Transcript The Basics of Negotiating Mental Health Care

The Basics of Negotiating
Mental Health Care
Margarita Alegria, Ph.D.
Harvard University and
Cambridge Health Alliance
Worcester County Mental Health and Cultural
Competency Conference Agenda
May 31, 2006
.
The Changing Demographics of the
US Population
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The mental health system is
challenged to meet the needs of
our increasingly diverse
population.
African Americans, Asian
Americans, Latinos, American
Indians, Alaskan Natives, and
Native Hawaiians accounted for
30% of the US population in
2000.
These groups are projected to
account for about 40% of the
population in 2025.
Patient Reports of How Culture
Matters in the Clinical Encounter
“Understanding. Sometimes you come from
different backgrounds, different lifestyles.
Sometimes they don’t get overall picture
and think things are easier. They tend to
water things down.”
“Language is always important, but doctors
need to be bicultural. The way one thinks
and express himself/herself has to do with
the culture. One is going to feel like is
being understood better. The doctor can
visualize it because he/she already lived it
or because he/she has a previous
knowledge. He/she doesn’t have to be from
the same race but to speak the same
language and have knowledge of the
culture.
Overview of Presentation
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Present trends and findings of the
rates of mental health problems and
service disparities across ethnic and
racial groups in the US.
Discuss some of the mechanisms
that could explain mental health
service disparities.
Illustrate the importance of better
negotiating mental health care.
Combined NLAAS/NCS-R Study
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A national psychiatric epidemiologic survey
conducted to measure psychiatric disorders
and mental health service usage in a
nationally representative sample of Asians
and Latinos (NLAAS).
We also use data from the NCS-R
(conducted in 2001-2002) to incorporate
contrasts to Non-Latino whites and African
Americans.
NLAAS was conducted in 2002 and 2003 in
English, Spanish, Chinese, Tagalog and
Vietnamese, based on the respondents’
language preference
Contains detailed information on psychiatric
disorders using the Composite International
Diagnostic Interview (CIDI) and chronic
conditions to do health adjustments.
% of K10 distress being medium or
high
Prevalence of K10 distress being
medium or high (>=16) by race and
immigration groups
25%
23.0%
22.2%
21.8%
20%
15%
17.1%
14.5%
10%
5%
0%
NLAAS Non-Hispanic
White
US Born
Latino
Asian
Immigrant
Levels of Unmet Need by Racial/Ethnic Groups
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
78.2%
72.2%
69.5%
61.1%
Non-Hispanic
white
Latino
Asian
African
American
Not receiving Speciality or generalist care in the past 12 months for those with any last year
psychiatric disorder
Differences in proportion in predicted probability of any 12-month
MH service use after transforming age, gender and health status
of minority to match that of non-Latino Whites
0.00%
-5.00%
-10.00%
-15.00%
-20.00%
-25.00%
-22.25%
-23.41%
-28.04%
-30.00%
Latinos-White
Asian-White
African American-White
Mechanism 1:Failure in Health Care Markets
Precipitating
Factors
Limited
Political
Power &
Voice of
Immigrant
Groups
Primary
Mechanisms:
Health
Disparities:
Failure of
public health
in health care
markets
Decreased
access and
utilization of
health care
services and
resources
Adjusted1 Distribution of Insurance Outcomes for Latinos and Asians
(Ages 18-64)
% Private
Insurance
% Public
Insurance
%
Uninsured
48.1
11.5
40.4
49.0
14.5
36.4
Immigrant
(>5)
49.0
11.2
39.7
Immigrant
(≤5)
36.8
4.6
58.6
82.5
5.7
11.8
87.3
4.0
8.7
Immigrant
(>5)
82.2
6.3
11.6
Immigrant
(≤5)
74.0
6.4
19.6
All Latinos
2
3
Nativity , time in
**
country (y)
U.S. born
All Asians
2
Nativity, time in
country (y)
U.S. born
Mechanism 2 :Differential Pathways into
Health Care
Precipitating Primary
Health
Factors
Mechanisms:
Disparities:
Lack of
Differential
Patient
pathways into
Problem
Recognition healthcare
Lack of
Provider
Referral
Uninsurance
Differential
treatment,
differential
outcomes
Clients’ description of their MH problems-Approximately half of Clients
see a Mismatch between what they need and what they get in care
1. Psychiatric
4. Interpersonal Problems:
Language: (15.8%) (26.7%)
- Depression
- Marital or family problems
- Drug or alcohol
- Alcoholism or drug use of a
problems
family member
- Schizophrenia
- Tense relationships with
2. Wide Range of
friends or neighbors
Symptoms of
Psychiatric Disorders:
5. Physical Problems: (7.1%
(34.4%)
- AIDS; Epilepsy
- Uncontrolled crying
- Chronic back pain
- Nervousness
- Excessive aggression6. Social Problems: (6.4%)
- Becoming unemployed
3. Traumas: (8.3%)
- Economic problems
- Death of family
- Bad living conditions
or close friend
Mechanism 3:Poor Patient-Provider Interaction
Precipitating
Factors
Different
meaning of
signal,
signal
endorsed at
different
Illness
threshold,
signal too
vague or
muddled
Primary
Mechanisms:
Health
Disparities:
Poor patientprovider
interaction
Drop out from
care,
Differential TX
outcomes
BIAS or PREJUDICE
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lack an understanding of the psychosocial
needs and the living circumstances of
minority families ( Finn, 1994; Guendelman, 1985) and
consequently provide culturally
inappropriate interventions (Castaneda, 1994)
AA and Latinos are more likely to feel that a
doctor or health provider judges them
unfairly or treats them with disrespect
because of their race or ethnic background
(Brown et al., 1999; LaVeist et al., 2000).
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Having a successful interaction between
caregiver and clinician has an effect on the
degree of resistance or cooperation, the
level of disclosure (Chiu, 1994), and the rejection
of treatment options (Temkin-Greener and Clark, 1988).
Did the provider accept you and
make you feel understood? * Only asked
of participants who are in MH care in the past twelve months.
White
Latino
Asian
No
1.7%
14.6%
11.7%
Yes
98.3%
85.4%
88.3%
P = .01, National Latino and Asian American Study, 2005
An Interpretation of an Interpretation
Most treatment is dependent on:
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patients’ capacity to describe symptoms and present nonverbal cues that corroborate symptom descriptions -- this is the
patient’s interpretation of a culturally constructed experience
•
clinicians’ ability to accurately comprehend patients’ language
used for symptoms, correctly translate it and attribute meaning
to those symptoms. Most of this process is driven by clinician’s
own interpretation of symptom and affect – this is also the
clinician’s interpretation of a culturally constructed experience
Interpreting the Patient’s signal using
Clinician’s own cultural interpretations
“The diagnosis was anxiety disorder, but
obviously I was feeling at that time that
he was feeling quite depressed, and I was
connecting more with the sense of not
only the panic thing, but also the sense of
being lonely and sad.. So I was taking
cues from the patient’s reporting, but also
clues from the patient’s [tones, gestures],
you know, non-verbal, you know the mood
disorder was more like, this guy is
depressed, although he was not saying,
‘I’m feeling depressed’...”
Different Meaning of the Signal
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Clinicians’ limited cultural competence may
cause misdiagnosis of psychosis in crosscultural settings
• Lower “signal to noise ratio” for majority
clinician-minority patient dyads as a factor in
psychiatric misdiagnosis (Balsa & McGuire, 2003)
• Ethnic-specific “information variance” –
psychotic-like complaints not well investigated
in less valued social groups (Strakowski et al, 1997)
Endorsement of psychotic symptoms by Latinos:
signals emotional distress but not necessarily true
psychosis
“A Good Therapist or Clinician Can Understand
Any Patient, Independently of their Gender,
Race, Ethnicity or SES.”
‘I liked the Puerto Rican counselors…I
felt they could understand where I was
coming from and what I was about.
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Most providers trained in the U.S. help
their patients become independent,
however Latinos value interdependence.
Therapists unaware of this value may
lose patients (Ruiz, 1995).
Latino clients mention the desire for
warmer and more open relationships
with their providers, while US providers
feel their training reinforces
interpersonal boundaries.
Asymmetrical Information Transfer
Development of hypotheses about
“What is the Problem”
Central because it determines
the questions that will be asked,
what treatment alternatives will
be offered, and how outcomes
will be interpreted. The patientprovider match of the
explanatory model of illness and
expectations for the visit have
been shown to be important in
determining outcome of Tx .
Right Question Project:
A Different Approach
to Patient Activation
Minority patients are
typically disengaged
from health care, w/
limited opportunity to
take charge of their
healthcare. This leads
to low retention in
health care. Evidence
of higher patient
involvement leads to
higher retention, more
satisfaction and better
outcomes.
Treatment Engagement and
Retention
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After adjusting for age, sex, race/ethnicity, and
education, intervention subjects were almost 5 times
more likely to be retained in treatment (odds ratio
[95% confidence interval]: 4.88 [2.17, 11.00]). In
terms of having at least one scheduled visit during the
follow-up period, intervention subjects were almost 15
times more likely than control subjects (adjusted OR =
5.5 [1.95, 123.2]) -- the unusually high odds ratio is
attributed to the fact that virtually all intervention
subjects had a scheduled visit. When assessing the
intensity of visits for those subjects having at least one
visit, intervention subjects were 29% more likely to be
engaged in treatment than control subjects (rate ratio
[95% CI]: 1.29 [1.16,1.42)].
RQP continued
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Adapt RQP methodology and materials offering
activation skills to Latino and African Caribbean
patients. RQP methodology is not to supply clients
with solutions to problems, but rather provide
clients with democratic experiences to develop
their own solutions by formulating questions and
focusing on key decisions.
• Patients learn how to formulate questions about
their mental health care. (How will this
medication work for me?)
• Patients learn how to focus on key decisions that
are made during the course of treatment. (What
will happen if I decide not to continue w/
medication?)
• Patients learn to formulate a disease
management plan in conjunction with their
provider. (What Tx options will best work for me
given my life circumstances?)
Conclusions
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Much of the MH service disparity for minority groups
seems to be more in accessing care than in the
intensity or the expenditures once in care. This
suggests that not focusing on access might be a
problem.
Policy interventions might be central to dealing with
disparities in access-such as revising PWRORA or
fiscal requirements for covering mental health care
for immigrants.
Differential pathways into care might be one target to
explore the mechanisms of service disparities,
particularly social services and criminal justice
pathways. Central seems to be the role of problem
recognition and patient’s health literacy.
Poor provider patient communication and interaction
requires understanding both the content and
differential process that might take place when
provider and patient don’t share the same cultural
background. Strategies for patient activation and
empowerment might be key for reducing disparities.