Conceptualizing Mental Health Disparities in Communities of Color

1. 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

2. 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

3. 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

4. Conceptualizing Disparities • Prevalence Rehabilitation • Incidence Participation • Services Outcomes • Treatment Access • Prevention Quality • Recovery Use of Medication King Davis, 2003

5. 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

6. 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)

7. 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

8. 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

9. Expanded View of Disparities Economic Dental Health Political/ Legal Mental Health Employment Health Educational Substance King Davis, 2003

10. An Expanded View of Disparities Uninsured Maternal/ Infant Deaths Literacy Nutrition Crime Victims Sickle Cell Low Birth Weight Babies Criminal Justice Sentencing Diabetes Housing & Homelessness Cardiovascular Disease Periodontal Disease Political Office Voting HIV Asset Accumulation Environmental Pollution Alcohol Abuse Cancer Obesity Graduation Rates Low Income Cocaine Use/Sale Mental Retardation Schizophrenia Depression Bipolar Domestic Violence Homicides Personality Disorder Dementia Capital Punishment Unemployment King Davis, 2003

11. 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

12. 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

13. 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

14. 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

15. Primary Strategy: • How to develop & implement? • What are the key strategies? • What are the critical challenges? State Mental Health Plan

16. The Challenge of Reform: Help seeking Health Insurance Voluntary Participation System Reform Disproportionate Poverty General Fund Pressure State Policy Reform Service Redesign: EBP Private Sector Human Resources Federal Government State Government

17. 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)

18. Contextual Hypotheses • Immunity Hypothesis 1763-1865 • Exaggerated Risk Hypothesis -1865-1980 • No-difference Hypothesis 1981-1990s • _____________________ • Immunity Hypothesis Recycled 2001 • Exaggerated Risk Hypothesis Recycled 2001 • No-difference Hypothesis Recycled 2001

19. Historical Hypotheses

20. Historical Hypotheses - Continued

21. 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

22. Need for Behavioral Health Care • African Americans: • Overall rates of mental illness similar to non-Hispanic 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

23. 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.

24. 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

25. Need for Behavioral Health Care • Latinos/Hispanic Americans: • Overall rates of MI similar to non-Hispanic whites • Higher rates of some disorders • Anxiety-related and delinquency behaviors, depression and drug use, more common among Latino youth • Higher rates of depression among elderly Latinos • Culture-bound syndromes: • Susto (fright), nervios (nerves), mal de ojo (evil eye), and ataque de nervios • Access to behavioral health services is limited

26. 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

27. All Health Care is Cultural • Conceptualization • Diagnosis • Treatment • Training • Research • Policy • Help Seeking • Compliance • Participation • Health Beliefs • Expectations • Employment

28. 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).

29. 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)

30. Status of Cultural Knowledge: • The Clinical Application of Cultural Competency is Relative Non English Speaking Native Americans African Americans Mexican Americans Anglo Americans Mexican Immigrants Lowest Income Asian/ Pacific Islanders & Indian/Pakistani Middle Income Men Lowest Highest

31. 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

32. Figure 1.Conceptual Framework D. Formal Helping System Individual Church Organizations C. Individual & Community Factors Degree of Impairment Practitioner: Evidence Base Professional: Evidence Based Family Burden Theory and Model: Recovery Faith Community Stigma Absorption Consumer Self help Delayed Help Seeking Information DECISIONS TO UTILIZE SOME FORM OF HELP COMMUNITIES OF COLOR A. Organizing Concepts Boundary Expansion Self Help Collective Caring PHASE 2 PHASE 3 Religious Based Help PHASE 1 Family Choices/Actions King Davis, Hogg Foundation 2003 B. Number of Psychiatric Episodes

33. Social Marketing Study Culture: Help Seeking Definitions of Health/Illness Information Use Learning Style Leadership Family Systems Media Outlets Languages Spoken Schools Religious Ideas Neighborhoods Consideration and integration of social variables in the design of plans and policies in health care services

34. 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.