Disparities in Mental Health Care of Diverse Populations: The Process of Elimination

1. Disparities in Mental Health Care of Diverse Populations: The Process of Elimination University of Texas Health Sciences Center Committee of Advancement of Women and Minorities Distinguished Speakers Series San Antonio, Texas March 27, 2009 Annelle B. Primm, MD, MPH Director, Minority and National Affairs American Psychiatric Association

2. Public Health Model • Population perspective – tip of the iceberg, the evidence of [people] not seen • Case finding • Risk factors and protective factors • Prevention: • Primary (prophylaxis) • Secondary (early intervention) • Tertiary (chronic care, maintenance)

3. Determinants of Mental Health • Individual Biology • Individual Behavior • Social Environment • Physical Environment • Access to Quality Care • Policies & Interventions

4. Major Racial Ethnic Groups in U.S. • Latinos/Hispanics - 15% • African Americans - 13% • Asian American/Pacific Islanders - 5% • American Indians/Alaska Natives - 1% U.S. Census 2007

6. Surgeon General’s Report on Mental Health: Race, Culture, and Ethnicity • Striking disparities in mental health care for people of color • Less likely to receive services • Poorer quality of care • Underrepresented in mental health research • Disparities impose great disability burden on people of color • Culture counts

7. Influence of Culture on Mental Illness and Mental Health • How patients communicate • How patients manifest symptoms • How patients cope • Range of family and community support • Willingness to seek treatment U.S. Dept. of Health and Human Services Office of the Surgeon General, SAMHSA August 2001

8. Factors in Mental Health, Mental Illness and Service Use • Racism • Discrimination • Economic impoverishment • Mistrust • Fear • Cultural and social influences • Biological, psychological and environmental factors U.S. Dept. of Health and Human Services Office of the Surgeon General, SAMHSA August 2001

9. High Need Populations • Overrepresentation of ethnically diverse populations • Homeless • Chronic Disease and Disability • Correctional facilities • Victims of violence • Child welfare • Immigrants and refugees U.S. DHHS, Office of the Surgeon General, SAMHSA August 2001

10. What Are Racial and Ethnic Health Disparities? • Differences and inequalities among racial, ethnic, linguistic, and cultural groups in • Risk and predisposition • Disease prevalence, health status,and diagnosis • Health care quality not due to access-related factors or clinical needs, preferences, and appropriateness of intervention • Health outcomes and mortality

11. IOM Report: Unequal Treatment • Racial and ethnic disparities exist regardless of SES • Higher morbidity and mortality from the leading causes of death • Poorer quality of care • Worse outcomes • Racial and ethnic minorities tend to receive a lower quality of healthcare than non-minorities, even when access-related factors, such as patients’ insurance status and income, are controlled. Smedley et al 2003; IOM 2002

12. Outcomes: Higher Mortality • African-Americans • Heart disease and stroke, cancer (breast, lung, and prostate), diabetes, infant mortality, HIV/AIDS • American Indians and Alaska Natives • Diabetes, infant mortality • Asian Americans and Pacific Islanders • Tuberculosis, stroke, cervical cancer • Hispanics • Diabetes, uncontrolled hypertension, HIV/AIDS

13. Disparities in Seeking Mental Health Care African Americans: more likely to use emergency services or primary care providers than mental health specialists. (Surgeon General, 2001) Asian Americans: Only 4% would seek help from mental health specialist vs. 26 percent of whites. (Zhang et al., 1998) Latinos: < 1 in 11 with mental disorders contact mental health specialists, & < 1 in 5 contact primary care providers. (Surgeon General, 2001) Native Americans: 44% with a mental health problem sought any kind of help--and only 28% of those contacted a mental health agency. (King, 1999)

14. Unmet Need • Levels of unmet need (not receiving specialist or generalist care in past 12 months, with identified diagnosis in same period) • African Americans – 72% • Asian Americans – 78% • Hispanics – 70% • Non-Hispanic Whites – 61% Alegria et al 2006

15. Mental Health Disparities • Underuse of community outpatient care • Use of alternative sources of help (faith, family, folk) primary care and alternative medicine • Later entry into treatment, especially at the crisis or emergency stage • High drop-out rate and fewer treatment sessions • High rates of inpatient care, especially involuntary Cultural Competence Standards, 1997

16. Mental Health Disparities • Less access to bi-lingual services • More likely to be misdiagnosed • Less evidence based care • More inpatient hospitalizations • Less follow up after psychiatric hospitalization

17. Mental Health Disparities • Underdiagnosis and undertreatment of anxiety and mood disorders • Differential prescribing patterns • Lower metabolism of certain psychotropic medications • More side effects and less adherence • More seclusion and restraint

18. Ethnocultural Influences onMental Health Care Outcomes Direct: • Cultural beliefs and preferences • Pathoplasticity • Ethnopsychopharmacology

19. Ethnocultural Influences onMental Health Care Outcomes Indirect: • Bias and stereotyping • Misinterpretation of behavior and belief • Lack of symptom recognition • Misdiagnosis and inappropriate treatment • Ignorance of ethnocultural issues

20. Vicious Cycle Violence and Incarceration Poverty, Homelessness, Unemployment Substance Abuse Unmet Mental Health Needs Poor Physical Health STIs, DM, CAD, CA, etc

21. Personal/Family Acceptability Cultural beliefs Language/literacy Attitudes, beliefs Preferences Involvement in care Health behavior Education/income Structural Availability Appointments How organized Transportation Financial Insurance coverage Reimbursement levels Public support Visits Primary care Specialty Emergency Procedures Preventive Diagnostic Therapeutic Barriers and Mediators to Equitable Mental Health Care for Diverse Racial and Ethnic Groups Barriers Mediators Outcomes Use of Services Quality of providers • Cultural competence • Communication skills • Medical knowledge • Technical skills • Bias/stereotyping • Appropriateness of care • Efficacy of treatment • Patient adherence Health Status • Mortality • Morbidity • Well-being • Functioning Equity of Services Patient Views of Care • Experiences • Satisfaction • Effective partnership Modified from Institute of Medicine. Access to Health Care in America: A Model for Monitoring Access. Washington, DC: National Academy Press; 1993. Cooper LA, Hill MN, Powe NR. J Gen Internal Med. 2002;477-486.

22. Barriers: Attitudes and Language • Immigrant populations (Asian Americans and Hispanics) with limited English proficiency report communication a major obstacle in addressing MH concerns • Cultural perception of mental illness affects: • likelihood of seeking care • support • feelings of shame, stigma, weakness • help seeking at crisis stage rather than earlier Alegria et al 2006; Minski S 2003; Cooper et al 2001; Yeh & Inose 2002

23. Barriers: Language • 18 % of the U.S. population (nearly 47 million people) speak a language other than English at home • 28% of all Spanish speakers, 22.5% of Asian and Pacific Islander speakers and 13% of Indo-European language speakers speak English either not well or not at all • Limited English Proficiency (LEP) affects a person’s ability to access and receive health and mental health care National Health Law Program NHeLP, 2006

24. Barriers: Attitudes and Beliefs • African Americans and Hispanics had lower odds than non-Hispanic whites of finding antidepressant medications acceptable • African Americans had lower odds and Hispanics had higher odds than non-Hispanic whites of finding counseling acceptable. Cooper et al 2003

25. Barriers: Health Behavior • Physicians were less patient-centered with African American than non-Hispanic white patients • Less patient input is associated with less information recall, treatment adherence, satisfaction with care, return visits, and suboptimal health outcomes Roter et al 1997

26. Availability of Mental Health Services by Race, Ethnicity • African Americans account for 2% psychologists, 4% social workers in U.S. • In 2005, 16.7% of psychiatrists were from the 4 major racial/ethnic groups: (Black 2.6%; Asian 9.6%, Hispanic 4.4%, Native American 0.07%) • Percentage of Spanish-speaking healthcare professionals unknown • In 1996, only 29 psychiatrists identified as AIAN heritage U.S. Dept. of Health and Human Services Office of the Surgeon General, SAMHSA August 2001

27. Mediators: Cultural Competence • Limited racial/ethnic diversity of MH providers • Greater cultural difference may result in higher likelihood of misdiagnosis • Cultural incompetence, including language barriers, increase likelihood of misdiagnosis • When needed, less than 20% of patients seeking MH services, had interpreter services available Alegria et al 2006; Minski S et al 2003

28. Culturally Competent Care Health and human services are offered and delivered in a way that are sensitive to the language, culture and traditions of non-native immigrants, migrants and ethnic minorities with the goal of minimizing or eliminating long standing disparities in the health status of people with diverse racial, ethnic or cultural backgrounds. (www.icfdn.org)

29. Culturally Competent Care The ability of any health care provider of any cultural background in one’s organization to effectively treat any patient of any cultural background. (Matus, JC 2004, Health Care Manag)

30. Cultural Competence A set of congruent behaviors, attitudes and policies that come together as a system, agency or among professionals and enable that system, agency or those professionals to work effectively in cross-cultural situations. (AAFP, 2001)

31. Cultural Competence • Acceptance and respect for differences • Continuing self assessment regarding culture • Attention to the dynamics of difference • Ongoing development of cultural knowledge and resources • Dynamic and flexible application of service models to meet the needs of diverse populations SAMHSA, CMHS, 1998

32. Outline for Cultural FormulationDSM IV-TR • cultural identity of the individual • cultural explanations of the individual’s illness • cultural factors related to psychosocial environment and levels of functioning • cultural elements of the relationship between the individual and the clinician • overall cultural assessment for diagnosis and care

33. Mediators: Cultural Competence • At least 1 in 5 resident physicians surveyed (from seven specialties) reported not being prepared to deal with cross-cultural issues • Approximately half of residents reported receiving little or no training in understanding how to address patients from different cultures (50%), or how to identify patient mistrust (56%), relevant religious beliefs (50%), and relevant cultural customs (48%) Weisman et al 2005

34. Mediators: Cultural Competence

35. Mediators: Bias and Stereotyping • Un-structured interviews lead to greater variability in diagnosis, greater reliance on bias/stereotypes • Psychometric validation is needed to determine whether disparities in diagnoses reflect differences in detection (clinical uncertainty, biases) Strakowski SM et al 2003; West et al 2006

36. The Ethnopsychopharmacological Approach • Assessment • Cultural formulation for diagnosis • Choice of medication • Use medical history, concurrent medications, diet, food supplements, and herbals combined with knowledge of enzyme activity in certain ethnic groups. • Start at lower doses. • Monitor patient • Proceed slowly - involve family • If side effects are intolerable - lower dosage or choose drug metabolized through different route • If no response - check adherence, raise dose and monitor levels; add inhibitors; switch drug (Henderson, 2007)

37. Outcomes: Patient Views of Care • Reported spending enough time with providers • 50% of Asian Americans • 57% of Hispanics • 70% of non-Hispanic Whites • Reported having negative experience with service providers • 20% of Asian Americans and Hispanics (NLAAS) • Reported being treated with disrespect or looked down on in their patient/provider relationship • 14% of African Americans • 20% of Asian Americans • 19% of Hispanics • 9% of non-Hispanic Whites Alegria et al 2006; Blanchard & Lurie, 2004; Collins et al 2002

38. Outcomes: Patient Satisfaction • Patients feel more involved with their care when their physician is of the same race • Greater involvement with care translates into higher patient satisfaction and better medical care Cooper-Patrick et al 1999

39. Outcomes: Effective Partnership • Racial/ethnic minorities rate the quality of interpersonal care by physicians and within the health care system in general more negatively than non-Hispanic whites. Collins et al 2002

40. Landmark Reports & National Initiatives • 1997 Cultural Competence Standards • 1998 President Clinton’s Presidential Initiative on Healthcare Disparities • 2000 IOM Crossing the Quality Chasm • 2001 SG Report on MH: Culture, Race, & Ethnicity • 2002 IOM Unequal Treatment: Confronting Racial & Ethnic Disparities in Health Care

41. Landmark Reports & Initiatives • 2003 President Bush’s New Freedom Commission on Mental Health • 2004 IOM In the Nation’s Compelling Interest: Ensuring Diversity in the Health Care Workforce • 2005 Commission to End Health Care Disparities (AMA, NMA, NHMA) • 2005 Sullivan Report, Missing Persons • AAMC Health Professionals for Diversity • 2005 IOM Health Care for Mental and Substance Use Conditions

42. Synopsis of Culturally and Linguistically Appropriate Services (CLAS) Standards • Quality care • Diverse staff • Ongoing education and training • Free and competent language assistance services • Patient-related materials and signage • Strategic plan • Organizational self-assessment • Collect data • Profile and needs assessment • Collaborative partnerships • Conflict and grievance process • Publicize successes

43. Health Disparities Collaboratives • Community of Learners • HRSA support of strategic state and national partnerships • Improving systems of health care • Planned care model • Model for improvement in the context of community-oriented primary care • Improve health outcomes (diabetes, asthma, depression) and organizational sustainability

44. Nat’l Network to Eliminate Disparities in Behavioral Health - NNED • SAMHSA in partnership with the National Alliance of Multi-ethnic Behavioral Health Associations • Vision: diverse families thrive, participate and contribute to healthy communities • Community and ethnic-based organizations and networks, knowledge discovery centers, and a national facilitation center • Equity in care is an inadequate outcome, rather transformation is needed for behavioral health focused on culturally and linguistically competent interventions

45. IOM Unequal Treatment: Recommendations • Increase public and provider awareness of disparities • Change financial incentives to improve quality, decrease fragmentation of care • Ensure provider supply, reduce barriers and promote quality evidence-based practice • Promote civil rights enforcement Institute of Medicine, 2003

46. IOM Unequal Treatment: Recommendations • Promote provider training, cultural competence, translation services, community health workers and multidisciplinary teams • Promote patient education to enhance access and participation in treatment decisions • Collect data on access, utilization and quality including race/ethnicity/language and monitor progress • Conduct more research on sources of disparities and interventions to eliminate them Institute of Medicine, 2003

47. Rationale for Culturally Competent Health Care • Responding to demographic changes • Eliminating disparities in the health status of people of diverse racial, ethnic, & cultural backgrounds • Improving the quality of services & outcomes • Meeting legislative, regulatory, & accreditation mandates • Gaining a competitive edge in the marketplace • Decreasing the likelihood of liability/malpractice claims Cohen E, Goode T. Policy Brief 1: Rationale for cultural competence in primary health care. Georgetown University Child Development Center, The National Center for Cultural Competence. Washington, D.C., 1999.

48. Cultural Competence Guiding Principles • Quality • Data Driven Systems • Outcomes • Prevention

49. Cultural Competence Techniques • Interpreter Services • Written Translations • Concordant Clinicians and Staff • Education and Training • Community Health Workers • Health Promotion • Organizational Supports Brach and Fraser, Quality Management in Health Care, 2002, 10(4), 15-28

50. Clinician Patient Behavioral Change • Improved Communication • Increased Trust • Improved Epidemiologic and Treatment Efficacy Knowledge • Expanded Cultural and Environmental Understanding Brach and Fraser, Quality Management in Health Care, 2002, 10(4), 15-28