Closing the Gap: Eliminating Mental Health Disparities

1. Curley L. Bonds, MD Medical Director Didi Hirsch Mental Services Associate Professor & Chair Charles Drew University Clinical Health Sciences Professor UCLA School of Medicine Closing the Gap: Eliminating Mental Health Disparities

2. Disclosures

3. An Overview • Define healthcare disparities • Discuss the impact of culture on the presentation of neuropsychiatric disorders • Identify barriers to quality treatment for diverse communities • Explore solutions to overcoming healthcare disparities

4. Culture? Race? Or Ethnicity? • Biological • Psychological • Sociological

6. Demographics • Five ethnic/racial groups in the US • Caucasian American • African American • American Indian/Alaska Native (AIAN) • Asian American/Pacific Islander • Hispanic/Latino

7. Socioeconomic Disparities • Education • Income • Insurance Status • Language

8. Income by Race

9. Mental Health Care Disparities • Minorities have less access to mental health care • Racial, ethnic and socioeconomic differences in the use of psychiatric medications and of psychiatric outpatient, ER, and inpatient services have been documented • Difference may reflect variations in preferences and cultural attitudes

10. Unequal Treatment • Disparities are associated with worse outcomes in many cases, are unacceptable • Racial and ethnic disparities occur in the context of broader social and economic inequality • Many sources contribute

11. Unequal Treatment • Bias, stereotyping, prejudice, and clinical uncertainty on the part of health care providers may contribute to racial and ethnic disparities in health care • Minority patient refusal rates do not fully explain health care disparities

12. Statistics and Facts: • According to U.S. Census Bureau projections, African Americans, American Indians, Asian Americans, and Latinos will make up roughly 50 percent of the total U.S. population by 2050. • According to the Commonwealth Fund 2001 Health Care Quality Survey, One of three Hispanics and one of four Asian Americans have problems communicating with their doctors, and

13. Statistics and Facts: • Fifteen percent of African Americans, 13 percent of Hispanics, and 11 percent of Asian Americans said there had been a time when they felt they would have received better care if they had been of a different race or ethnicity. • Access to language interpreters is limited. Among non-English speakers who said they needed an interpreter during a health care visit, fewer than one-half (48 percent) said they always or usually had one

14. Culturally Congruent Care Studies show that patient satisfaction is higher when the patient and doctor are of the same race or ethnicity Minority physicians tend to care for minority patients in greater numbers and to work in medically underserved areas (United States Department of Health and Human Services, 2000).

15. Asian American/PI Issues • Suicide is the 5th leading cause of death • Asian Am women aged 15-24 have the highest suicide rates across all racial/ethnic groups\ • Asian Am women over 65 have the highest rates of all women over 65 • High rates of PTSD among refugees • Have the lowest rates of utilization

16. African American Issues • Have traditionally have lower rates of suicide, but incidence is increasing • Often delay seeking help until symptoms are very serious • More religious than other groups • May use alternative language to describe symptoms “Blues” or “Bad Nerves”

17. American Indian/Alaska Native • Alcoholism death rates are more than seven times the national average. • Thirty-two percent of people live below the poverty rate. • Unemployment is 2.5 times the national average. • Suicide is nearly twice and homicide more than twice the national average.

18. Latin/Hispanic • Rates of mental health problems are higher amongst US born Latinos than immigrants • Latinos are twice as likely to seek mental health care in other settings than in CMHCs (clergy, primary care) • Overrepresented in the criminal justice system and tend to receive longer/harsher sentences

19. Culture-Bound Syndromes

20. Falling-Out/Blacking Out (Southern US, Caribbean) • The individual experiences dizziness and a spinning sensation before a sudden collapse.  Although the eyes may be open, the person reports being unable to see, although they hear and understand what is happening around them without being able to interact.

21. Koro (Malaysia) • The primary symptoms is that the penis (in males) or the vulva and breasts (in women) are receding into the body, possibly causing death.  It is more common in males, who will go to great lengths to stop this from happening.

22. Susto (Latino) • Literally "fright", this generally falls into either natural or supernatural origin.  Natural origins are cultural stressors, and are more likely to affect women than men.  Supernatural origins may be thought to have been sent by a sorcerer, and may be triggered by witnessing supernatural phenomenon such as ghosts.  Symptoms include nervousness, anorexia, insomnia, listlessness, fatigue, despondency, muscle tics and diarrhea.

23. Ghost Sickness (Navajo) • Weakness, bad dreams, feelings of danger, confusion, feelings of futility, loss of appetite, feelings of suffocation, fainting, dizziness, hallucinations and loss of consciousness.  May become preoccupied with death or with someone who died. The cause is usually considered to be ghosts or, less often, witches.  The person may have hallucinations

24. Uninsured • Highest among AIAN and Latino Populations • Citizenship status affects Asian American and Latino populations disproportionately • Affordable Care Act • 1115 Wavier • MHSA funded programs

25. Language • Home language other than English - higher proportion of Asian Americans and Latinos • Higher percentage of foreign born individuals

26. Language • Language barriers may impair the development of trust, respect and understanding

27. Stigma • Impacts likelihood of an individual seeking help

28. NAMI ROCKS!!! • ..

29. Recommendations • Increase minority specific research • Collect Data and Monitor Progress • Diversify the mental health workforce • Train providers on cultural competence • Improve access to care by decreasing barriers to treatment • Promote mental health and combat stigma • Educate, empower and support consumer families

30. Workforce Diversity* • State planning should promote increased opportunities to include individuals from diverse cultural backgrounds in the mental health workforce • Recruitment from racial and ethnic minority groups, and bilingual professionals (loan repayment) *President’s New Freedom Commission on Mental Health 2003

31. Solutions • Stay Strong Foundation (African Americans) • http://www.storiesthatheal.samhsa.gov • The Black Mental Health Alliance • The Mental Health Act in Schools • Grace Napolitano • Social Adjustment Program - SE Asians • NOPCAS • Toolkit and Training on Assessing Cultural Competency

32. References • Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (Institute of Medicine Report 2003) • NAMI Mental Health Fact Sheets • President’s New Freedom Commission on Mental Health 2003 • Mental Health: Culture, Race and Ethnicity, A Supplement to Mental Health: A Report of the Surgeon General 2001