularly high among young
    Native American males ages 15-24.
  • There is no study that has addressed the rates of
    mental disorders for Pacific Islander American
    ethnic groups.
  • This does not include the high-need populations
    of refugees, a group that studies have documented
    to have high rates of mental disorders. (Chung
    Kagawa-Singer, 1993) Cambodians reported the
    highest distress levels, followed by Laotians,
    and then Vietnamese.

4
Mental Health
  • Although Mexican Americans and white Americans
    had very similar rates of psychiatric disorder,
    when the Mexican American group is separated into
    sub-groups those born in Mexico and those born
    in the US studies found that those born in the
    US had higher rates of depression and phobias.
    (Robins Regier, 1991 Burnam et al, 1987)
  • Approximately 25 of the Mexican immigrants had
    some disorder (including both mental disorders
    and substance abuse), whereas 48 of the
    U.S.-born Mexican Americans had a disorder (Vega
    et al, 1998).
  • Immigrants who had lived in the US for at least
    13 years had higher prevalence rates of disorders
    than those who had lived in the US fewer than 13
    years. (Vega et al, 1998)
  • Some have interpreted these findings as
    suggesting that acculturation may lead to an
    increased risk of mental disorders (Vega et al,
    1998 Escobar et al, 2000 Ortega et al, 2000).
    The limitation of this interpretation is that
    none of the studies directly tested whether
    acculturation and prevalence rates are indeed
    related .

5
Mental Health
  • Studies of Latino children and adolescent,
    however, show that Latino youth experience a
    significant number of mental health problems, and
    in most cases, more problems than whites. (Mental
    Health Culture, Race, and Ethnicity
    (Supplement), DHHS, US Public Health Services,
    Aug. 27, 2001)
  • One of the studies found that youth in Puerto
    Rico have significantly higher total problem
    score (35 vs. 20) and prevalence rate of
    cases (36 vs. 9) than a three-State sample
    comprised primarily f whites (Achenbach et al.,
    1990)

6
Substance Abuse
  • In 1999, the percentage of
  • African Americans who reported being current
    users of illicit drugs 7.7
  • Majority of AIDS cases among African American
    women and children are attributable to alcohol
    and illicit drug use.
  • American Indians/Alaskan Natives who reported
    being current users of illicit drugs 10.6
  • Native Americans have very high prevalence of
    past-year substance use, alcohol dependence, and
    need for illicit drug abuse treatment.
  • Asian/Pacific Islanders who reported being
    current users of illicit drugs 3.2
  • Asian/Pacific Islanders have relatively low
    prevalence of substance abuse, alcohol
    dependence, and need for illicit drug abuse
    treatment.

7
Substance Abuse
  • Among Hispanics, particularly Mexicans and
    Puerto Ricans, there is a high prevalence of
    illicit drug use, heavy alcohol use, alcohol
    dependence, and need for drug abuse treatment.
  • More than 40 of all Hispanic women in the US
    with AIDS contracted it through injecting drugs.

8
Risk Factors
  • For Substance Abuse
  • Low family income
  • Residence in the Western US
  • Residence in metropolitan areas with populations
    greater than 1 million
  • Tendency to use English rather than Spanish
  • Lack of insurance coverage
  • Unemployed
  • Have not completed high school
  • Never been married
  • Reside in households with fewer than two
    biological parents
  • Relatively high prevalence of past-year use of
    cigarettes, alcohol, and illicit drugs.
  • (Depression in Racial/Ethnic Minorities,
    Minorities with Depression Face Barriers to
    Getting Help, HealthyPlace.com)

9
Risk Factors
  • For Mental Health
  • Poverty
  • Lower levels of education
  • Lack of insurance coverage
  • Unemployed
  • Reside in households with fewer than two
    biological parents
  • Physical health status
  • Disproportionate burden of health problems
    e.g., among African Americans there is a higher
    rate of diabetes, heart disease, prostate cancer
    compared to whites and higher infant mortality
    rates and incidence of HIV/AIDS. Among Alaskan
    Natives there is a higher rate of diabetes
    compared to white and higher infant mortality
    rates as well.
  • Racism
  • Mistrust and fear of treatment
  • For example, for American Indians/Alaska Natives,
    past governmental policies have led this
    population to mistrust many government services
    or care provided by white practitioners.
  • Exposure to trauma
  • Exposure to trauma is related to the development
    of subsequent mental disorders in general and
    post-traumatic stress disorder in particular.
    (Kessler et al., 1995)
  • Residence in rural areas
  • (Depression in Racial/Ethnic Minorities,
    Minorities with Depression Face Barriers to
    Getting Help, HealthyPlace.com Mental Health
    Culture, Race, and Ethnicity (Supplement), DHHS,
    US Public Health Services, Aug. 27, 2001 and The
    Presidents New Freedom Commission on Mental
    Health Report, July 22, 2003)

10
Disparities
  • Several disparities affect mental health care of
    minorities compared with whites
  • Minorities have less access to and availability
    of mental health services
  • Minorities are less likely to utilize mental
    health services
  • Minorities often receive poorer quality of mental
    health care.
  • Minorities are underrepresented in mental health
    research.
  • (Mental Health Culture, Race, and Ethnicity
    (Supplement), DHHS, US Public Health Services,
    Aug. 27, 2001)

11
Mental Health Services
  • Availability
  • Among clinically trained mental health
    professionals 2 of psychiatrists, 2 of
    psychologist, and 4 of social workers said they
    were African American. (Holzer et al, 1998)
  • In 1996, only an estimated 29 psychiatrists in
    the US were of Indian or Native heritage.
  • Approximately, 101 American Indian and Alaska
    Native mental health provider are available per
    100,000 members of this ethnic group (vs. 173 per
    100,000 for whites). (Manderscheid Henderson,
    US, 1998)

12
Mental Health Services
  • Availability
  • Nearly half of the Asian American and Pacific
    Islander populations ability to use mental
    health care services is limited due to lack of
    English proficiency as well as shortage of
    providers who posses appropriate language skills.
  • In the late 1990s, approximately 70 Asian
    American providers were available for every
    100,000 Asian Americans in the US. This is
    about half the ratio for white. (Manderscheid
    Henderson, 1998)

13
Mental Health Services
  • Availability
  • Spanish-speaking providers is likely to be a
    problem for many Spanish-speaking Hispanics.
  • A survey of 1,507 school psychologist who carry
    out psychoeducational assessments of bilingual
    children in the 8 states with the highest
    percentages of Latinos found that 43 of the
    psychologists identified themselves as
    English-speaking monolinguals (Ochoa et al.,
    1996).
  • This means a large number of English-speaking
    only psychologists are evaluating bilingual
    children a problem for children whose English
    language skills are limited.
  • There are 28 Latino mental health professionals
    for every 100,000 Latinos in the US.
    (Manderscheid Henderson, 1998)

14
Mental Health Services
  • Accessibility
  • Nearly a quarter of African Americans are
    uninsured, a percentage 1.5 times greater than
    the white rate. (Brown et al, 2000)
  • Only 1 in 5 American Indians reports access to
    the Indian Health Service about half have
    employer-based insurance coverage and 24 are
    uninsured. (Brown et al, 2000)
  • Medicaid is the primary source of coverage for
    25 of American Indians and Alaska Natives.

15
Mental Health Services
  • Accessibility
  • About 21 of Asian Americans and Pacific
    Islanders lack health insurance.
  • 37 of Latinos are uninsured. Medicaid reaches
    18 of Latinos.
  • This is mostly driven by Latinos lack of
    employer based coverage.
  • Compared to Asian Americans, African Americans,
    and white American children, Latino children were
    the least likely to be insured, regardless of
    citizenship.
  • (Mental Health Culture, Race, and Ethnicity
    (Supplement), DHHS, US Public Health Services,
    Aug. 27, 2001)

16
Mental Health Services
  • Utilization
  • The percentage of adult African Americans
    receiving treatment from any source was only
    about half that of white. (Swartz et al, 1998)
  • This is after eliminating the impact of
    sociodemographic difference and differences in
    need.
  • African American children were less likely than
    white children to have made a mental health
    outpatient visit.
  • Among those who received outpatient mental
    treatment, African Americans and white had
    similar rates of receiving care from a mental
    health specialist.
  • Perhaps there are few African American children
    in psychiatric inpatient care due to lack of
    health insurance, but there are many black
    children in residential treatment centers for
    emotionally disturbed youth.
  • In many cases, it is not the parents, but child
    welfare authorities who initiate treatment for
    these children. This access via the child welfare
    system, however, often does not results in
    beneficial treatment.
  • 58 of older African American adults with mental
    disorders were not receiving care. (Black et al.,
    1997)
  • (Mental Health Culture, Race, and Ethnicity
    (Supplement), DHHS, US Public Health Services,
    Aug. 27, 2001)

17
Mental Health Services
  • Utilization
  • 1 in 7 Cherokee child diagnosed with a
    psychiatric disorder received professional mental
    health treatment. A rate similar to non-Indian
    sample. (Based on The Great Smoky Mountain Study,
    Costello, et al, 1997)
  • However, they were more likely to receive this
    through the juvenile justice system and inpatient
    facilities than non-Indian children.
  • Two-thirds of those who receive services were
    seen through school.
  • Based on 3 comprehensive studies that examined
    the entire formal mental health system found that
    Asian Americans used fewer services per capita
    than did other group. (Snowden Cheung, 1990
    Cheung Snowden, 1990 Matsuoka et al, 1997)
  • Many studies demonstrate that Asian Americans who
    use mental health services are more severely ill
    than white Americans who use the same services.
  • Several studies suggest that among Hispanic
    Americans with mental disorders, fewer than 1 in
    11 contact mental health care specialists, while
    fewer than 1 in 5 contact general health care
    providers.
  • Among Hispanic American immigrants with mental
    health disorders, fewer than 1 in 20 use services
    from mental health specialists, while fewer than
    1 in 10 use services from general health care
    providers.
  • (Mental Health Culture, Race, and Ethnicity
    (Supplement), DHHS, US Public Health Services,
    Aug. 27, 2001)

18
Mental Health
  • On April 20, 2002, President Bush identified
    three obstacles preventing Americans with mental
    illnesses from getting the excellent care they
    deserve
  • Stigma that surrounds mental illnesses,
  • Unfair treatment limitations and financial
    requirements placed on mental health benefits in
    private health insurance, and
  • The fragmented health service delivery system.

19
Mental Health
  • The Presidents New Freedom Commission on Mental
    Health identified these barriers
  • Stigma
  • Fragmented services
  • Cost
  • Workforce shortages
  • Unavailable services
  • Not knowing where or how to get care.

20
Recommendations to Address Disparities and
Barriers to Treatment
  • From the Surgeon General Supplemental Report
  • From The Presidents New Freedom Commission on
    Mental Health

21
A Vision for the Future
  • From the supplement report of the Surgeon
    General
  • Continue to expand the science base
  • Inclusion of racial and ethnic minorities in
    study populations need to be significantly
    strengthened.
  • Clinicians awareness of their own cultural
    orientation, their knowledge of the clients
    background, and their skills with different
    cultural groups
  • Awareness that the manifestations of mental
    illnesses may vary with age, gender, race,
    ethnicity, and culture.
  • Researchers should study cultural differences in
    stress, coping, and resilience as part of the
    complex of factors that influence mental health
    to lay the groundwork for developing new
    prevention and treatment strategies.
  • Improve access to treatment
  • Provision of high-quality, culturally responsive,
    and language-appropriate mental health services
    in locations accessible to racial and ethnic
    minorities.
  • Integrate mental health and primary care.
  • Coordinate and integrate mental health services
    for high-need populations.
  • Reduce barriers to treatment
  • Ensure parity and expand public health insurance.
  • Extend health insurance for the uninsured
  • Examine the costs and benefits of culturally
    appropriate services
  • Reduce barriers to managed care
  • Overcome shame, stigma, and discrimination
  • Build trust in mental health
  • Improve quality of care
  • Ensure evidence-based treatment

22
A Vision for the Future
  • From the supplement report of the Surgeon
    General
  • Improve quality of care
  • Ensure evidence-based treatment
  • Develop and evaluate culturally responsive
    services
  • Engage consumers, families and communities in
    developing services
  • Support capacity development
  • Train mental health professionals
  • Encourage consumer and family leadership
  • Promote mental health
  • Address social adversities poverty, community
    violence, racism and discrimination
  • Build on natural supports build on intrinsic
    community strengths such as spirituality,
    positive ethnic identity, traditional values,
    educational attainment, and local leadership.
  • Strengthen families to function at their
    fullest potential and to mitigate the stressful
    effects of caring for a relative with mental
    illness or serious emotional disturbance.

23
The Presidents New Freedom Commission on Mental
Health
  • To improve access to quality care and services,
    the Commission recommends fundamentally
    transforming how mental health care is delivered
    in America.
  • Successfully transforming the mental health
    service delivery system rests on two principles
  • Services and treatment must be consumer and
    family centered.
  • Care must focus on increasing consumers ability
    to successfully cope with lifes challenges, on
    facilitating recovery, and on building
    resilience.
  • The system must be seamless and convenient.

24
The Presidents New Freedom Commission on Mental
Health
  • Goals in a transformed mental health system
  • Americans understand that mental health is
    essential to overall health.
  • Education campaigns to rural Americans who many
    have little exposure to the mental health service
    system racial/ethnic minority groups who may
    hesitate to seek treatment in the current system
    and people whose primary language is not English.
  • Mental health care is consumer and family driven.
  • Giving consumers the ability to participate fully
    will require access to health care, gainful
    employment opportunities adequate and affordable
    housing and assurance of not being unjustly
    incarcerated.
  • Disparities in mental health services are
    eliminate.
  • Improve access to quality care that is culturally
    competent and improve access to quality care in
    rural and geographically remote areas.
  • Early mental health screening, assessment and
    referral to services are common practice.
  • - Promote the mental health of young children
    improve and expand school mental health programs
    screen for co-occurring mental and substance use
    disorders and link with integrated treatment
    strategies and screen for mental disorders in
    primary health care, across the lifespan, and
    connect to treatment and supports.

25
The Presidents New Freedom Commission on Mental
Health
  • Excellent mental health care is delivered and
    research is accelerated.
  • Accelerate research to promote recovery and
    resilience, and ultimately to cure and prevent
    mental illness advance evidence-based practices
    using dissemination and demonstration projects
    and create a public-private partnership to guide
    their implementation improve and expand the
    workforce providing evidence-based mental health
    services and supports and develop the knowledge
    base in four understudied areas mental health
    disparities, long-term effects of medications,
    trauma, and acute care.
  • Technology is used to access mental health care
    and information.
  • This goal envisions two critical technological
    component robust telehealth system and
    integrated health records system and a personal
    health information system for providers and
    patients.
  • Recommendations are Use health technology and
    telehealth to improve access and coordination of
    mental health care and develop and implement
    integrated electronic health record and personal
    health information systems.
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