Transcript State of Mental Health of African American and African

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
Public Health Model
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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)
Determinants of Mental Health
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Individual Biology
Individual Behavior
Social Environment
Physical Environment
Access to Quality Care
Policies & Interventions
Major Racial Ethnic Groups in U.S.
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Latinos/Hispanics - 15%
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African Americans - 13%
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Asian American/Pacific Islanders - 5%
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American Indians/Alaska Natives - 1%
U.S. Census 2007
US Population Percentage Change
2000-2006
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fr i
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In
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30%
25%
20%
15%
10%
5%
0%
Surgeon General’s Report on Mental Health:
Race, Culture, and Ethnicity
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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
Influence of Culture on
Mental Illness and Mental Health
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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
Factors in Mental Health,
Mental Illness and Service Use
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Racism
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Discrimination
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Economic impoverishment
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Mistrust
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Fear
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Cultural and social influences
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Biological, psychological and
environmental factors
U.S. Dept. of Health and Human Services Office of the Surgeon General, SAMHSA August 2001
High Need Populations
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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
What Are Racial and Ethnic
Health Disparities?
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Differences and inequalities among racial,
ethnic, linguistic, and cultural groups in
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Risk and predisposition
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Disease prevalence, health status,
and diagnosis
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Health care quality not due to access-related
factors or clinical needs, preferences, and
appropriateness of intervention
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Health outcomes and mortality
IOM Report:
Unequal Treatment
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Racial and ethnic disparities exist regardless of SES
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Higher morbidity and mortality from the leading
causes of death
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Poorer quality of care
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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
Outcomes: Higher Mortality
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African-Americans
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American Indians and Alaska Natives
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Diabetes, infant mortality
Asian Americans and Pacific Islanders
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Heart disease and stroke, cancer (breast, lung, and
prostate), diabetes, infant mortality, HIV/AIDS
Tuberculosis, stroke, cervical cancer
Hispanics
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Diabetes, uncontrolled hypertension, HIV/AIDS
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)
Unmet Need
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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%
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Alegria et al 2006
Mental Health Disparities
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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
Mental Health Disparities
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Less access to bi-lingual services
More likely to be misdiagnosed
Less evidence based care
More inpatient hospitalizations
Less follow up after psychiatric
hospitalization
Mental Health Disparities
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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
Ethnocultural Influences on
Mental Health Care Outcomes
Direct:
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Cultural beliefs and preferences
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Pathoplasticity
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Ethnopsychopharmacology
Ethnocultural Influences on
Mental Health Care Outcomes
Indirect:
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Bias and stereotyping
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Misinterpretation of behavior and belief
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Lack of symptom recognition
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Misdiagnosis and inappropriate
treatment
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Ignorance of ethnocultural issues
Vicious Cycle
Violence and
Incarceration
Substance
Abuse
Unmet Mental
Health Needs
Poor Physical Health
STIs, DM, CAD, CA, etc
Poverty,
Homelessness,
Unemployment
Barriers and Mediators to Equitable Mental
Health Care for Diverse Racial and Ethnic Groups
Barriers
Personal/Family
 Acceptability
Cultural beliefs
 Language/literacy
 Attitudes, beliefs
 Preferences
 Involvement in care
 Health behavior
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Education/income
Structural
 Availability
 Appointments
 How organized
 Transportation
Financial
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Mediators
Use of Services
Visits
Primary care
 Specialty
 Emergency
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Procedures
 Preventive
 Diagnostic
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Therapeutic
Quality of providers
 Cultural competence
 Communication skills
Medical knowledge
 Technical skills
 Bias/stereotyping
 Appropriateness of
care
 Efficacy of treatment
 Patient adherence
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Outcomes
Health Status
 Mortality
 Morbidity
Well-being
 Functioning
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Equity of Services
Patient Views of Care
 Experiences
 Satisfaction
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Effective partnership
Insurance coverage
 Reimbursement levels
 Public support
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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.
Barriers: Attitudes and Language
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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
Barriers: Language
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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
Barriers: Attitudes and Beliefs
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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 nonHispanic whites of finding counseling
acceptable.
Cooper et al 2003
Barriers: Health Behavior
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Physicians were less patient-centered with
African American than non-Hispanic white
patients
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Less patient input is associated with less
information recall, treatment adherence,
satisfaction with care, return visits, and
suboptimal health outcomes
Roter et al 1997
Availability of Mental Health
Services by Race, Ethnicity
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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
Mediators: Cultural Competence
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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
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)
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)
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 crosscultural situations.
(AAFP, 2001)
Cultural Competence
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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
Outline for Cultural Formulation
DSM IV-TR
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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
Mediators: Cultural Competence
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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
Mediators: Cultural Competence
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
The Ethnopsychopharmacological
Approach
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Assessment
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Choice of medication
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Cultural formulation for diagnosis
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
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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)
Outcomes: Patient Views of Care
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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
Outcomes: Patient Satisfaction
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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
Outcomes: Effective Partnership
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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
Landmark Reports &
National Initiatives
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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
Landmark Reports & Initiatives
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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
Synopsis of Culturally and Linguistically
Appropriate Services (CLAS) Standards
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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
Health Disparities Collaboratives
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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
Nat’l Network to Eliminate Disparities
in Behavioral Health - NNED
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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
IOM Unequal Treatment:
Recommendations
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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
IOM Unequal Treatment:
Recommendations
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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
Rationale for Culturally Competent
Health Care
•
Responding to demographic changes
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Eliminating disparities in the health status of people of
diverse racial, ethnic, & cultural backgrounds
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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.
Cultural Competence
Guiding Principles
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Quality
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Data Driven Systems
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Outcomes
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Prevention
Cultural Competence
Techniques
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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
Clinician Patient Behavioral Change
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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
Reducing Health Disparities Through the
Implementation of Cultural Competency
Diverse
Populations
Cultural
Competency
• linguistically
• ethnically
• culturally
• effective
techniques
• sound
implementation
+
Appropriate
Services for
Diverse Groups
Improved
Outcomes for
Diverse Groups
• preventive
• screening
• diagnostic
• treatment
• health status
• functioning
• satisfaction
Reduction of
Health
Disparities
Source: Brach and Fraser, Cultural Competency; 2000
General Strategies to Address
Disparities
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Must address all potential factors
affecting disparities
May need to address subpopulations of
diverse ethnic and racial groups
differently, dependent on how various
factors affect them
Include diverse communities at all
levels of research, policy, planning,
programs, evaluation
Strategies
to Increase Use of Services
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Integration of Mental Health in Primary care
settings
Increase screening and focus on prevention
Increase knowledge of ethnic and racial
differences for effective diagnosis and
treatment (address at level of training, medical
school, residency, and CME)
Standards for screening, referral, diagnosis,
and treatment
Strategies to Reduce Barriers
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Policy and funding to improve/increase
(structural and personnel) MH services in
human services, and other public sectors
where populations are affected (correctional,
child welfare, school, community health)
Universal health insurance to assure
coverage
Mental health parity
Public marketing to increase population
knowledge, change health behavior
Patient activation
Strategies to Enhance
Mediating Factors
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Provider education on cultural competence
Clinicians should consider patients’ cultural
and social context when negotiating
treatment decisions
Provider incentives (career, financial) for
successful referral and engagement
Increase ethnic and racial minority
representation in all clinical trials (better
understand environmental and biological
interactions and effect on
symptomatology/drug interaction)
Language competency in
assessment/diagnostic instruments
Strategies to Improve Outcomes
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Greater public health interventions as basis
for correctional, child welfare, human
services systems
Collecting data and reporting on race and
ethnic groups’ health status (mental health,
functioning, co-morbidities)
Clinicians to screen for suicide risk and
monitor carefully consumers with anxiety
and mood disorders
Longitudinal studies to evaluate equity of
services, patient experiences
Office of Minority
and National Affairs
(OMNA)
APA’s nerve center for the mental
health of diverse and underserved
populations
Our Mission
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To contribute to the improvement of the
quality of care for diverse and underserved
populations
To meet the professional needs of
psychiatrists from under-represented
(MUR) groups
Our Main Issues & Constituencies
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People of African, Asian, Hispanic,
Native American descent
Women
Gay, Lesbian and Bisexual Issues
International Medical Graduates
Religious and Spiritual Issues
Our Priorities
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Increase diversity in psychiatry
Foster the professional well-being of
psychiatrists from underrepresented
groups
Increase knowledge of the mental health
needs of underserved populations
Educate communities about mental health
disparities
Forge alliances to prevent and eliminate
disparities
American Psychiatric Association
Disparities Elimination Efforts
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Buy-in at the top: elected leaders, Board of
Trustees, executive staff
Support of the Office of Minority and National
Affairs (OMNA)
Recommendations stemming from SGR
Supplement passed by board of trustees:
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Increase access to quality care
Support capacity development, education and
training
Expand the science base
Promote collaboration and advocacy
Eliminating Mental Health Disparities
Roundtable
.
Fellowship Programs
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Minority Fellowships Program
 SAMHSA, AstraZeneca
Program for Minority Research Training in
Psychiatry (in collaboration with APIRE)
Spurlock Congressional Fellowship
Medical student programs
 Mentoring, travel scholarships, addiction
and HIV psychiatry summer externships
Recognition Awards
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Simon Bolivar Award (Hispanic leaders)
Solomon Carter Fuller Award (pioneering
African-Americans)
John Fryer Award (GLBT health)
Oskar Pfister Award (religion, spirituality,
and psychiatry)
Kun-Po Soo Award (Asian cultural
heritage)
George Tarjan Award (IMG advocacy)
Jeanne Spurlock Achievement Award
(MFP graduate)
OMNA Products
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CME curriculum, NAMI-APA effort
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Let’s Talk Facts series on Mental Health of
Diverse Populations available at
healthyminds.org
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People of African, Asian, American Indian,
Hispanic descent
Book
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In Living Color: Treating Depression in Diverse
Populations for primary care
Disparities in Psychiatric Care: Clinical and CrossCultural Perspectives
DVDs
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Latino Mental Health DVD and Guidebook
Real Psychiatry: Doctors in Action
OMNA Special Projects
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Women’s Mental Health Roundtable
All Healers Mental Health Alliance
OMNA on Tour
Community Connections
Doctors Back to School
Transformational Leadership in Psychiatry
Academy
National Minority Mentors Network
 Collaboration with Texas Regional
Psychiatry Minority Mentorship Network
(TRMMN)
Diversity-Related Outcomes
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TRPMMN illustrates: Increased medical
school diversity is associated with white
students feeling better prepared to care for
diverse patients.*
Compositional Diversity: proportions of URM
students and non-white, non-URM students
Interactional Diversity: climate for interracial
interaction, individual exposure to diverse
perspectives
*Saha et al, Student Body Racial and Ethnic Composition and Diversity-Related
Outcomes in US Medical Schools, JAMA, Sept. 10, 2008, 300(10): 1135-1145
OMNA Future Priorities
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Support TRPMMN and other regional
mentorship networks
Psychiatrists Back To School
Aspiring Psychiatrists
Community of Scholars, national network
of minority psychiatry faculty and mentors
Collaborate with APA district branches and
a variety of educational and ethnic medical
and psychiatric associations to foster
diversity, recruitment, retention,
advancement and leadership
What can you do to eliminate
disparities?
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Know your population
Demographics
 Socio-environmental conditions
 Epidemiologic vulnerabilities
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Know yourself (challenge your biases)
Listen to your patients and make a
concerted effort to understand cultural
context and belief system
What can you do to eliminate
disparities?
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Notice patterns of health care delivery
and question differences in quality by
race, ethnicity and linguistic background
Collect data by race and ethnicity (or
encourage your institution to) in order to
uncover disparities in care
Educate your patients about what their
illness is, what to do to manage it, and
why it is important (health literacy)
What can you do to eliminate
disparities?
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Treat your patients like they want to be
treated. Look for the commonalities that
arise from sheer humanity
Encourage patients to ask questions and
be active participants in their health care
Showing patients you care engenders
trust, regardless of differences
Trust is key to establishing an effective
patient–health professional partnership
Crossing the Quality Chasm:
A New Health System for the 21st Century
Six Aims for Improvement
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Safe
Effective
Patient-centered
Timely
Efficient
Equitable
IOM, 2001
Patient-centered Care
Providing care that is respectful of and
responsive to individual patient preferences,
needs, and values, and ensuring that patient
values guide all clinical decisions.
Person-centered Care
Healthcare partnership among practitioners, patients,
and their families to ensure that decisions respond to
and respect patients' wants, needs, and preferences
and solicit patients' input on the education and support
they need to make decisions and participate in their
own care. (Adapted from Agency for Healthcare
Research and Quality, 2002)
Six dimensions of person-centered care:
1.
Respect for patient’s values, preferences, and
expressed needs
2.
Coordination and integration of care
3.
Information, communication, and education
4.
Physical comfort
5.
Emotional support
6.
Involvement of family and friends
(Gerteis et al, 1993)
Recovery-oriented Care
“Mental health recovery is a journey of healing and
transformation enabling a person with a mental
health problem to live a meaningful life in a
community of his or her choice while striving to
achieve his or her full potential.”
(SAMHSA Consensus Statement, 2006)
It is important to convey a sense of hope that
this is achievable for all Americans with mental
health needs.