NAMI CA 2014 Annual Conference “Growing Minds in Changing Times”

1. NAMI CA 2014 Annual Conference “Growing Minds in Changing Times” If You Build It, Will They Come? Addressing and Reducing Mental Health Treatment Gaps in Underserved Populations Sergio Aguilar-Gaxiola, MD, PhD Professor of Clinical Internal Medicine Director, Center for Reducing Health Disparities University of California, Davis Newport Beach, CA August 2, 2014

2. Disclosure I have no relevant financial interest/arrangement or affiliation with any organizations related to commercial products or services to be discussed at this presentation

3. Mental and/or substance abuse disorders are major drivers of suffering, disability, cost and are associated with poverty

5. The “Treatment Gap” Between 50 to 90% of people with serious mental disorders have not had received appropriate mental health care in the previous year

6. Treatment Gap in the U.S. • Levels of unmet need (not receiving specialist or generalist care in past 12 months, with identified diagnosis in the same period) • Hispanics – 70% • African Americans – 72% • Asian Americans – 78% • Non-Hispanic Whites – 61% Source: Alegria et al., 2006

7. Mexican American Prevalence and Services Survey (MAPSS) Who Utilized Services? • 38% of U.S. born received care • 15% of immigrants received care • 9% of migrant agricultural workers received care Source: Aguilar-Gaxiola, Vega, et al., 2000

8. Treatment Gap: Is it Only in the U.S. Serious cases NOT receiving treatment during the past12 months 90 85% 80 76% 70 60 61% 50 40 35% 30 20 10 0 Lower range Upper range Lower range Upper range Developed countries Developing countries Source: Saxena, 2011; Alegria, 2006; WHO World Mental Health Consortium, JAMA, June 2nd, 2004

9. Multiple barriers Individual level (e.g., stigma) Community level (e.g., Lack of culturally and linguistically appropriate services) Systemic level (e.g., Lack of social and economic resources and poor living conditions) Lack of Engagement in Behavioral Healthcare Why the Treatment Gap?

10. High caseloads, “burn out” Prescribers Lack of adequate training and graduate preparation programs Limited training in providing family-centered or recovery-oriented care Lack of positions in the public mental health system for consumers and family members Limited opportunities for advancement Workforce Challenges in Mental Health Source: Alonzo-Diaz. 2014

11. Latinos’ Lack of Engagement in Behavioral Healthcare • Latinos are more likely than non-Hispanic Whites to terminate treatment prematurely, with as many as 60-75% dropping out after just one session(McCabe, 2002) • Mode number of visits is 1 and median is 3 to both psychiatrists and psychologists (Alegria, 2007) • Action Needed: Consumer Engagement

12. Untreated Mental Illness Intensify over time…can reduce life expectancy Causes intense and prolonged suffering to individuals and their families Limits individuals’ ability to reach social and educational normative goals Leads to expensive costs to individuals, families, and communities

13. Key Issues In Mental Health Care • The 5 A’s: • Accessibility • Affordability • Availability • Appropriateness • Advocacy

14. How can we transform services and supports to prevent high risk behaviors and improve outcomes especially in underserved populations?

15. Going Beyond Services and Supports • Integration of Primary and Behavioral Health Care • Adaptations and Practice-based Evidence • Community-based Partnerships • Community Outreach and Engagement • Prevention and Early Intervention and Health Promotion are Key Source: Huang, 2007

16. “No mass disorder afflicting humankind has been eliminated or brought under control by attempts at treating the affected individual, nor by training large numbers of individual practitioners” George AlbeePast President, American Psychological Association

17. The Role of Prevention in Reducing the Treatment Gap Health care is not the primary determinant of health • Improving health access is only part of the solution to improving health outcomes and reducing health disparities; • There are three reasons why improving access to health care alone will not close the treatment gap: • Clinical care treats one person at a time; • Intervention often comes late; • Clinical care is usually sought after people are sick (“fail first”). Source: Mikkelsen, Cohen, Bhattacharyya, Valenzuela, Davis, & Gantz, 2002

18. The Role of Prevention in Closing the Treatment Gap • Prevention and Early Intervention can make a vital contribution to current efforts to reduce disparities in health. • By addressing the underlying factors that negatively influence health and mental health, prevention has the power to reduce the incidence of poor mental health and disability and premature death. Source: Mikkelsen, Cohen, Bhattacharyya, Valenzuela, Davis, & Gantz, 2002

19. Report of the Committee on the Prevention of Mental Disorders and Substance Abuse IOM Public Briefing March 25, 2009 Washington DC

20. Mental, Emotional and Substance Abuse Disorders Are Common and Costly • Around 1 in 5 young people (14-20%) have a current disorder • Estimated $247 billion in annual costs • Costs to multiple sectors – education, justice, health care, social welfare • Costs to the individual and family

21. Preventive Opportunities Early in Life • Early onset (75% of adult disorders had onset by age 24; 50% by age 14) • First symptoms occur 2-4 years prior to onset of a diagnosable disorder • Common risk factors for multiple problems and disorders

22. Prevention Window

23. Core Concepts of Prevention • Prevention requires a change in thinking • Mental health and physical health are inseparable • Successful prevention is inherently interdisciplinary • Mental, emotional, and behavioral (MEB) disorders are developmental • Developmental perspective is key

24. Preventive Intervention Opportunities Parent hood

25. Two Approaches to Targeting Interventions • Target specific disorders -- depression, substance abuse, schizophrenia • Target risk and protective factors for multiple disorders -- poverty, maltreatment, family disruption, community and school risk factors

26. Impressive Evidence of Efficacy • Interventions show effects on wide range of serious problems such as substance abuse, depression, antisocial behavior, child abuse • Interventions improve positive outcomes such as school success, self-esteem • Multi-year effects of some interventions

27. Evidence from Studies that Target Specific Disorders • Indications that incidence of adolescent depression can be reduced • Emerging evidence to prevent onset of full-blown schizophrenic episodes

28. Long-term Impact of Prevention Teacher training in classroom instruction and management, child social and emotional skill development and parent workshops were the intervention. A significant multi-varied effect across all 16 primary outcome indices were found. Specific effects included significantly better educational and economic attainment, mental health and sexual health by age 27 years. So prevention is possible. Hawkins JD, Kosterman R, Catalano RF, Hill KG, and Abbott RD. Effects of Social Development Intervention in Childhood 15 Years Later. Arch Pediatr Adolesc Med. 162(12), pp 1133-1141, 2008.

29. Community-Defined Solutions for Reducing Mental Health Disparities California Reducing Disparities Project

30. California Reducing Disparities Project • Main goal is to develop a Statewide Comprehensive Strategic Plan. • Identify community-defined promising practices, models, resources/approaches helpful for county program planners, practitioners, and policy makers in designing programs to better address the needs of these communities. • Contribute culturally relevant recommendations from each ethnic/cultural group to develop a comprehensive statewide strategic plan towards the reduction of mental health disparities Source: Guerrero, 2009

31. CA Reducing Disparities Project: Latino SPW • The Latino Statewide Reducing Disparities Project started July 1, 2010. • The main goal was to produce a community-defined, strength-based, culturally and linguistically appropriate report on reducing disparities in mental health services for Latinos. • Identified and engaged a diverse range of Latino stakeholder representatives at the state, regional, and local levels. • Stakeholders included consumers, providers, public agencies, and representatives of community interests, and have diversity in terms of gender, age, and mental health and health issues.

32. CA Reducing Disparities ProjectLatino SPW: Governance and Structure The Concilio

33. Latino Strategic Planning Workgroup – LATINO CONCILIO Website: http://www.latinomentalhealthconcilio.org

34. Forum Sites by City, Region & County Exhibit 5: Forum Sites by City, Region, and County

35. California Reducing Disparities Project Full report (PDF) available at: http://www.latinomentalhealthconcilio.org/mhsa/crdp-latino-population-report/ Spanish version will be soon available

36. Three Major Types of Barriers • Individual-Level Barriers • Stigma • Culture • Gender (masculinity) • Violence and trauma • Knowledge and awareness • Community-Level Barriers • Lack of culturally and linguistically appropriate services • Shortage of bilingual and bicultural mental health workers • Lack of school-based mental health programs • Organizational and systemic barriers • Systemic-Level Barriers • Lack of social and economic resources and poor living conditions • Inadequate transportation • Social exclusion

37. Strategic Directions to Improve Access, Availability, Appropriateness, Affordability, and Advocacy School-based mental health programs; Community-based organizations and co-location of resources; Community and social media; Culturally and linguistically appropriate treatment; Workforce development to sustain culturally and linguistically competent workforce; Community capacity building and community outreach and engagement.

38. Ventura County Strategic Directions: Reducing Disparities* * CRDP Latino Population Report, UC Davis Center for Reducing Health Disparities, 2012

39. Ventura County Demographics

40. Strategic Direction #2: Community-Based Organizations and Co-Locating Resources Faith-Based Collaborations • Guadalupe Church, Project Esperanza • St. Paul’s Baptist Church • Word of Life: Community Coalition for Stronger Families Co-located Integrated Primary Care • Health Care Agency: Fillmore, Oxnard, Santa Paula, Simi Valley, Thousand Oaks, Ventura • Clinicas del Camino Real

41. Mixteco Indigena Community Organizing Project (MICOP) Services: Community Coalition for Stronger Families (CCSF) • Training - Mental health training for Mixteco Health Promotores to reduce stigma and other barriers to seeking services • Outreach & Engagement – Sharing mental health education and raising awareness in Mixteco community • Education – Presentation for partners and community agencies about Mixteco mental health needs, culture, and community • Violence Prevention – Developed culturally appropriate training curriculum with The Partnership for Safe Families & Communities of Ventura County

42. Strategic Direction #6: Community Capacity-Building and Outreach and Engagement • Promotores and Promotoras Training • Mixteco Engagement & Farm-worker Outreach & Treatment Project • City Impact – Community Coalitions for Stronger Families • Kids & Families Together – Foster Youth Kinship Project

45. Is it possible to improve community mental health by focusing primarily in access to care?

46. The “Ecology” of Medical Care Source: Green LA, et al. N Engl J Med 2001;344:2021-5.

47. Determinants of Health “Even if the entire U.S. population had access to excellent medical care — which it does not — only a small fraction of these deaths could be prevented. The single greatest opportunity to improve health and reduce premature deaths lies in personal behavior. In fact, behavioral causes account for nearly 40% of all deaths in the United States” (p. 1222). Source: Schroeder, 2007

48. Source: Miller, 2014

49. The Affordable Care Act (ACA) Source: Figueroa, 2013

50. Conclusions • Mental health care disparities in access to care (for those who need treatment) exist in the U.S. • They are a major public health problem at the national, state, and local levels. • They lead to significant burden of unmet mental health needs. • This translates into ill health, prolonged suffering, premature death, diminished productivity, and social and economic disparities.