Title: Conceptualizing Mental Health Disparities in Communities of Color
1Conceptualizing Mental Health Disparities in
Communities of Color
- May 19, 2005
- King Davis, PhD, Executive Director
- Hogg Foundation for Mental Health Services,
Research, Policy Education - Robert Lee Sutherland Chair in Mental Health
Social Policy - School of Social Work
- The University of Texas at Austin
- Austin, Texas
2Purpose of the Presentation
- Conceptualize the term disparities
- Place disparities in context
- Link various types of disparities
- Define key terms
- Link health and mental health disparities
- Propose solutions and directions
3Foci of the Presentation
- Disparities have an extensive history
- Disparities are related to a perverse
conceptualization of people of color - This conceptualization pervaded clinical
practice, research, education policy - Disparities are imbedded in differences in
income, access to information, and cultural
traditions social structures
4Conceptualizing Disparities
- Prevalence Rehabilitation
- Incidence Participation
- Services Outcomes
- Treatment Access
- Prevention Quality
- Recovery Use of Medication
King Davis, 2003
5DISPARITIES IN MENTAL HEALTH CARE FOR RACIAL AND
ETHNIC MINORITIES
- Minorities have less access to, and availability
of, mental health services - Minorities are less likely to receive needed
mental health services - Minorities in treatment often receive a poorer
quality of mental health care - Minorities are underrepresented in mental health
research - Mental Health Culture, Race, and
Ethnicity, a Supplement to the Surgeon Generals
Report on Mental Health -
6Service Disparities
- Racial, ethnic, and cultural differences in
twenty characteristics designed to define and
describe the nature of behavioral health service
provision. - Source K. Davis (2003)
7Service Disparities 1760-2000
- gtFrequency of Inaccurate Diagnosis
- gtFindings of Severe Mental Disorder
- gtInpatient Hospitalization/LOS
- gtInvoluntary Commitments
- gtRecidivism/Relapse
- gtInvolvement in Criminal Justice System
- gtMortality Rates (Primary Health Problems
Suicide) - ltRecovery
- gtUninsured/Underinsured
- ltAccess to Outpatient/Early Access
- ltAccess to Providers of Color
- ltUtilization of Cultural Competency in Service
Design - ltParticipation in Behavioral Health Volunteer
Organizations - ltAccess to Information about Behavioral
Disorder/Services - ltFamily Support
8Service Disparities
- gtDelays in help seeking
- ltHousing alternatives
- ltAccess to trained interpreters
- ltInclusion in research/clinical trials
- gtExecutions while mentally disabled
- ltIntegrated behavioral health services
9Expanded View of Disparities
Economic
Dental Health
Political/ Legal
Mental Health
Employment
Health
Educational
Substance
King Davis, 2003
10An Expanded View of Disparities
Maternal/ Infant Deaths
Uninsured
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
Alcohol Abuse
Environmental Pollution
Cancer
Obesity
Low Income
Graduation Rates
Cocaine Use/Sale
Mental Retardation
Schizophrenia
Depression
Bipolar
Domestic Violence
Homicides
Personality Disorder
Dementia
Capital Punishment
Unemployment
King Davis, 2003
11Removal of Disparities
- Recent efforts at the federal (Clinton 1994)
presidential level are designed to eliminate
disparities in health and mental health by 2010 - President Bush (2003) has included this goal in
the recent report on mental health - Bush identifies cultural competence as the
vehicle for eliminating disparities in mental
health
12Six Critical Goals
- Americans understand that mental health is
essential to overall health - Mental health is consumer and family driven
- Disparities in mental health are eliminated
- Early intervention is common
- Excellent care is delivered and research is
accelerated - Technology is used to access mental health care
and information - Source New Freedom Commission
13Disparities in Mental Health Services are
Eliminated
- In a transformed mental health system, all
Americans will share equally in the best
available services and outcomes, regardless of
race, gender, ethnicity, or geographic location. - Source New Freedom Commission
14Recommendations
- Improve access to quality care that is culturally
competent - Improve access to quality care in rural and
geographically remote areas - Source New Freedom Commission
15Primary Strategy
- How to develop implement?
- What are the key strategies?
- What are the critical challenges?
16The Challenge of Reform
System Reform
17The Immunity Hypothesis
- Slaves are immune from stress and from the
subsequent risk of mental illness because they do
not own property.
18Contextual Hypotheses
- Immunity Hypothesis 1763-1865
- Exaggerated Risk Hypothesis -1865-1980
- No-difference Hypothesis 1981-1990s
- _____________________
- Immunity Hypothesis Recycled 2001
- Exaggerated Risk Hypothesis Recycled 2001
- No-difference Hypothesis Recycled 2001
19Historical Hypotheses
20Historical Hypotheses - Continued
21Multiple Costs
- Excess Preventable Deaths
- Untreated Illness Lower Lifetime Achievement
- Excess Hospital Admissions Readmissions
- Misdiagnosis Inappropriate Care (LLOS)
- Community Suspicion and Mistrust
- Staff Division and Conflict
- Absence of Scientific Knowledge Theory
- Ethical Conflict Professional Personal
- Increased Taxes Agency Budgets Waste
22Need for Behavioral Health Care
- African Americans
- Overall rates of mental illness similar to
non-Hispanic whites - Differences in prevalence of specific illnesses
- Suicide rates lower but on the rise
- Environmental, economic and social factors
- Exposure to violence, homelessness,
incarceration, social welfare involvement - Less access to behavioral health services
23Prospective Frequency Of Illness
Source Davis, King., Johnson, Toni,
McClendon,A. (2002). Guidebook. Baltimore Casey
Foundation Mental Health A Report of the Surgeon
General, DHHS, 1999.
24Need for Behavioral Health Care
- American Indians and Alaska Natives
- Limited data on prevalence of MI
- One small study with 20 year follow-up found 70
lifetime prevalence of MI - Increase rise of depression among older adults
- Suicide rate 1.5xs national average with young
males accounting for 2/3 of suicides - 2nd decade of life has highest mortality rate
- Alcohol dependence, alcohol related deaths
- Little information on service utilization
patterns
25Need for Behavioral Health Care
- Latinos/Hispanic Americans
- Overall rates of MI similar to non-Hispanic
whites - Higher rates of some disorders
- Anxiety-related and delinquency behaviors,
depression and drug use, more common among Latino
youth - Higher rates of depression among elderly Latinos
- Culture-bound syndromes
- Susto (fright), nervios (nerves), mal de ojo
(evil eye), and ataque de nervios - Access to behavioral health services is limited
26Need for Behavioral Health Care
- Asian Americans/Pacific Islanders
- Limited data on prevalence of MI
- Existing data suggests overall rates similar to
whites - Higher rates of depression, PTSD
- Somatic complaints of depression
- Culture-bound syndromes
- Lower suicide rates - except elderly women who
have the highest suicide rates in U.S. - Refugees with PTSD
- Language barrier limits access to services
27All Health Care is Cultural
- Conceptualization
- Diagnosis
- Treatment
- Training
- Research
- Policy
- Help Seeking
- Compliance
- Participation
- Health Beliefs
- Expectations
- Employment
28Defining Cultural Competence
- Market-Based Definition
- Cultural competence is the integration and
transformation of knowledge, information, and
data about individuals and groups of people into
specific clinical standards, skills, service
approaches, techniques, and marketing programs
that match the individuals culture and increase
the quality and appropriateness of health care
and outcomes (Davis, 1997).
29Defining Cultural Competence
- Cultural competence is the conclusion reached and
shared by members of a nation, community, group,
organization, business, or a board that
constitutes how the individual wants to be
treated with respect by others based on their
culture (T.Davis, 2002)
30Status 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
Asian/ Pacific Islanders Indian/Pakistani
Middle Income
Men
Lowest
Highest
31Elements of Cultural Competence
- Attitudes of respect Agency Evaluation
- Beliefs Agency Plan
- Knowledge and Skills Inclusion in Vision
- Language and Communication
- Community Analysis Inclusion in Services
- Valuing Diversity Outcomes
- Cultural Self-Assessment Staffing
32Figure 1.Conceptual Framework
D. Formal Helping System
Individual
Church Organizations
C. Individual Community Factors
Degree of Impairment
Practitioner Evidence Base
Family Burden
Theory and Model Recovery
Professional Evidence Based
Faith
Community Stigma
Consumer Self help
Absorption
Delayed Help Seeking
Information
DECISIONS TO UTILIZE SOME FORM OF HELP
COMMUNITIES OF COLOR
A. Organizing Concepts
Boundary Expansion
Self Help
Collective Caring
PHASE 2
PHASE 3
Religious Based Help
PHASE 1
Family Choices/Actions
- King Davis, Hogg Foundation 2003
B. Number of Psychiatric Episodes
33Social Marketing
- Consideration and integration of social variables
in the design of plans and policies in health
care services
Study Culture Help Seeking
Definitions of Health/Illness
Information Use Learning Style
Leadership Family Systems
Media Outlets Languages Spoken
Schools Religious Ideas
Neighborhoods
34General Conclusions
- Too much new information (format) to
access/digest or use - Transformation cannot occur fully without
addressing the complex issue of disparities
knowledge, evidence, research, participation,
help seeking - Transformation comes at a time of significant
reductions in state budgets for human services - Evidence based approaches must be expanded to
include the 4 populations of color - Cultural competence offers promise but requires
national field testing, cost estimation,
educational trials, linkages to licensure,
accreditation, and further development - Cultural competence must demonstrate outcome and
cost efficacy - Poverty and related socio-economic issues will
affect the application of evidence based
approaches - New epidemiological studies are needed on the
four populations of color to increase knowledge
of help seeking and utilization. -