Executive Summary Contents

	Summary
	Main Findings
	Main Message
	Personal Health Recommendations
	Organization of Supplement and Major Topics Covered
	Chapter Summaries & Conclusions Chapter 2 Chapter 3 Chapter 4 Chapter 5 Chapter 6 Chapter 7
	References
	Report Home Page

Chapter 2: Culture Counts

• Cultural and social factors contribute to the causation of mental illness, yet that contribution varies by disorder. Mental illness is considered the product of a complex interaction among biological, psychological, social, and cultural factors. The role of any of these major factors can be stronger or weaker depending on the specific disorder.
• Ethnic and racial minorities in the United States face a social and economic environment of inequality that includes greater exposure to racism, discrimination, violence, and poverty. Living in poverty has the most measurable effect on the rates of mental illness. People in the lowest strata of income, education, and occupation (known as socioeconomic status) are about two to three times more likely than those in the highest strata to have a mental disorder.
• Racism and discrimination are stressful events that adversely affect health and mental health. They place minorities at risk for mental disorders such as depression and anxiety. Whether racism and discrimination can by themselves cause these disorders is less clear, yet deserves research attention.
• Mistrust of mental health services is an important reason deterring minorities from seeking treatment. Their concerns are reinforced by evidence, both direct and indirect, of clinician bias and stereotyping.
• The cultures of racial and ethnic minorities alter the types of mental health services they need. Clinical environments that do not respect, or are incompatible with, the cultures of the people they serve may deter minorities from using services and receiving appropriate care.

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  Chapter 3: African Americans

  The overwhelming majority of today's African American population traces its ancestry to the slave trade from Africa. The legacy of slavery, racism, and discrimination continues to influence the social and economic standing of this group. Almost one-quarter of African Americans are poor, and their per capita income is much lower than that of whites. They bear a disproportionate burden of health problems and higher mortality rates from disease. Nevertheless, African Americans are a diverse group, experiencing a range of challenges as well as successes in measures of education, income, and other indices of social well-being. Their steady improvement in social standing is significant and serves as testimony to the resilience and adaptive traditions of the African American community.
  
• Need for Services: For African Americans who live in the community, rates of mental illness appear to be similar to those for whites. In one study, this similarity was found before, and in another study, after controlling for differences in income, education, and marital status. But African Americans are overrepresented in vulnerable, high-need populations because of homelessness, incarceration, and, for children, placement in foster care. The rates of mental illness in highneed populations are much higher.
• Availability of Services: "Safety net" providers furnish a disproportionate share of mental health care to African Americans. The financial viability of such providers is threatened as a result of the national transformation in financing of health care over the past two decades. A jeopardized safety net reduces availability of care to African Americans. Further, there are very few African American mental health specialists for those who prefer specialists of their own race or ethnicity.
• Access to Services: African Americans have less access to mental health services than do whites. Less access results, in part, from lack of health insurance, especially for working poor who do not qualify for public coverage and who work in jobs that do not provide private health coverage. About 25 percent of African Americans are unisured. Yet better insurance coverage by itself is not sufficient to eliminate disparities in access because many African Americans with adequate private coverage still are less inclined to use services.
• Utilization of Services: African Americans with mental health needs are less likely than whites to receive treatment. If treated, they are likely to have sought help in primary care, as opposed to mental health specialty care. They frequently receive mental health care in emergency rooms and in psychiatric hospitals. They are overrepresented in these settings partly because they delay seeking treatment until their symptoms are more severe.
• Appropriateness and Outcomes of Services: For certain disorders (e.g., schizophrenia and mood disorders), errors in diagnosis are made more often for African Americans than for whites. The limited body of research suggests that, when receiving care for appropriate diagnoses, African Americans respond as favorably as do whites. Increasing evidence suggests that, in clinical settings, African Americans are less likely than whites to receive evidence-based care in accordance with professional treatment guidelines.

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  Chapter 4: American Indians and Alaska Natives

  American Indians and Alaska Natives (AI/ANs) flourished in North America for thousands of years before Europeans colonized the continent. As Europeans migrated westward through the 19th century, the conquest of Indian lands reduced the population to 5 percent of its original size. Movement to reservations and other Federal policies have had enduring social and economic effects, as AI/ANs are the most impoverished of today's minority groups. Over one quarter live in poverty, compared to 8 percent of whites. A heterogeneous grouping of more than 500 Federally recognized tribes, the AI/AN population experiences a range of health and mental health outcomes. While AI/ANs are, on average, five times more likely to die of alcohol-related causes than are whites, they are less likely to die from cancer and heart disease. The Indian Health Service, established in 1955, is the Federal agency with primary responsibility for delivering health and mental health care to AI/ANs. Traditional healing practices and spirituality figure prominently in the lives of AI/ANs - yet they complement, rather than compete with Western medicine.
• Need for Services: Research on AI/ANs is limited by the small size of this population and by its heterogeneity. Nevertheless, existing studies suggest that youth and adults suffer a disproportion- ate burden of mental health problems and disorders. As one indication of distress, the suicide rate is 50 percent higher than the national rate. The groups within the AI/AN population with the greatest need for services are people who are homeless, incarcerated, or victims of trauma.
• Availability of Services: The availability of mental health services is severely limited by the rural, isolated location of many AI/AN communities. Clinics and hospitals of the Indian Health Service are located on reservations, yet the majority of American Indians no longer live on them. Moreover, there are fewer mental health providers, especially child and adolescent specialists, in rural communities than elsewhere.
• Access to Services: About 20 percent of AI/ANs do not have health insurance, compared to 14 percent of whites.
• Utilization of Services: An understanding of the nature and the extent to which AI/ANs use mental health services is limited by the lack of research. Traditional healing is used by a majority of AI/ANs.
• Appropriateness and Outcomes of Services: The appropriateness and outcomes of mental health care for AI/ANs have yet to be examined, but are critical for planning treatment and prevention programs.

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  Chapter 5: Asian Americans and Pacific Islanders

  Asian Americans and Pacific Islanders (AA/PIs) are highly diverse, consisting of at least 43 separate ethnic groups. The AA/PI population in the United States is increasing rapidly; in 2001, about 60 percent were born overseas. Most Pacific Islanders are not immigrants; their ancestors were original inhabitants of land taken over by the United States a century ago. While the per capita income of AA/PIs is almost as high as that for whites, there is great variability both between and within subgroups. For example, there are many successful Southeast Asian and Pacific Islander Americans; however, overall poverty rates for these two groups are much higher than the national average. AA/PIs collectively exhibit a wide range of strengths - family cohesion, educational achievements, and motivation for upward mobility - and risk factors for mental illness such as pre-immigration trauma from harsh social conditions. Diversity within this population and other hurdles make research on AA/PIs difficult to carry out.
• Need for Services: Available research, while limited, suggests that the overall prevalence of mental health problems and disorders among AA/PIs does not significantly differ from prevalence rates for other Americans. Thus, contrary to popular stereotypes, AA/PIs are not, as a group, "mentally healthier" than other groups. Refugees from Southeast Asian countries are at risk for post-traumatic stress disorder as a result of the trauma and terror preceding their immigration.
• Availability of Services: Nearly half of AA/PIs have problems with availability of mental health services because of limited English proficiency and lack of providers who have appropriate language skills.
• Access to Services: About 21 percent of AA/PIs lack health insurance, but again there is much variability. The rate of public health insurance for AA/PIs with low income, who are likely to qualify for Medicaid, is well below that of whites from the same income bracket.
• Utilization of Services: AA/PIs have lower rates of utilization compared to whites. This underrepresentation in care is characteristic of most AAPI groups, regardless of gender, age, and geographic location. Among those who use services, the severity of their condition is high, suggesting that they delay using services until problems become very serious. Stigma and shame are major deterrents to their utilization of services.
• Appropriateness and Outcomes of Services: There is very limited evidence regarding treatment outcomes for AA/PIs. Because of differences in their rates of drug metabolism, some AA/PIs may require lower doses of certain drugs than those prescribed for whites. Ethnic matching of therapists with AAPI clients, especially those who are less acculturated, has increased their use of mental health services.

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  Chapter 6: Hispanic Americans

  The Spanish language and culture forge common bonds for many Hispanic Americans, regardless of whether they trace their ancestry to Africa, Asia, Europe or the Americas. Hispanic Americans are now the largest and fastest growing minority group in the United States. Their per capita income is among the lowest of the minority groups covered by this Supplement. Yet there is great diversity among individuals and groups, depending on factors such as level of education, generation, and country of origin. For example, 27 percent of Mexican Americans live in poverty, compared to 14 percent of Cuban Americans. Despite their lower average economic and social standing, which place many at risk for mental health problems and illness, Hispanic Americans display resilience and coping styles that promote mental health.
• Need for Services: Hispanic Americans have overall rates of mental illness similar to those for whites, yet there is wide variation. Rates are lowest for Hispanic immigrants born in Mexico or living in Puerto Rico, compared to Hispanic Americans born in the United States. Hispanic American youth are at significantly higher risk for poor mental health than white youth are by virtue of higher rates of depressive and anxiety symptoms, as well as higher rates of suicidal ideation and suicide attempts.
• Availability of Services: About 40 percent of Hispanic Americans in the 1990 census reported that they did not speak English very well. Very few providers identify themselves as Hispanic or Spanish-speaking. The result is that most Hispanic Americans have limited access to ethnically or linguistically similar providers.
• Access to Services: Of all ethnic groups in the United States, Hispanic Americans are the least likely to have health insurance (public or private). Their rate of uninsurance, at 37 percent, is twice that for whites.
• Utilization of Services: Hispanic Americans, both adults and children, are less likely than whites to receive needed mental health care. Those who seek care are more likely to go to primary health providers than to mental health specialists.
• Appropriateness and Outcomes of Services: The degree to which Hispanic Americans receive appropriate diagnoses is not known because of limited research. Research on outcomes, while similarly sparse, indicates that Hispanic Americans can benefit from mental health treatment. Increasing evidence suggests that Hispanic Americans are less likely in clinical settings to receive evidence-based care in accordance with professional treatment guidelines.

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  Chapter 7: A Vision for the Future

  This Supplement has identified striking disparities in knowledge, access, utilization, and quality of mental health care for racial and ethnic minorities. Reducing or eliminating these disparities requires a steadfast commitment by all sectors of American society. Changing systems of mental health care must bring together the public and private sectors, health service providers, universities and researchers, foundations, mental health advocates, consumers, families, and communities. Overcoming mental health disparities and promoting mental health for all Americans underscores the Nation's commitment to public health and to equality. This chapter highlights promising courses of action for reducing barriers and promoting equal access to quality mental health services for all people who need them.

  1. Continue to expand the science base.
  Good science is an essential underpinning of the public health approach to mental health and mental illness. The science base regarding racial and ethnic minority mental health is limited but growing. Since 1994, the National Institutes of Health (NIH) has required inclusion of ethnic minorities in all NIH-funded research (NIH Guidelines, 1994, p. 14509). Several large epidemiological studies that include significant samples of racial and ethnic minorities have recently been initiated or completed. These surveys, when combined with smaller, ethnic-specific epidemiological surveys, may help resolve some of the uncertainties about the extent of mental illness among racial and ethnic groups.

  These studies also will facilitate a better understanding of how factors such as acculturation, helpseeking behaviors, stigma, ethnic identity, racism, and spirituality provide protection from, or risk for, mental illness in racial and ethnic minority populations. The researchers have collaborated on a set of core questions that will enable them to compare how factors such as socioeconomic status, wealth, education, neighborhood context, social support, religiosity, and spirituality relate to mental illness. Similarly, it will be possible to assess how acculturation, ethnic identity, and perceived discrimination affect mental health outcomes for these groups. With these ground-breaking studies, the mental health field will gain crucial insight into how social and cultural factors operate across race and ethnicity to affect mental illness in diverse communities.

  A major aspect of the vision for an adequate knowledge base includes research that confirms the efficacy of guideline- or other evidence-based treatments for racial and ethnic minorities. A special analysis performed for this Supplement reveals that the researchers who conducted the clinical trials used to generate treatment guidelines for several major mental disorders did not conduct specific analyses for any minority group. While the lack of ethnic-specific analyses does not mean that current treatment guidelines are ineffective for racial or ethnic minorities, it does highlight a gap in knowledge. Nevertheless, these guidelines, extrapolated from largely majority populations, are clearly the best available treatments for major mental disorders affecting all Americans. As a matter of public health prudence, existing treatment guidelines should continue to be used as research proceeds to identify ways in which service delivery systems can better serve the needs of racial and ethnic minorities.

  The science base of the future will also determine the efficacy of ethnic- or culture-specific interventions for minority populations and their effectiveness in clinical practice settings. In the area of psychopharmacology, research is needed to determine the extent to which the variability in peoples' response to medications is accounted for by factors related to race, ethnicity, age, gender, family history, and/or lifestyle.

  This Supplement documents the fact that minorities tend to receive less accurate diagnoses than whites. While further study is needed on how to address issues such as clinician bias and diagnostic accuracy, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, now under development, will extend and elaborate the "Glossary of Culture-Bound Syndromes," the "Outline for Cultural Formulation," and other concepts introduced in DSM-IV regarding the role and importance of culture and ethnicity in the diagnostic process.

  In terms of the promotion of mental health and the prevention of mental and behavioral disorders, important opportunities exist for researchers to study cultural differences in stress, coping, and resilience as part of the complex of factors that influence mental health. Such work will lay the groundwork for developing new prevention and treatment strategies - building upon community strengths to foster mental health and ameliorate negative health outcomes.

  2. Improve access to treatment.
  Simply put, the Nation's health systems must work to bring mental health services to where the people are. Many racial and ethnic minorities live in areas where general health care and specialty mental health care are in short supply. One major course of action is to improve geographic availability of mental health services. Innovative strategies for training providers, delivering services, creating incentives for providers to work in underserved areas, and strengthening the public health safety net promise to provide greater geographic access to mental health services for those in need.

  Another step towards better access to care is to integrate mental health care and primary care. Primary care is where many minority individuals prefer to receive mental health care and where most people who need treatment are first recognized and diagnosed. A variety of research and demonstration programs have been or will be created to strengthen the capacity of these providers to meet the demand for mental health services and to encourage the delivery of integrated primary health and mental health services that match the needs of the diverse communities they serve.

  Another major step in improving access to mental health services is to improve language access. Improving communication between clinicians and patients is essential to mental health care. Service providers receiving Federal financial assistance have an obligation under the 1964 Civil Rights Act to ensure that people with limited English proficiency have meaningful and equal access to services (DHHS, 2000).

  Finally, a major way to improve access to mental health services is to coordinate care to vulnerable, highneed groups. People from all backgrounds may experience disparities in prevalence of illness, access to services, and quality of services if they are in under-served or vulnerable populations such as people who are incarcerated or homeless and children living in out of home placements. As noted earlier, racial and ethnic minorities are overrepresented in these groups. To prevent individuals from entering these vulnerable groups, early intervention is an important component to systems of care, though research is needed to determine which interventions work best at prevention. For individuals already in underserved or high-need groups, mental health services, delivered in a comprehensive and coordinated manner, are essential. It is not enough to deliver effective mental health treatments: Mental health and substance abuse treatments must be incorporated into effective service delivery systems, which include supported housing, supported employment, and other social services (DHHS, 1999).

  3. Reduce barriers to mental health care.
  The foremost barriers that deter racial and ethnic minorities from reaching treatment are the cost of services, the fragmented organization of these services, and societal stigma toward mental illness. These obstacles are intimidating for all Americans, yet they may be even more formidable for racial and ethnic minorities. The Nation must strive to dismantle these barriers to care.

  Mental Health: A Report of the Surgeon General (DHHS, 1999) spotlighted the importance of overcoming stigma, facilitating entry into treatment, and reducing financial barriers to treatment (DHHS, 1999). This Supplement brings urgency to these goals. It aims to make services more accessible and appropriate to racial and ethnic minorities, it encourages mental health coverage for the millions of Americans who are uninsured, and it maintains that parity, or equivalence, between mental health coverage and other health coverage is an affordable and effective strategy for reducing racial and ethnic disparities.

  4. Improve quality of mental health services.
  Above all, improving the quality of mental health care is a vital goal for the Nation. Persons with mental illness who receive quality care are more likely to stay in treatment and to have better outcomes. This result is critical, as many treatments require at least four to six weeks to show a clear benefit to the patient. Through relief of distress and disability, consumers can begin to recover from mental illness. They can become more productive and make more fulfilling contributions to family and community.

  Quality care conforms to professional guidelines that carry the highest standards of scientific rigor. To improve the quality of care for minorities, this Supplement encourages providers to deliver effective treatments based on evidence-based professional guidelines. Treatments with the strongest evidence of efficacy have been incorporated into treatment guidelines issued by organizations of mental health professionals and by government agencies.
  A major priority for the Nation is to transform mental health services by tailoring them to meet the needs of all Americans, including racial and ethnic minorities. To be most effective, treatments always need to be individualized in the clinical setting according to each patient's age, gender, race, ethnicity, and culture (DHHS, 1999). No simple blueprint exists for how to accomplish this transformation, but there are many promising courses of action for the Nation to pursue.

  At the same time, research is needed on several fronts, such as how to adapt evidence-based treatments to maximize their appeal and effectiveness for racial and ethnic minorities. While "ethnic-specific" and "culturally competent" service models take into account the cultures of racial and ethnic groups, including their languages, histories, traditions, beliefs, and values, these approaches to service delivery have thus far been promoted on the basis of humanistic values rather than rigorous empirical evidence. Further study may reveal how these models build an important, yet intangible, aspect of treatment: trust and rapport between patients and service providers.

  5. Support capacity development.
  This Supplement encourages all mental health professionals to develop their skills in tailoring treatment to age, gender, race, ethnicity, and culture. In addition, because minorities are dramatically underrepresented among mental health providers, researchers, administrators, policy makers, and consumer and family organizations, racial and ethnic minorities are encouraged to enter the mental health field. Training programs and funding sources also need to work toward equitable racial and ethnic minority representation in all these groups.

  Another way to support capacity development and maximize systems of care is to promote leadership from within the community in which a mental health system is located. Issues of race, culture, and ethnicity may be addressed while engaging consumers, families, and communities in the design, planning, and implementation of their own mental health service systems. To reduce disparities in knowledge, and the availability, utilization, and quality of mental health services for racial and ethnic minority consumers, mental health educational, research, and service programs must develop a climate that conveys an appreciation of diverse cultures and an understanding of the impact of these cultures on mental health and mental illness. Doing so will help systems better meet the needs of all consumers and families, including racial and ethnic minorities.

  6. Promote mental health.
  Mental health promotion and mental illness prevention can improve the health of a community and the Nation. Because mental health is adversely affected by chronic social conditions such as poverty, community violence, racism, and discrimination, the reduction of these adverse conditions is quite likely to be vital to improving the mental health of racial and ethnic minorities. Efforts to prevent mental illness and promote mental health should build on intrinsic community strengths such as spirituality, positive ethnic identity, traditional values, educational attainment, and local leadership. Programs founded on individual, family, and community strengths have the potential to both ameliorate risk and foster resilience.

  Families are the primary source of care and support for the majority of adults and children with mental problems or disorders. Efforts to promote mental health for racial and ethnic minorities must include strategies to strengthen families to function at their fullest potential and to mitigate the stressful effects of caring for a relative with a mental illness or a serious emotional disturbance.

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