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

1. National African American Drug Policy CoalitionHealth 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 President’s 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 population’s 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 President’s 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 President’s 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 client’s 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 President’s 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 life’s challenges, on facilitating recovery, and on building resilience. The system must be seamless and convenient.

24. The President’s 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 President’s 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.