Executive Summary Contents
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Chapter Summaries & Conclusions
Chapter 2: Culture Counts
The cultures of racial and ethnic minorities influence
many aspects of mental illness, including how patients
from a given culture communicate and manifest their
symptoms, their style of coping, their family and community
supports, and their willingness to seek treatment.
Likewise, the cultures of the clinician and the service
system influence diagnosis, treatment, and service delivery.
Cultural and social influences are not the only determinants
of mental illness and patterns of service use, but
they do play important roles.
- 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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