Reducing Mental Health Disparities King Davis, Ph.D .

1. Reducing Mental Health Disparities King Davis, Ph.D.

2. What is the relationship between the mental health services system and help seeking behavior patterns of people of color?

3. Prevalence Service Delivery System Help-Seeking Behaviors Incidence What Causes the Problem: Either or Approaches/Answers

4. What is Help – Seeking? • Help-seeking involves a number of pro-active steps that take a person, family, or community from the point of recognizing a problem exists to using [entrusting] an external resource to solve, lessen, or cure the problem.

5. The Help Seeking Paradox • Although there are reportedly minimal differences in rates, there are marked differences in help seeking by race, ethnicity, language, gender, residence, and other identifiable characteristics.

6. Cultural Pathways to Help Use of Pastoral Care Use of Native Healers Use of Emergency Rooms Family Support Episodic Use of Primary Care >Advocacy Participation Lengthy Delay Post Onset Elastic Boundaries Fear Embarrassment Language Trust Insurance MH Literacy Negative Experience Confidentiality Stigma Snowden (2004); Neighbors (2007)

7. 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 Female & Male Asian/ Pacific Islanders & Indian/Pakistani Middle Income Women Men Lowest Highest

8. Working Definition of Disparity • Measurable, not assumed, differences between two or more objects, groups, people, or an absence of parity or equality between them. Unlike health disparities, mental health disparities are mainly in service patterns rather than rates of morbidity. King Davis, 2009

9. Mental Health Disparity Principally, a measurable difference in services [clinical choices and decisions], risk, help seeking, outcome, prevalence/incidence, and/or mortality by race, culture, ethnicity, language, gender, or any other identifiable characteristic.

10. Help-Seeking Behaviors Elements in Disparities Academic Training & Education Programs Service System Public Policies

11. Disparity “…should be viewed as a train of events leading to a difference in: • Access to, utilization of, or quality of care • Health status, or • Health outcome ….that deserves scrutiny.” Pearcy & Keppel 2009

12. Train of Events Provider System Workforce Diversity Fragmentation Ethics/IRB Issues Commitment Resources/Costs Availability/Access Location/Hours Service Design EBPs/PBEs Courts/Police Knowledge Base Conceptualization Problem Formulation Theory/Hypotheses Research Methods Sampling Bias Community Involvement Public Policy Impact University Education Media Portrayals/Stigma Cultural Competence Comparative Outcomes Family/Community Help Seeking Stigma Religious Based Family Burden(?) Vol. Participation Myth & Fear Cultural Beliefs Discrimination MH Literacy History/Memory Davis 2009; IOM 2005; HHS 2001

13. FRAGMENTATION • The U.S. health, mental health and substance abuse treatment systems have developed independent of each other and of primary care. They typically are operated separately, without regard for the reality that physical and behavioral health are linked if not the same. • Training programs reflect the same fragmentation.

14. Historical Research Hypotheses byAuthor and Chronological Period King Davis, 2007

15. Examples of Disparities • Admissions Involuntary Commitments • Length of Stay Access to Service • Recidivism Rates Diagnosis of SMI • Use of Police Quality of Care • Homelessness Use of Medication - EBPs • Mortality Rates Accuracy of Diagnosis King Davis, 2009

16. Mental Health, Health, Mortality and Race • Individuals with a diagnosis of severe mental illness die an average of 25-32 years earlier than individuals without mental illness. • What are the implications for people of color with severe mental illness? • What solutions can be offered to prevent or reduce the rate of deaths?

17. Mortality Associated with Mental Disorders: Mean Years of Potential Life Lost Compared with the general population, persons with major mental illness lose 25-30 years of normal life span Lutterman, T; Ganju, V; Schacht, L; Monihan, K; et.al. Sixteen State Study on Mental Health Performance Measures. DHHS Publication No. (SMA) 03-3835. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 2003. Colton CW, Manderscheid RW. Prev Chronic Dis. Available at: ttp://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm.

18. Access and Quality of Care • SMI may be a health risk factor because of: • Patient factors, e.g.: amotivation, fearfulness, homelessness, victimization/trauma, resources, advocacy, unemployment, incarceration, social instability, IV drug use, etc • Provider factors: Comfort level and attitude of healthcare providers, coordination between mental health and general health care, stigma, • System factors: Funding, fragmentation Joe Parks, MD 2009

19. Table 19. Death rates for diseases of heart, by race and Hispanic origin 1990 and 2004

20. Table 2. Changes in Ranking of mortality by race, Hispanic origin, and year

21. Neighbors, Baser & Martin (2007). unpublished data from the National Survey of American Life Black-White Comparison of Cumulative Proportions of Cases making Treatment Contact by Selected Years After Disorder Onset

22. 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 Sub-Prime Loans 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

23. Why be Concerned: Multiple Costs • Excess Preventable Deaths • Untreated Illness & Lower Achievement • Excess Hospital Admissions & Readmissions • Misdiagnosis & Poor Application of EBPs • Community Suspicion and Mistrust • Staff Division and Conflict • Absence of Scientific Knowledge & Theory • Ethical Conflict: Professional & Personal • Increased Direct and Indirect Costs: Tremendous Waste • Loss of Input from Special Markets: Volunteers/Policy • Clinical Dropouts • Cultural Malpractice • Public Customers are Disproportionately Persons of Color! King Davis, 2008

24. Path Dependence Analysis Police/Sheriff Family Support >Funding Fragmentation Delayed Help FL. Statutes Emergency Use Courts Usage Rate >Illness Trauma Beliefs Info Stigma Increased Admissions Fear

25. Research Foci: Train of Events Provider System Workforce Diversity Fragmentation Ethics/IRB Issues Commitment Resources/Costs Availability/Access Location/Hours Service Design EBPs/PBEs Courts/Police Knowledge Base Conceptualization Problem Formulation Theory/Hypotheses Research Methods Sampling Bias Community Involvement Public Policy Impact University Education Media Portrayals/Stigma Cultural Competence Comparative Outcomes Family/Community Help Seeking Stigma Religious Based Family Burden(?) Vol. Participation Myth & Fear Cultural Beliefs Discrimination MH Literacy History/Memory Davis 2009; IOM 2005; HHS 2001