Conceptualizing Mental Health Disparities in Communities of Color May 19, 2005 King Davis, PhD, Executive Director Hogg Foundation for Mental Health Services, Research, Policy & Education Robert Lee Sutherland Chair in Mental Health & Social Policy School of Social Work The University of Texas at Austin Austin, Texas Purpose of the Presentation Conceptualize the term disparities Place disparities in context Link various types of disparities Define key terms Link health and mental health disparities Propose solutions and directions Foci of the Presentation Disparities have an extensive history Disparities are related to a perverse conceptualization of people of color This conceptualization pervaded clinical practice, research, education & policy Disparities are imbedded in differences in income, access to information, and cultural traditions & social structures Conceptualizing Disparities Prevalence Incidence Services Treatment Prevention Recovery King Davis, 2003 Rehabilitation Participation Outcomes Access Quality Use of Medication DISPARITIES IN MENTAL HEALTH CARE FOR RACIAL AND ETHNIC MINORITIES Minorities have less access to, and availability of, mental health services Minorities are less likely to receive needed mental health services Minorities in treatment often receive a poorer quality of mental health care Minorities are underrepresented in mental health research Mental Health: Culture, Race, and Ethnicity, a Supplement to the Surgeon General’s Report on Mental Health Service Disparities Racial, ethnic, and cultural differences in twenty characteristics designed to define and describe the nature of behavioral health service provision. Source: K. Davis (2003) Service Disparities 1760-2000 >Frequency of Inaccurate Diagnosis >Findings of Severe Mental Disorder >Inpatient Hospitalization/LOS >Involuntary Commitments >Recidivism/Relapse >Involvement in Criminal Justice System >Mortality Rates (Primary Health Problems & Suicide) <Recovery >Uninsured/Underinsured <Access to Outpatient/Early Access <Access to Providers of Color <Utilization of Cultural Competency in Service Design <Participation in Behavioral Health Volunteer Organizations <Access to Information about Behavioral Disorder/Services <Family Support Service Disparities >Delays in help seeking <Housing alternatives <Access to trained interpreters <Inclusion in research/clinical trials >Executions while mentally disabled <Integrated behavioral health services Expanded View of Disparities Economic Dental Health Political/ Legal Mental Health Employment Health King Davis, 2003 Substance Educational Uninsured Housing & Homelessness Voting Sentencing Political Office Asset Accumulation Graduation Low Income Rates Homicides Environmental Pollution Sickle Diabetes Cell Low Birth Weight Babies HIV Cardiovascular Disease Alcohol Abuse Cancer Domestic Violence Depression Schizophrenia Personality Disorder Dementia Crime Victims Periodontal Disease Obesity Cocaine Use/Sale Unemployment King Davis, 2003 Nutrition Literacy Criminal Justice Maternal/ Infant Deaths Mental Retardation Bipolar Capital Punishment Removal of Disparities Recent efforts at the federal (Clinton 1994) presidential level are designed to eliminate disparities in health and mental health by 2010; President Bush (2003) has included this goal in the recent report on mental health Bush identifies cultural competence as the vehicle for eliminating disparities in mental health Six Critical Goals Americans understand that mental health is essential to overall health Mental health is consumer and family driven Disparities in mental health are eliminated Early intervention is common Excellent care is delivered and research is accelerated Technology is used to access mental health care and information Source: New Freedom Commission Disparities in Mental Health Services are Eliminated In a transformed mental health system, all Americans will share equally in the best available services and outcomes, regardless of race, gender, ethnicity, or geographic location. Source: New Freedom Commission Recommendations: Improve access to quality care that is culturally competent Improve access to quality care in rural and geographically remote areas Source: New Freedom Commission Primary Strategy: How to develop & implement? What are the key strategies? What are the critical challenges? State Mental Health Plan The Challenge of Reform: Help seeking Health Insurance Voluntary Participation System Reform Private Sector Human Resources State Government Disproportionate Poverty General Fund Pressure State Policy Reform Service Redesign: EBP Federal Government The Immunity Hypothesis “Slaves are immune from stress and from the subsequent risk of mental illness because they do not own property.” John Galt, M.D.(1840) Contextual Hypotheses Immunity Hypothesis 1763-1865 Exaggerated Risk Hypothesis -18651980 No-difference Hypothesis 1981-1990s _____________________ Immunity Hypothesis Recycled 2001 Exaggerated Risk Hypothesis Recycled 2001 No-difference Hypothesis Recycled 2001 Historical Hypotheses Historical Hypotheses - Continued Multiple Costs Excess Preventable Deaths Untreated Illness & Lower Lifetime Achievement Excess Hospital Admissions & Readmissions Misdiagnosis & Inappropriate Care (LLOS) Community Suspicion and Mistrust Staff Division and Conflict Absence of Scientific Knowledge & Theory Ethical Conflict: Professional & Personal Increased Taxes & Agency Budgets: Waste Need for Behavioral Health Care African Americans: Overall rates of mental illness similar to nonHispanic whites Differences in prevalence of specific illnesses Suicide rates lower but on the rise Environmental, economic and social factors Exposure to violence, homelessness, incarceration, social welfare involvement Less access to behavioral health services Prospective Frequency Of Illness Source: Davis, King., Johnson, Toni, & McClendon,A. (2002). Guidebook. Baltimore: Casey Foundation Mental Health: A Report of the Surgeon General, DHHS, 1999. Need for Behavioral Health Care American Indians and Alaska Natives Limited data on prevalence of MI One small study with 20 year follow-up found 70% lifetime prevalence of MI Increase rise of depression among older adults Suicide rate 1.5xs national average with young males accounting for 2/3 of suicides 2nd decade of life has highest mortality rate Alcohol dependence, alcohol related deaths Little information on service utilization patterns Need for Behavioral Health Care Latinos/Hispanic Americans: Overall rates of MI similar to non-Hispanic whites Higher rates of some disorders Higher rates of depression among elderly Latinos Culture-bound syndromes: Anxiety-related and delinquency behaviors, depression and drug use, more common among Latino youth Susto (fright), nervios (nerves), mal de ojo (evil eye), and ataque de nervios Access to behavioral health services is limited Need for Behavioral Health Care Asian Americans/Pacific Islanders Limited data on prevalence of MI Existing data suggests overall rates similar to whites Higher rates of depression, PTSD Somatic complaints of depression Culture-bound syndromes Lower suicide rates - except elderly women who have the highest suicide rates in U.S. Refugees with PTSD Language barrier limits access to services All Health Care is Cultural Conceptualization Diagnosis Treatment Training Research Policy Help Seeking Compliance Participation Health Beliefs Expectations Employment Defining Cultural Competence Market-Based Definition Cultural competence is the integration and transformation of knowledge, information, and data about individuals and groups of people into specific clinical standards, skills, service approaches, techniques, and marketing programs that match the individual’s culture and increase the quality and appropriateness of health care and outcomes (Davis, 1997). Defining Cultural Competence Cultural competence is the conclusion reached and shared by members of a nation, community, group, organization, business, or a board that constitutes how the individual wants to be treated with respect by others based on their culture (T.Davis, 2002) Status of Cultural Knowledge: The Clinical Application of Cultural Competency is Relative Non English Speaking Native Americans Lowest Income Asian/ Mexican Pacific Immigrants Islanders & Indian/Pakistani Lowest African Americans Mexican Americans Middle Income Anglo Americans Men Highest Elements of Cultural Competence Attitudes of respect Agency Evaluation Beliefs Agency Plan Knowledge and Skills Inclusion in Vision Language and Communication Community Analysis Inclusion in Services Valuing Diversity Outcomes Cultural Self-Assessment Staffing Figure 1. Conceptual Framework Individual C. Individual & Community Factors Professional: Evidence Based Delayed Help Seeking Self Help Church Organizations Degree of Impairment Practitioner: Evidence Base Family Burden Theory and Model: Recovery Community Stigma Consumer Self help DECISIONS TO UTILIZE SOME FORM OF HELP COMMUNITIES OF COLOR PHASE 2 PHASE 3 Religious Based Help PHASE 1 Family Choices/Actions King Davis, Hogg Foundation 2003 D. Formal Helping System B. Number of Psychiatric Episodes Social Marketing Consideration and integration of social variables in the design of plans and policies in health care services Study Culture: Help Seeking Definitions of Health/Illness Information Use Learning Style Leadership Family Systems Media Outlets Languages Spoken Schools Religious Ideas Neighborhoods General Conclusions Too much new information (format) to access/digest or use Transformation cannot occur fully without addressing the complex issue of disparities: knowledge, evidence, research, participation, help seeking Transformation comes at a time of significant reductions in state budgets for human services; Evidence based approaches must be expanded to include the 4 populations of color; Cultural competence offers promise but requires national field testing, cost estimation, educational trials, linkages to licensure, accreditation, and further development; Cultural competence must demonstrate outcome and cost efficacy; Poverty and related socio-economic issues will affect the application of evidence based approaches; New epidemiological studies are needed on the four populations of color to increase knowledge of help seeking and utilization.