Mental Health Disparities Summit

1. Mental Health Disparities Summit William A. Vega Professor, School of Medicine-UCLA Sacramento Convention Center May 21-22, 2009

2. Percent Distribution of Hispanicsby Type: 2002 Source: Current Population Survey, March 2002, PGP-5

3. Age Distribution by Sex and Hispanic Origin: 2002 Non-Hispanic White Hispanic Male Female Male Female Note: Each bar represents the percent of the Hispanic (non-Hispanic White) population who were within the specified age group and of the specified sex. Source: Current Population Survey, March 2002, PGP-5

4. Percent of Full-Time, Year-Round Workers With Earnings of Less Than $35,000 in 2001 by Type of Hispanic Origin: 2002 (Population 15 years and over with earnings) Percent Source: Current Population Survey, March 2002, PGP-5

5. Challenges Ahead • Gaining access in a cost-control environment • Confronting a fragmented health care system • Poor coordination of payers to providers • Low visibility of mental health providers • Low availability of linguistically competent staff or translators • Low availability of trained specialists • Current levels of practicing mental health professionals: 29 Hispanics per 100,000 vs. 173 European Americans per 100,000

6. Science to Practice • Era of clinical guidelines and evidence based practices to improve quality of care • Existing therapies are effective with Latinos • Latinos are unlikely to get care and when they receive it, the treatment is not likely to meet the criteria for guideline based care • Latinos prefer talk therapies but very unlikely to receive them

7. Recommendations of recent expert reviews • Improve and disseminate knowledge about culturally competent care • Rapid information transfer to practitioners • Identify and address documented disparities in quality of care • Increase accountability through monitoring outcomes of care

8. Uniqueness of mental health • Emphasis on communication accuracy and fidelity of meaning between patient and therapist • Disorders have multiple idioms, signals are often confusing • DSM-IV offers little guidance about how to use culture in assessment • Stigma may be strong for individual and family

9. Perspectives of Latino Clients –The Centrality of Language • Latinos felt that it was important that the clinician could communicate in Spanish. Even those who spoke English, felt there were times when switching to Spanish would get the point across more effectively. • “The language is the most important thing. Nothing replaces the language.” • “The doctor told my interpreter that I need to learn English.” • “I was in a treatment where I was not able to communicate well and that affected the treatment.”

10. Perspectives of Latino Clients –Understanding Cultural Idioms • Not only do clinicians need to understand the language in a general sense, they need to understand the specific meanings of cultural idioms that people use to describe their emotional problems • “I told my doctor that my nerves were bothering me a lot and he didn’t understand.”

11. Perspectives of Latino Clients –Being Able to Share Emotions • Latinos felt like they and clinicians needed to be able to share their emotions with each other; they needed a personal connection. • “Therapists can cope if you are mentally imbalanced, but can’t cope if you pour your heart out. The best way to deal with emotion is with emotion.”

12. Perspectives of Latino Clients –Collectivism is Not Dependence • Extended family is central in Latino culture. There is a tendency for intensive involvement with family to be viewed as dependence and to judge it negatively. • “Therapists need to understand the value systems of the culture because what may seem to be an unhealthy dependence, you know, may be just a natural value like, you know, a culture that prizes collectivism. We belong all to the bigger group as opposed to just being very independent.”

13. Cross-Cutting Concerns –The Stigma of Mental Illness • All of the clients emphasized the challenge of dealing with the stigma of mental illness from family and the broader community • “We need to educate our families more and churches about mental illness and what it means – a lot of stigma’s out there about exactly what it means when they say you’re crazy. … I think mental health professionals need to get out there into the community more… and talk to people directly… It’s not just television and the media. …

14. Cross-Cutting Concerns –Clients are Raising the Cultural Issues • During assessment, clients reported that it was often their role to educate the clinicians about the larger issues in their lives and to make the connections between cultural issues and their mental health problems.

15. Therapists Need to Understand Their Own Values • “The actual therapist should understand his or her own values. I mean, what you walk in the room with. Because if you understand that as a factor, then, you know, it kind of puts things in perspective when dealing with other people. You don’t assume, you know? You just see yourself as one of many. And you kind of have better control of your own assumptions and stereotypes and gut reactions that you would have.”

16. Support System Barriers (Multiple responses possible) I wouldn’t have childcare My friends might find out My spouse/partner might disapprove My family would be upset (N = 90)

17. Focus group feedback • Clinicians are skeptical of the term cultural competence because it implies judgments • Training on working with multicultural clients needs to be infused through all aspects of the program • Administrative support at all levels is critical if cultural competence programs are to be successfully implemented • Issues of language and interpretation are critical in working with Latino clients (and others whose first language is not English)

18. What Have We Learned Already from Focus Groups with Clinicians and Clients (cont......) Religious beliefs and experiences get misinterpreted as mental health problems (signs of psychoticism) • Family involvement is critical in mental health treatment, especially in working with multicultural clients. • Stigma of mental illness is strong in minority communities and family psychoeducation is needed to reduce stigma and enable families to support ill relatives.

19. Quality of mental health treatment in primary care • Screening and diagnosis problematic • Somatization tendencies • Representations of illness (terminology) • Comorbidity problems, physical illnesses, alcohol and drug problems co–occurring with psychiatric symptoms may create diagnostic uncertainty

20. Children’s Mental Health problems • High rates of demoralization and suicidal ideation among Latino youth • High rates of disability and academic failure • High rates of substance use problems among U.S born Latinos and immigrant children who arrived early in life • Low access to preventive care and screening results in late detection

21. Access To and Context Of Care · Work to increase mental health literacy for Latinos: methods, applicability, and evaluation of results and its impact on existing mental health services capacity. ·   Study cultural interpretations of services available, how these are actually used, characteristics of usage by cultural groups. ·   Study help seeking pathways: How these differ by cultural groups, or other conditions such as residency status, SES, etc.

22. Access To and Context Of Care Issues ·  Investigate what types of policy/systemic barriers impede access/retention in care, etc. and which have the most negative impact on quality mental health care, including evaluation of relevant outcomes. ·  Conduct studies of severely mental ill Latinos who are sexual minorities with a focus on stigma, discrimination, lack of access, lack of trained professionals, high risk for HIV/AIDS. ·  Conduct studies to improve the mental health literacy of health care providers that includes promotoras, clergy, and others.

23. Behavioral-Psychoeducation Intervention · Study how to reduce medical errors and misdiagnoses attributed to language and cultural differences between patients and practitioners. ·   Explore the importance of culture, spirituality, family and language in behavioral psychoeducation interventions. ·   Examine efficacies of long-term treatments and consideration of step-care models for PMD.

24. Illness Course and Family Environment ·   Study the course and outcome of PMD in relation to cultural features such as family response to patient medications. ·   Investigate approaches to determine if we can learn from immigrant experience on serious mental illness among Latinos ·   Study what constitutes the positive protective factors of the Latino family and their culture of origin, and how role strain of caregivers depletes emotional resources.

25. Culturally Appropriate Mental Health Care/Services ·  Develop, test and evaluate promising interventions that expand cultural competence models into programs of care for specific disorders in Hispanic patients. ·   Develop, test and evaluate training models in cultural competency for integration into services. ·   Test models of dissemination of empirically supported, culturally appropriate interventions and training models.

26. Treatment Interventions and Adherence ·  Examine medication compliance /adherence in relation to empirical understanding of subjective experience and meaning of medication from Latino patients from family cultural points of view. ·  Study the relationship between the medication (dosage and toxicity), and perceived effects (both deleterious and beneficial). Modify this to relate to Latino culture, family. ·  Develop and test interventions that boost recruitment, retention and adherence in treatment. ·   Develop coordinated (culturally competent) approaches that involve different locations of care and stepped care algorithms for treatment modalities to enhance adherence and retention for Latinos.

27. Treatment Innovation ·   Study the use of telepsychiatry (telemedicine/e-mental health, etc) as a means of increasing access to Latinos that is culturally appropriate and effective. ·   Investigate the use of paraprofessionals and peer educators, promotoras to increase access and retention ·   Develop new innovative treatments for youth that consider cultural factors such as family, spirituality, etc. (draw from evidenced-based literature).

28. Rural Services and Access To Care ·   Develop and test telephone-based psychotherapy and telephone-based medication follow-up visits. ·   Develop and test consultation-liaison models with rural health professionals. This may allow initial consultation in an urban setting by a mental health specialist with follow-up by a general practitioner (e.g., nurse practitioner, social worker) in the rural setting.

29. Prevention ·   Conduct research on the identification of prodromal psychosis and early detection of serious disorders in high risk children ·   Develop suicide risk detection and interventions for Latino youth.

30. Take home message • We will make significant headway in improving quality over the next ten years but access problems will worsen with changes in health care system • The key to change is increased awareness of the need for change, production of new knowledge and efficient transfer • Cultural competence will become part of the cultural of health care – tipping point • Key to improving quality for Spanish speakers will be training of Spanish speaking professionals

31. Recommendations for moving forward • We need much more focused research on ethnic issues • Need to go beyond rhetoric – need policy commitment • Ethnicity needs to be defined more precisely • Ethnic issues need to be depoliticized – “quality of care” • Provide “crisp” examples, practical guidelines, “vignettes” and model scripts for clinician training

32. Recommendations for moving forward (cont.) • Do not continue to blend Latino populations into a single group for example– recognize inter group and internal subgroup differences • Recommendations should be research-based and testable • Use of brief, illustrative appendices in DSM-V, and train clinicians using case consultation • Provide feedback, rewards, accountability mechanisms in systems of care