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Disparities in Mental Health Care of Diverse Populations: The Process of Elimination


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Title: Disparities in Mental Health Care of Diverse Populations: The Process of Elimination

Disparities in Mental Health Care of Diverse
Populations The Process of Elimination
  • University of Texas Health Sciences Center
  • Committee of Advancement of Women and Minorities
  • Distinguished Speakers Series
  • San Antonio, Texas
  • March 27, 2009
  • Annelle B. Primm, MD, MPH
  • Director, Minority and National Affairs
  • American Psychiatric Association

Public Health Model
  • Population perspective tip of the iceberg, the
    evidence of people not seen
  • Case finding
  • Risk factors and protective factors
  • Prevention
  • Primary (prophylaxis)
  • Secondary (early intervention)
  • Tertiary (chronic care, maintenance)

Determinants of Mental Health
  • Individual Biology
  • Individual Behavior
  • Social Environment
  • Physical Environment
  • Access to Quality Care
  • Policies Interventions

Major Racial Ethnic Groups in U.S.
  • Latinos/Hispanics - 15
  • African Americans - 13
  • Asian American/Pacific Islanders - 5
  • American Indians/Alaska Natives - 1
  • U.S. Census 2007

(No Transcript)
Surgeon Generals Report on Mental Health Race,
Culture, and Ethnicity
  • Striking disparities in mental health care for
    people of color
  • Less likely to receive services
  • Poorer quality of care
  • Underrepresented in mental health research
  • Disparities impose great disability burden on
    people of color
  • Culture counts

Influence of Culture on Mental Illness and
Mental Health
  • How patients communicate
  • How patients manifest symptoms
  • How patients cope
  • Range of family and community support
  • Willingness to seek treatment

U.S. Dept. of Health and Human Services Office of
the Surgeon General, SAMHSA August 2001
Factors in Mental Health, Mental Illness and
Service Use
  • Racism
  • Discrimination
  • Economic impoverishment
  • Mistrust
  • Fear
  • Cultural and social influences
  • Biological, psychological and environmental

U.S. Dept. of Health and Human Services Office of
the Surgeon General, SAMHSA August 2001
High Need Populations
  • Overrepresentation of ethnically diverse
  • Homeless
  • Chronic Disease and Disability
  • Correctional facilities
  • Victims of violence
  • Child welfare
  • Immigrants and refugees
  • U.S. DHHS, Office of the Surgeon General,
    SAMHSA August 2001

What Are Racial and Ethnic Health Disparities?
  • Differences and inequalities among racial,
    ethnic, linguistic, and cultural groups in
  • Risk and predisposition
  • Disease prevalence, health status, and diagnosis
  • Health care quality not due to access-related
    factors or clinical needs, preferences, and
    appropriateness of intervention
  • Health outcomes and mortality

IOM Report Unequal Treatment
  • Racial and ethnic disparities exist regardless of
  • Higher morbidity and mortality from the leading
    causes of death
  • Poorer quality of care
  • Worse outcomes
  • Racial and ethnic minorities tend to receive a
    lower quality of healthcare than non-minorities,
    even when access-related factors, such as
    patients insurance status and income, are
  • Smedley et al 2003 IOM 2002

Outcomes Higher Mortality
  • African-Americans
  • Heart disease and stroke, cancer (breast, lung,
    and prostate), diabetes, infant mortality,
  • American Indians and Alaska Natives
  • Diabetes, infant mortality
  • Asian Americans and Pacific Islanders
  • Tuberculosis, stroke, cervical cancer
  • Hispanics
  • Diabetes, uncontrolled hypertension, HIV/AIDS

Disparities in Seeking Mental Health Care
  • African Americans more likely to use emergency
    services or primary care providers than mental
    health specialists. (Surgeon General, 2001)
  • Asian Americans Only 4 would seek help from
    mental health specialist vs. 26 percent of
    whites. (Zhang et al., 1998)
  • Latinos lt 1 in 11 with mental disorders contact
    mental health specialists, lt 1 in 5 contact
    primary care providers. (Surgeon General, 2001)
  • Native Americans 44 with a mental health
    problem sought any kind of help--and only 28 of
    those contacted a mental health agency. (King,

Unmet Need
  • Levels of unmet need (not receiving specialist or
    generalist care in past 12 months, with
    identified diagnosis in same period)
  • African Americans 72
  • Asian Americans 78
  • Hispanics 70
  • Non-Hispanic Whites 61
  • Alegria et al 2006

Mental Health Disparities
  • Underuse of community outpatient care
  • Use of alternative sources of help (faith,
    family, folk) primary care and alternative
  • Later entry into treatment, especially at the
    crisis or emergency stage
  • High drop-out rate and fewer treatment sessions
  • High rates of inpatient care, especially
  • Cultural Competence Standards, 1997

Mental Health Disparities
  • Less access to bi-lingual services
  • More likely to be misdiagnosed
  • Less evidence based care
  • More inpatient hospitalizations
  • Less follow up after psychiatric hospitalization

Mental Health Disparities
  • Underdiagnosis and undertreatment of anxiety and
    mood disorders
  • Differential prescribing patterns
  • Lower metabolism of certain psychotropic
  • More side effects and less adherence
  • More seclusion and restraint

Ethnocultural Influences on Mental Health Care
  • Direct
  • Cultural beliefs and preferences
  • Pathoplasticity
  • Ethnopsychopharmacology

Ethnocultural Influences on Mental Health Care
  • Indirect
  • Bias and stereotyping
  • Misinterpretation of behavior and belief
  • Lack of symptom recognition
  • Misdiagnosis and inappropriate treatment
  • Ignorance of ethnocultural issues

Vicious Cycle
Violence and Incarceration
Poverty, Homelessness, Unemployment
Substance Abuse
Unmet Mental Health Needs
Poor Physical Health STIs, DM, CAD, CA, etc
Barriers and Mediators to Equitable Mental Health
Care for Diverse Racial and Ethnic Groups
Use of Services
  • Personal/Family
  • Acceptability
  • Cultural beliefs
  • 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
  • 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
  • Visits
  • Primary care
  • Specialty
  • Emergency
  • Procedures
  • Preventive
  • Diagnostic
  • Therapeutic

Modified from Institute of Medicine. Access to
Health Care in America A Model for Monitoring
Access. Washington, DC National Academy Press
1993. Cooper LA, Hill MN, Powe NR. J Gen
Internal Med. 2002477-486.
Barriers Attitudes and Language
  • Immigrant populations (Asian Americans and
    Hispanics) with limited English proficiency
    report communication a major obstacle in
    addressing MH concerns
  • Cultural perception of mental illness affects
  • likelihood of seeking care
  • support
  • feelings of shame, stigma, weakness
  • help seeking at crisis stage rather than earlier
  • Alegria et al 2006 Minski S 2003 Cooper et al
    2001 Yeh Inose 2002

Barriers Language
  • 18 of the U.S. population (nearly 47 million
    people) speak a language other than English at
  • 28 of all Spanish speakers, 22.5 of Asian and
    Pacific Islander speakers and 13 of
    Indo-European language speakers speak English
    either not well or not at all
  • Limited English Proficiency (LEP) affects a
    persons ability to access and receive health and
    mental health care
  • National Health Law Program NHeLP, 2006

Barriers Attitudes and Beliefs
  • African Americans and Hispanics had lower odds
    than non-Hispanic whites of finding
    antidepressant medications acceptable
  • African Americans had lower odds and Hispanics
    had higher odds than non-Hispanic whites of
    finding counseling acceptable.
  • Cooper et al 2003

Barriers Health Behavior
  • Physicians were less patient-centered with
    African American than non-Hispanic white patients
  • Less patient input is associated with less
    information recall, treatment adherence,
    satisfaction with care, return visits, and
    suboptimal health outcomes
  • Roter et al 1997

Availability of Mental Health Services by Race,
  • African Americans account for 2 psychologists,
    4 social workers in U.S.
  • In 2005, 16.7 of psychiatrists were from the 4
    major racial/ethnic groups (Black 2.6 Asian
    9.6, Hispanic 4.4, Native American 0.07)
  • Percentage of Spanish-speaking healthcare
    professionals unknown
  • In 1996, only 29 psychiatrists identified as AIAN

U.S. Dept. of Health and Human Services Office of
the Surgeon General, SAMHSA August 2001
Mediators Cultural Competence
  • Limited racial/ethnic diversity of MH providers
  • Greater cultural difference may result in higher
    likelihood of misdiagnosis
  • Cultural incompetence, including language
    barriers, increase likelihood of misdiagnosis
  • When needed, less than 20 of patients seeking MH
    services, had interpreter services available
  • Alegria et al 2006 Minski S et al 2003

Culturally Competent Care
  • Health and human services are offered and
    delivered in a way that are sensitive to the
    language, culture and traditions of non-native
    immigrants, migrants and ethnic minorities with
    the goal of minimizing or eliminating long
    standing disparities in the health status of
    people with diverse racial, ethnic or cultural
    backgrounds. (www.icfdn.org)

Culturally Competent Care
  • The ability of any health care provider of any
    cultural background in ones organization to
    effectively treat any patient of any cultural
  • (Matus, JC 2004, Health Care Manag)

Cultural Competence
  • A set of congruent behaviors, attitudes and
    policies that come together as a system, agency
    or among professionals and enable that system,
    agency or those professionals to work effectively
    in cross-cultural situations.

  • (AAFP, 2001)

Cultural Competence
  • Acceptance and respect for differences
  • Continuing self assessment regarding culture
  • Attention to the dynamics of difference
  • Ongoing development of cultural knowledge and
  • Dynamic and flexible application of service
    models to meet the needs of diverse
    populations SAMHSA,
    CMHS, 1998

Outline for Cultural Formulation DSM IV-TR
  • 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

Mediators Cultural Competence
  • At least 1 in 5 resident physicians surveyed
    (from seven specialties) reported not being
    prepared to deal with cross-cultural issues
  • Approximately half of residents reported
    receiving little or no training in understanding
    how to address patients from different cultures
    (50), or how to identify patient mistrust (56),
    relevant religious beliefs (50), and relevant
    cultural customs (48)
  • Weisman et al 2005

Mediators Cultural Competence
Mediators Bias and Stereotyping
  • Un-structured interviews lead to greater
    variability in diagnosis, greater reliance on
  • Psychometric validation is needed to determine
    whether disparities in diagnoses reflect
    differences in detection (clinical uncertainty,
  • Strakowski SM et al 2003 West et al 2006

The Ethnopsychopharmacological Approach
  • Assessment
  • Cultural formulation for diagnosis
  • Choice of medication
  • Use medical history, concurrent medications,
    diet, food supplements, and herbals combined with
    knowledge of enzyme activity in certain ethnic
  • Start at lower doses.
  • Monitor patient
  • Proceed slowly - involve family
  • If side effects are intolerable - lower dosage or
    choose drug metabolized through different route
  • If no response - check adherence, raise dose and
    monitor levels add inhibitors switch drug
  • (Henderson, 2007)

Outcomes Patient Views of Care
  • Reported spending enough time with providers
  • 50 of Asian Americans
  • 57 of Hispanics
  • 70 of non-Hispanic Whites
  • Reported having negative experience with service
  • 20 of Asian Americans and Hispanics (NLAAS)
  • Reported being treated with disrespect or looked
    down on in their patient/provider relationship
  • 14 of African Americans
  • 20 of Asian Americans
  • 19 of Hispanics
  • 9 of non-Hispanic Whites
  • Alegria et al 2006 Blanchard Lurie, 2004
    Collins et al 2002

Outcomes Patient Satisfaction
  • Patients feel more involved with their care when
    their physician is of the same race
  • Greater involvement with care translates into
    higher patient satisfaction and better medical
  • Cooper-Patrick et al 1999

Outcomes Effective Partnership
  • Racial/ethnic minorities rate the quality of
    interpersonal care by physicians and within the
    health care system in general more negatively
    than non-Hispanic whites.
  • Collins et al 2002

Landmark Reports National Initiatives
  • 1997 Cultural Competence Standards
  • 1998 President Clintons Presidential Initiative
    on Healthcare Disparities
  • 2000 IOM Crossing the Quality Chasm
  • 2001 SG Report on MH Culture, Race, Ethnicity
  • 2002 IOM Unequal Treatment Confronting Racial
    Ethnic Disparities in Health Care

Landmark Reports Initiatives
  • 2003 President Bushs New Freedom Commission on
    Mental Health
  • 2004 IOM In the Nations Compelling Interest
    Ensuring Diversity in the Health Care Workforce
  • 2005 Commission to End Health Care Disparities
    (AMA, NMA, NHMA)
  • 2005 Sullivan Report, Missing Persons
  • AAMC Health Professionals for Diversity
  • 2005 IOM Health Care for Mental and Substance Use

Synopsis of Culturally and Linguistically
Appropriate Services (CLAS) Standards
  • Quality care
  • Diverse staff
  • Ongoing education and training
  • Free and competent language assistance services
  • Patient-related materials and signage
  • Strategic plan
  • Organizational self-assessment
  • Collect data
  • Profile and needs assessment
  • Collaborative partnerships
  • Conflict and grievance process
  • Publicize successes

Health Disparities Collaboratives
  • Community of Learners
  • HRSA support of strategic state and national
  • Improving systems of health care
  • Planned care model
  • Model for improvement in the context of
    community-oriented primary care
  • Improve health outcomes (diabetes, asthma,
    depression) and organizational sustainability

Natl Network to Eliminate Disparities in
Behavioral Health - NNED
  • SAMHSA in partnership with the National Alliance
    of Multi-ethnic Behavioral Health Associations
  • Vision diverse families thrive, participate and
    contribute to healthy communities
  • Community and ethnic-based organizations and
    networks, knowledge discovery centers, and a
    national facilitation center
  • Equity in care is an inadequate outcome, rather
    transformation is needed for behavioral health
    focused on culturally and linguistically
    competent interventions

IOM Unequal Treatment Recommendations
  • Increase public and provider awareness of
  • Change financial incentives to improve quality,
    decrease fragmentation of care
  • Ensure provider supply, reduce barriers and
    promote quality evidence-based practice
  • Promote civil rights enforcement

Institute of Medicine, 2003
IOM Unequal Treatment Recommendations
  • Promote provider training, cultural competence,
    translation services, community health workers
    and multidisciplinary teams
  • Promote patient education to enhance access and
    participation in treatment decisions
  • Collect data on access, utilization and quality
    including race/ethnicity/language and monitor
  • Conduct more research on sources of disparities
    and interventions to eliminate them

Institute of Medicine, 2003
Rationale for Culturally Competent Health Care
  • Responding to demographic changes
  • Eliminating disparities in the health status of
    people of diverse racial, ethnic, cultural
  • Improving the quality of services outcomes
  • Meeting legislative, regulatory, accreditation
  • Gaining a competitive edge in the marketplace
  • Decreasing the likelihood of liability/malpractice

Cohen E, Goode T. Policy Brief 1 Rationale for
cultural competence in primary health care.
Georgetown University

Development Center, The National Center for
Cultural Competence. Washington, D.C., 1999.
Cultural Competence Guiding Principles
  • Quality
  • Data Driven Systems
  • Outcomes
  • Prevention

Cultural Competence Techniques
  • Interpreter Services
  • Written Translations
  • Concordant Clinicians and Staff
  • Education and Training
  • Community Health Workers
  • Health Promotion
  • Organizational Supports
  • Brach and Fraser, Quality Management in Health
    Care, 2002, 10(4), 15-28

Clinician Patient Behavioral Change
  • Improved Communication
  • Increased Trust
  • Improved Epidemiologic and Treatment Efficacy
  • Expanded Cultural and Environmental Understanding
  • Brach and Fraser, Quality Management in Health
    Care, 2002, 10(4), 15-28

Reducing Health Disparities Through the
Implementation of Cultural Competency
Source Brach and Fraser, Cultural Competency
General Strategies to Address Disparities
  • Must address all potential factors affecting
  • May need to address subpopulations of diverse
    ethnic and racial groups differently, dependent
    on how various factors affect them
  • Include diverse communities at all levels of
    research, policy, planning, programs, evaluation

Strategies to Increase Use of Services
  • Integration of Mental Health in Primary care
  • Increase screening and focus on prevention
  • Increase knowledge of ethnic and racial
    differences for effective diagnosis and treatment
    (address at level of training, medical school,
    residency, and CME)
  • Standards for screening, referral, diagnosis, and

Strategies to Reduce Barriers
  • Policy and funding to improve/increase
    (structural and personnel) MH services in human
    services, and other public sectors where
    populations are affected (correctional, child
    welfare, school, community health)
  • Universal health insurance to assure coverage
  • Mental health parity
  • Public marketing to increase population
    knowledge, change health behavior
  • Patient activation

Strategies to Enhance Mediating Factors
  • Provider education on cultural competence
  • Clinicians should consider patients cultural and
    social context when negotiating treatment
  • Provider incentives (career, financial) for
    successful referral and engagement
  • Increase ethnic and racial minority
    representation in all clinical trials (better
    understand environmental and biological
    interactions and effect on symptomatology/drug
  • Language competency in assessment/diagnostic

Strategies to Improve Outcomes
  • Greater public health interventions as basis for
    correctional, child welfare, human services
  • Collecting data and reporting on race and ethnic
    groups health status (mental health,
    functioning, co-morbidities)
  • Clinicians to screen for suicide risk and monitor
    carefully consumers with anxiety and mood
  • Longitudinal studies to evaluate equity of
    services, patient experiences

Office of Minority and National
Affairs (OMNA)
  • APAs nerve center for the mental health of
    diverse and underserved populations

Our Mission
  • To contribute to the improvement of the quality
    of care for diverse and underserved populations
  • To meet the professional needs of psychiatrists
    from under-represented (MUR) groups

Our Main Issues Constituencies
  • People of African, Asian, Hispanic, Native
    American descent
  • Women
  • Gay, Lesbian and Bisexual Issues
  • International Medical Graduates
  • Religious and Spiritual Issues

Our Priorities
  • Increase diversity in psychiatry
  • Foster the professional well-being of
    psychiatrists from underrepresented groups
  • Increase knowledge of the mental health needs of
    underserved populations
  • Educate communities about mental health
  • Forge alliances to prevent and eliminate

American Psychiatric Association Disparities
Elimination Efforts
  • Buy-in at the top elected leaders, Board of
    Trustees, executive staff
  • Support of the Office of Minority and National
    Affairs (OMNA)
  • Recommendations stemming from SGR Supplement
    passed by board of trustees
  • Increase access to quality care
  • Support capacity development, education and
  • Expand the science base
  • Promote collaboration and advocacy
  • Eliminating Mental Health Disparities Roundtable
  • .

Fellowship Programs
  • Minority Fellowships Program
  • SAMHSA, AstraZeneca
  • Program for Minority Research Training in
    Psychiatry (in collaboration with APIRE)
  • Spurlock Congressional Fellowship
  • Medical student programs
  • Mentoring, travel scholarships, addiction and HIV
    psychiatry summer externships

Recognition Awards
  • Simon Bolivar Award (Hispanic leaders)
  • Solomon Carter Fuller Award (pioneering
  • John Fryer Award (GLBT health)
  • Oskar Pfister Award (religion, spirituality, and
  • Kun-Po Soo Award (Asian cultural heritage)
  • George Tarjan Award (IMG advocacy)
  • Jeanne Spurlock Achievement Award (MFP graduate)

OMNA Products
  • CME curriculum, NAMI-APA effort
  • In Living Color Treating Depression in Diverse
    Populations for primary care
  • Lets Talk Facts series on Mental Health of
    Diverse Populations available at healthyminds.org
  • People of African, Asian, American Indian,
    Hispanic descent
  • Book
  • Disparities in Psychiatric Care Clinical and
    Cross-Cultural Perspectives
  • DVDs
  • Latino Mental Health DVD and Guidebook
  • Real Psychiatry Doctors in Action

(No Transcript)
OMNA Special Projects
  • Womens Mental Health Roundtable
  • All Healers Mental Health Alliance
  • OMNA on Tour
  • Community Connections
  • Doctors Back to School
  • Transformational Leadership in Psychiatry Academy
  • National Minority Mentors Network
  • Collaboration with Texas Regional Psychiatry
    Minority Mentorship Network (TRMMN)

Diversity-Related Outcomes
  • TRPMMN illustrates Increased medical school
    diversity is associated with white students
    feeling better prepared to care for diverse
  • Compositional Diversity proportions of URM
    students and non-white, non-URM students
  • Interactional Diversity climate for interracial
    interaction, individual exposure to diverse
  • Saha et al, Student Body Racial and Ethnic
    Composition and Diversity-Related Outcomes in US
    Medical Schools, JAMA, Sept. 10, 2008, 300(10)

OMNA Future Priorities
  • Support TRPMMN and other regional mentorship
  • Psychiatrists Back To School
  • Aspiring Psychiatrists
  • Community of Scholars, national network of
    minority psychiatry faculty and mentors
  • Collaborate with APA district branches and a
    variety of educational and ethnic medical and
    psychiatric associations to foster diversity,
    recruitment, retention, advancement and

What can you do to eliminate disparities?
  • Know your population
  • Demographics
  • Socio-environmental conditions
  • Epidemiologic vulnerabilities
  • Know yourself (challenge your biases)
  • Listen to your patients and make a concerted
    effort to understand cultural context and belief

What can you do to eliminate disparities?
  • Notice patterns of health care delivery and
    question differences in quality by race,
    ethnicity and linguistic background
  • Collect data by race and ethnicity (or encourage
    your institution to) in order to uncover
    disparities in care
  • Educate your patients about what their illness
    is, what to do to manage it, and why it is
    important (health literacy)

What can you do to eliminate disparities?
  • Treat your patients like they want to be treated.
    Look for the commonalities that arise from sheer
  • Encourage patients to ask questions and be active
    participants in their health care
  • Showing patients you care engenders trust,
    regardless of differences
  • Trust is key to establishing an effective
    patienthealth professional partnership

Crossing the Quality Chasm A New Health System
for the 21st Century
  • Six Aims for Improvement
  • Safe
  • Effective
  • Patient-centered
  • Timely
  • Efficient
  • Equitable
  • IOM, 2001

Patient-centered Care
  • Providing care that is respectful of and
    responsive to individual patient preferences,
    needs, and values, and ensuring that patient
    values guide all clinical decisions.

Person-centered Care
  • Healthcare partnership among practitioners,
    patients, and their families to ensure that
    decisions respond to and respect patients' wants,
    needs, and preferences and solicit patients'
    input on the education and support they need to
    make decisions and participate in their own care.
    (Adapted from Agency for Healthcare Research and
    Quality, 2002)
  • Six dimensions of person-centered care
  • Respect for patients values, preferences, and
    expressed needs
  • Coordination and integration of care
  • Information, communication, and education
  • Physical comfort
  • Emotional support
  • Involvement of family and friends
  • (Gerteis et al, 1993)

Recovery-oriented Care
  • Mental health recovery is a journey of healing
    and transformation enabling a person with a
    mental health problem to live a meaningful life
    in a community of his or her choice while
    striving to achieve his or her full potential.
  • (SAMHSA Consensus Statement, 2006)
  • It is important to convey a sense of hope that
    this is achievable for all Americans with mental
    health needs.
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