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Office of the Surgeon General (US); Center for Mental Health Services (US); National Institute of Mental Health (US). Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2001 Aug.

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Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General.

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Chapter 1. Introduction

America draws strength from its cultural diversity. The contributions of racial and ethnic minorities have suffused all areas of contemporary life. Diversity has made our Nation a more vibrant and open society, ablaze in ideas, perspectives, and innovations. But the full potential of our diverse, multicultural society cannot be realized until all Americans, including racial and ethnic minorities, gain access to quality health care that meets their needs.

This Supplement to Mental Health: A Report of the Surgeon General (U.S. Department of Health and Human Services [DHHS], 1999) documents the existence of striking disparities for minorities in mental health services and the underlying knowledge base. Racial and ethnic minorities have less access to mental health services than do whites. 1 They are less likely to receive needed care. When they receive care, it is more likely to be poor in quality.

These disparities have powerful significance for minority groups and for society as a whole. A major finding of this Supplement is that racial and ethnic minorities bear a greater burden from unmet mental health needs and thus suffer a greater loss to their overall health and productivity. This conclusion draws on prominent international and national findings. One is that mental disorders are highly disabling across all populations. 2 According to a landmark study by the World Health Organization, the World Bank, and Harvard University, mental disorders are so disabling that, in established market economies like the United States, they rank second only to cardiovascular disease in their impact on disability (Murray & Lopez, 1996). Another important finding comes from the largest disability study ever conducted in the United States It found that one-third of disabled 3 adults (ages 18-55) living in the community 4 reported having a mental disorder contributing to their disability (Druss et al., 2000).

While neither of these studies addressed the disability burden for minorities relative to whites, key findings from this Supplement do: Most minority groups are less likely than whites to use services, and they receive poorer quality mental health care, despite having similar community rates of mental disorders. Similar prevalence, combined with lower utilization and poorer quality of care, means that minority communities have a higher proportion of individuals with unmet mental health needs. Further, minorities are overrepresented among the Nation's vulnerable, high-need 5 groups, such as homeless and incarcerated persons. These subpopulations have higher rates of mental disorders than do people living in the community Koegel et al., 1988; Vernez et al., 1988; Breakey et al., 1989; Teplin, 1990. Taken together, the evidence suggests that the disability burden from unmet mental health needs is disproportionately high for racial and ethnic minorities relative to whites.

The greater disability burden to minorities is of grave concern to public health, and it has very real consequences. Ethnic and racial minorities do not yet completely share in the hope afforded by remarkable scientific advances in understanding and treating mental disorders. Because of preventable disparities in mental health services, a disproportionate number of minorities are not fully benefiting from, or contributing to, the opportunities and prosperity of our society.

More is known about the existence of disparities in mental health services - and their significance - than the reasons behind them. The most likely explanations, identified in Mental Health: A Report of the Surgeon General, are expanded upon throughout this Supplement. They trace to a mix of barriers deterring minorities from seeking treatment or operating to reduce its quality once they reach treatment.

The foremost barriers include the cost of care, societal stigma, and the fragmented organization of services. Additional barriers include clinicians' lack of awareness of cultural issues, bias, or inability to speak the client's language, and the client's fear and mistrust of treatment. More broadly, disparities also stem from minorities' historical and present day struggles with racism and discrimination, which affect their mental health and contribute to their lower economic, social, and political status.

The cumulative weight and interplay of all of these barriers, not any single one alone, is likely responsible for mental health disparities. Furthermore, these barriers operate to discernibly different degrees for different individuals and groups, depending on life circumstances, age, gender, sexual orientation, or spiritual beliefs. What becomes amply clear from this report is that there are no uniform racial or ethnic groups, white or nonwhite. Rather, each is highly heterogeneous, including a diverse mix of immigrants, refugees, and multigenerational Americans, with vastly different histories, languages, spiritual practices, demographic patterns, and cultures.

Origins and Purposes of the Supplement

This Supplement, Mental Health: Culture, Race, and Ethnicity, is an outgrowth of the 1999 report, Mental Health: A Report of the Surgeon General, the first Surgeon General's report ever issued on mental health and mental illness. That report (hereinafter called the SGR) called attention to several overarching points that resonate throughout this Supplement (Box 1-1). Through extensive documentation of the scientific literature, the report found that mental disorders are real and disabling conditions for which there are a range of effective treatments. It found that the efficacy of mental health treatment is well documented. On the basis of these findings, the Surgeon General made a single, explicit recommendation for everyone: Seek help if you have a mental health problem or think you have symptoms of a mental disorder. This Supplement affirms this vital recommendation and the major findings in which it is firmly anchored.

Overall, the SGR provided hope for people with, or at risk for, mental disorders by presenting the evidence for what can be done to prevent and treat mental illness. It also provided hope for recovery from mental illness. In his Preface, however, the Surgeon General pointed out that all Americans do not share this hope equally: Even more than other areas of health and medicine, the mental health field is plagued by disparities in the availability of and access to its services. These disparities are viewed readily through the lenses of racial and cultural diversity, age, and gender. (DHHS, 1999, p. vi)

Box 1-1: Mental Health: A Report of the Surgeon General

Themes of the Report

  • Mental health and mental illness require the broad focus of a public health approach.
  • Mental disorders are disabling conditions
  • Mental health and mental illness are points on a continuum.
  • Mind and body are inseparable.
  • Stigma is a major obstacle preventing people from getting help.

Messages from the Surgeon General

  • Mental health is fundamental to health.
  • Mental illnesses are real health conditions.
  • The efficacy of mental health treatments is well documented
  • A range of treatments exists for most mental disorders.

This Supplement was undertaken to probe more deeply into mental health disparities affecting racial and ethnic minorities. Drawing on scientific evidence from a wide-ranging body of empirical research, the Supplement has three purposes:

  1. To understand better the nature and extent of mental health disparities,
  2. To present the evidence on the need for mental health services and on the provision of services to meet those needs, and
  3. To document promising directions toward the elimination of mental health disparities and the promotion of mental health.

This Supplement covers the four most recognized racial and ethnic minority groups in the United States. According to Federal classifications, African Americans (blacks), American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and white Americans (whites) are races. Hispanic American (Latino) is an ethnicity and may apply to a person of any race (U.S. Office of Management and Budget [OMB], 1978). For example, many people from the Dominican Republic identify their ethnicity as Hispanic or Latino and their race as black.

The U.S. Office of Management and Budget created these four categories for the collection of census and other types of information by Federal agencies. One limitation is that each category groups together an extremely heterogeneous array of ethnic groups. For example, the Bureau of Indian Affairs currently recognizes 561 American Indian and Alaska Native tribes. Further, the broad category labels are imprecise: People who are indigenous to the Americas, for example, may be called Hispanic if they are from Mexico but American Indian if they are from the United States. Despite these well recognized limitations, these categories are used for this Supplement because they serve as standard nomenclature for data collection and research. 6

This Supplement employs the term "racial and ethnic minorities" to refer collectively to people who identify as African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanic Americans. The term "minority" is used to signify the groups' limited political power and social resources, as well as their unequal access to opportunities, social rewards, and social status. The term is not meant to connote inferiority or to indicate small demographic size.

The four major groups covered by this Supplement accounted for about 30 percent of the U.S. population in 2000. They are projected to account for almost 40 percent by 2025. 7 Figure 1-1 illustrates the growth in population size across racial and ethnic groups. The demographic surge in minority populations projected over the next two decades is expected to accompany continuing economic gaps between rich and poor. These gaps progressively narrowed from 1947 to 1968 but then reversed course: Income inequality rose over a 25-year period, from 1968 to 1993 (U.S. Census, 2000). These trends swelled the ranks of rich and poor, and reduced the size of the middle class. From 1993 to 1998, changes in income inequality leveled off, but significant disparities still exist. 8 Income status is relevant to mental health because of the strong association between lower income and higher rates of mental health problems and disorders (Chapter 2), and because of the association between health insurance and the ability to pay for mental health services (Brown et al., 2000).

Figure 1-1. U.S. Population by Race and Hispanic Origin.

Figure

Figure 1-1. U.S. Population by Race and Hispanic Origin.

Scope and Terminology

Mental Health and Mental Illness

The focus of this Supplement is on mental health and mental illness in racial and ethnic minorities. Mental health and mental illness are not polar opposites, but points on a continuum. Somewhere in the middle of that continuum are "mental health problems," which most people have experienced at some point in their lives. The experience of feeling low and dispirited in the face of a stressful job is a familiar example. The boundaries between mental health problems and milder forms of mental illness are often indistinct, just as they are in many other areas of health. Yet at the far end of the continuum lie disabling mental illnesses such as major depression, schizophrenia, and bipolar disorder. Left untreated, these disorders erase any doubt as to their devastating potential.

The SGR offered general definitions of mental health, mental illness, and mental health problems (Box 1-2). It described mental health as important for personal well-being, family and interpersonal relationships, and successful contributions to community or society. These are jeopardized by mental health problems and mental illnesses.

Box 1-2: Mental Health and Mental Illness

Mental Health The successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with adversity.

Mental Illness The term that refers collectively to all mental disorders, which are health conditions characterized by alterations in thinking, mood, or behavior (or some combination thereof) associated with distress and/or impaired functioning.

Mental Health Problems Signs and symptoms of insufficient intensity or duration to meet the criteria for any mental disorder.

Source: DHHS (1999).

While these elements of mental health may be identifiable, mental health itself is not easy to define more precisely because any definition is rooted in value judgments that may vary across individuals and cultures. According to a distinguished leader in the field of mental health, "Because values differ across cultures as well as among some groups (and indeed individuals) within a culture, the ideal of the uniformly acceptable definition of [mental health] is illusory" (Cowen, 1994).

Mental illness refers collectively to all diagnosable mental disorders. Mental disorders feature abnormalities in cognition, emotion or mood, and the highest integrative aspects of human behavior, such as social interactions. Depression, anxiety, schizophrenia, and other mental disorders are commonly found in the U.S. population, affecting about 1 in 5 adults and children (DHHS, 1999). The prevalence rates for mental disorders in U.S. adults are presented in Table 1-1.

Table 1-1. Prevalence rates (1-year) of mental disorders: Best estimates for adults, ages 18-54.

Table

Table 1-1. Prevalence rates (1-year) of mental disorders: Best estimates for adults, ages 18-54.

It would be helpful to be able to construct a similar table for racial and ethnic minorities. The patterns of specific mental disorders could then be compared between each minority group and the U.S. population as a whole. Unfortunately, prevalence rates are not yet known for each mental disorder within a given minority population. The studies published thus far are not sufficiently nationally representative; however, such nationally representative studies are currently in progress. Nevertheless, this Supplement finds enough evidence from many smaller studies to conclude that the overall rate of mental illness among minorities is similar to the overall rate of about 21 percent across the U.S. population. In short, the patterns of prevalence for specific mental disorders within the overall rate may vary some-what, but the total prevalence appears to be similar across populations living in community settings. 9

Mental disorders reflect abnormal functioning of the brain. They alter mental life and behavior by affecting the function of neurocircuits, the elaborate pathways through which cells in the brain (neurons) communicate with one another and with other parts of the body. The precise causes of most mental disorders are not known; the broad forces that shape them are genetic, psychological, social, and cultural, which interact in ways not yet fully understood. The modern field of integrative neuroscience strives to explain how genes and environment (broadly defined to include culture) work together in a dynamic rather than a static manner to produce mental life and behavior. The field focuses on many levels of investigation - molecular, cellular, systems, and behavior - to uncover the basis for mental health and mental illness. It does not separate nature from nurture, pitting them against one another. Rather, the field examines their interaction, the ways in which mental life and experience over time actually change the structure and function of neurocircuits. Through learning and memories that come with personal experience and socialization, neurocircuits are sculpted and shaped throughout life Kandel, 1998; Hyman, 2000 .

Race, Ethnicity, and Culture

Any report of this magnitude needs to define the major terms it uses, all the more so when the terms are often controversial. The problem is that precise definitions of the terms "race," "ethnicity," and "culture" are elusive. As social concepts, they have so many different meanings, and those meanings evolve over time. With these caveats in mind, this section expands upon the general definitions of these terms adopted by the SGR.

Race

Most people think of "race" as a biological category - as a way to divide and label different groups according to a set of common inborn biological traits (e.g., skin color, or shape of eyes, nose, and face). Despite this popular view, there are no biological criteria for dividing races into distinct categories Lewontin, 1972; Owens & King, 1999. No consistent racial groupings emerge when people are sorted by physical and biological characteristics. For example, the epicanthic eye fold that produces the so-called "Asian" eye shape is shared by the !Kung San Bushmen, members of an African nomadic tribe.

The visible physical traits associated with race, such as hair and skin color, are defined by a tiny fraction of our genes, and they do not reliably differentiate between the social categories of race. As more is learned about the 30,000 genes of the human genome, variations between groups are being identified, such as in genes that code for the enzymes active in drug metabolism (Chapter 2). While such information may prove to have clinical utility, it is important to note that these variations cannot be used to distinguish groups from one another as they are outweighed by overwhelming genetic similarities across so-called racial groups (Paabo, 2001).

The strongest, most compelling evidence to refute race as a biological category comes from genetic analysis of different racial groups. There is overwhelmingly greater genetic variation within a racial group than across racial groups. One study examined the variation in 109 DNA regions that were known to contain a high level of polymorphisms, or DNA sequence variations. Published in one of the most respected scientific journals and in agreement with earlier research, it found that 85 percent of human genetic diversity is found within a given racial group (Barbujani et al., 1997).

Race is not a biological category, but it does have meaning as a social category. Different cultures classify people into racial groups according to a set of characteristics that are socially significant. The concept of race is especially potent when certain social groups are separated, treated as inferior or superior, and given differential access to power and other valued resources. This is the definition adopted by this Supplement because of its significance in understanding the mental health of racial and ethnic minority groups in American society.

Ethnicity

Ethnicity refers to a common heritage shared by a particular group (Zenner, 1996). Heritage includes similar history, language, rituals, and preferences for music and foods. Historical experiences are so pivotal to understanding ethnic identity and current health status that they occupy the introductory portion of each chapter covering a racial or ethnic group (Chapters 3- 6).

The term "race," when defined as a social category, may overlap with ethnicity, but each has a different social meaning. For example, in many national surveys and in the 1990 U.S. census, Native Hawaiians and Vietnamese Americans are classified together in the racial category of "Asian and Pacific Islander Americans." Native Hawaiians, however, have very little in common with Vietnamese Americans in terms of their heritage. Similarly, Caribbean blacks and Pacific Northwest Indians have different ethnicities than others within their same racial category. And, as noted earlier, because Hispanics are an ethnicity, not a race, the different Latino American ethnic subgroups such as Cubans, Dominicans, Mexicans, Puerto Ricans, and Peruvians include individuals of all races.

Culture

Culture is broadly defined as a common heritage or set of beliefs, norms, and values (DHHS, 1999). It refers to the shared, and largely learned, attributes of a group of people. Anthropologists often describe culture as a system of shared meanings. People who are placed, either by census categories or through self-identification, into the same racial or ethnic group are often assumed to share the same culture. Yet this assumption is an over-generalization because not all members grouped together in a given category will share the same culture. Many may identify with other social groups to which they feel a stronger cultural tie such as being Catholic, Texan, teenaged, or gay.

Culture is as applicable to groups of whites, such as Irish Americans or German Americans, as it is to racial and ethnic minorities. As noted, the term "culture" is also applicable to the shared values, beliefs, and norms established in common social groupings, such as adults trained in the same profession or youth who belong to a gang. The culture of clinicians, for example, is discussed in Chapter 2 to help explain interactions between patients and clinicians.

The phrase "cultural identity" refers to the culture with which someone identifies and to which he or she looks for standards of behavior (Cooper & Denner, 1998). Given the variety of ways in which to define a cultural group, many people consider themselves to have multiple cultural identities.

A key aspect of any culture is that it is dynamic: Culture continually changes and is influenced both by people's beliefs and the demands of their environment (Lopez & Guarnaccia, 2000). Immigrants from different parts of the world arrive in the United States with their own culture but gradually begin to adapt. The term "acculturation" refers to the socialization process by which minority groups gradually learn and adopt selective elements of the dominant culture. Yet that dominant culture is itself transformed by its interaction with minority groups. And, to make matters more complex, the immigrant group may form its own culture, distinct from both its country of origin and the dominant culture. The Chinatowns of major cities in the United States often exemplify the blending of Chinese traditions and an American context.

The dominant culture for much of U.S. history has centered on the beliefs, norms, and values of white Americans of Judeo-Christian origin, but today's America is much more multicultural in character. Still, its societal institutions, including those that educate and train mental health professionals, have been shaped by white American culture and, in a broader characterization, Western culture. That cultural legacy has left its imprint on how mental health professionals respond to patients in all facets of care, beginning with their very first encounter, the diagnostic interview.

Diagnosis and Culture

Western medicine has become a cornerstone of health worldwide because it is based on evidence from scientific research. A hallmark of Western medicine is its reliance on accurate diagnosis, the identification and classification of disease. An accurate diagnosis dictates the type of treatment and supportive care, and it sheds light on prognosis and course of illness. The diagnosis of a mental disorder is arguably more difficult than diagnoses in other areas of medicine and health because there are usually no definitive lesions (pathological abnormalities) or laboratory tests. Rather, a diagnosis depends on a pattern, or clustering, of symptoms (i.e., subjective complaints), observable signs, and behavior associated with distress or disability. Disability is impairment in one or more areas of functioning at home, work, school, or in the community (American Psychiatric Association [APA], 1994).

The formal diagnosis of a mental disorder is made by a clinician and hinges upon three components: a patient's description of the nature, intensity, and duration of symptoms; signs from a mental status examination; and a clinician's observation and interpretation of the patient's behavior, including functional impairment. The final diagnosis rests on the clinician's judgment about whether the patient's signs, symptom patterns, and impairments of functioning meet the criteria for a given diagnosis. The American Psychiatric Association sets forth those diagnostic criteria in a standard manual known as the Diagnostic and Statistical Manual of Mental Disorders. This is the most widely used classification system, both nationally and internationally, for teaching, research, and clinical practice (Maser et al., 1991).

Mental disorders are found worldwide. Schizophrenia, bipolar disorder, panic disorder, and depression have similar symptom profiles across several continents (Weissman et al., 1994, 1996, 1997, 1998). Yet diagnosis can be extremely challenging, even to the most gifted clinicians, because the manifestations of mental disorders and other physical disorders vary with age, gender, race, ethnicity, and culture. Take some of the symptoms of depression - persistent sadness or despair, hopelessness, social withdrawal - and imagine the difficulty of communication and interpretation within a culture, much less from one culture to another. The challenge rests not only with the patient, but also with the clinician, as well as with their dynamic interactions. Patients from one culture may manifest and communicate symptoms in a way poorly understood in the culture of the clinician. Consider that words such as "depressed" and "anxious" are absent from the languages of some American Indians and Alaska Natives (Manson et al., 1985). However, this does not preclude them from having depression or anxiety.

To arrive at a diagnosis, clinicians must determine whether patients' signs and symptoms significantly impair their functioning at home, school, work, and in their communities. This judgment is based on deviation from social norms (cultural standards of acceptable behavior) (Scadding, 1996). For example, among some cultural groups, perceiving visions or voices of religious figures might be part of normal religious experience on some occasions and aberrant social functioning on other occasions. It becomes obvious that the interaction between clinician and patient is rife with possibilities for miscommunication and misunderstanding when they are from different cultures. According to the American Psychiatric Association, Diagnostic assessment can be especially challenging when a clinician from one ethnic or cultural group uses the DSM-IV Classification to evaluate an individual from a different ethnic or cultural group. A clinician who is unfamiliar with the nuances of an individual's cultural frame of reference may incorrectly judge as psychopathology those normal variations in behavior, beliefs, or experience that are particular to the individual's culture. (APA, 1994)

The multifaceted ways that culture influences mental illness and mental health services are discussed at length in Chapter 2.

The issuance in 1994 of the fourth edition of the (DSM-IV) marked a new level of acknowledgment of the role of culture in shaping the symptom presentation, expression, and course of mental disorders. Whereas prior editions referred to such matters only in passing, this edition specifically included some discussion of cultural variations in the clinical presentation of each DSM-IV disorder, a glossary of some idioms of distress and "culture-bound syndromes" (Box 1-3), and a brief outline to assist the clinician in formulating the cultural dimensions for an individual patient (APA, 1994).

Box 1-3: Idioms of Distress and Culture-Bound Syndromes

Idioms of distress are ways in which different cultures express, experience, and cope with feelings of distress. One example is somatization, or the expression of distress through physical symptoms (Kirmayer & Young, 1998). Stomach disturbances, excessive gas, palpitations, and chest pain are common forms of somatization in Puerto Ricans, Mexican Americans, and whites (Escobar et al., 1987). Some Asian groups express more cardiopulmonary and vestibular symptoms, such as dizziness, vertigo, and blurred vision (Hsu & Folstein, 1997). In Africa and South Asia, somatization sometimes takes the form of burning hands and feet, or the experience of worms in the head or ants crawling under the skin (APA, 1994).

Culture-bound syndromes are clusters of symptoms much more common in some cultures than in others. For example, some Latino patients, especially women from the Caribbean, display ataque de nervios, a condition that includes screaming uncontrollably, attacks of crying, trembling, and verbal or physical aggression. Fainting or seizure-like episodes and suicidal gestures may sometimes accompany these symptoms (Guarnaccia et al., 1993). A culture-bound syndrome from Japan is taijin kyofusho, an intense fear that one's body or bodily functions give offense to others. This syndrome is listed as a diagnosis in the Japanese clinical modification of the World Health Organization (WHO) International Classification of Diseases, 10th edition (1993).

Numerous other culture-bound syndromes are given in the DSM-IV "Glossary of Culture-Bound Syndromes." Researchers have taken initial steps to examine the interrelationships between culture-bound syndromes and the diagnostic classifications of DSM-IV. For example, in a sample of Latinos seeking care for anxiety disorders, 70 percent reported having at least one ataque. Of those, over 40 percent met DSM-IV criteria for panic disorder, and nearly 25 percent met criteria for major depression (Liebowitz et al., 1994). In past research, there has been an effort to fit culture-bound syndromes into variants of DSM diagnoses. Rather than assume that DSM diagnostic entities or culture-bound syndromes are the basic patterns of illness, current investigators are interested in examining how the social, cultural, and biological contexts interact to shape illnesses and reactions to them. This is an important area of research in a field known as cultural psychiatry or ethnopsychiatry.

The "Outline for Cultural Formulation" in DSM-IV systematically calls attention to five distinct aspects of the cultural context of illness and their relevance to diagnosis and care. The clinician is encouraged to:

  1. Inquire about patients' cultural identity to determine their ethnic or cultural reference group, language abilities, language use, and language preference,
  2. Explore possible cultural explanations of the illness, including patients' idioms of distress, the meaning and perceived severity of their symptoms in relation to the norms of the patients' cultural reference group, and their current preferences for, as well as past experiences with, professional and popular sources of care,
  3. Consider cultural factors related to the psychosocial environment and levels of functioning. This assessment includes culturally relevant interpretations of social stressors, available support, and levels of functioning, as well as patients' disability,
  4. Critically examine cultural elements in the patient-clinician relationshipto determine differences in culture and social status between them and how those differences affect the clinical encounter, ranging from communication to rapport and disclosure,
  5. Render an overall cultural assessment for diagnosis and care, meaning that the clinician synthesizes all of the information to determine a course of care.

The "Outline for Cultural Formulation" has been heralded as a major step forward, but with limitations related to its scope, depth, and placement in an appendix (see review in Lopez & Guarnaccia, 2000). Because major areas were omitted in the final version of the Outline, some assert that the scope is too narrow to reflect the dynamic role of culture in mental health problems and disorders Lewis-Fernandez & Kleinman, 1995; Mezzich et al., 1999.

Other mental health experts point out that the discussion of idioms of distress is too limited and fails to capture their nuances, from their everyday meanings within a culture to their significance as symptoms of distress and their possible application to many different disorders across cultures Kirmayer & Young, 1998; see also Chapter 6. Finally, placement of the Outline in an appendix is seen as marginalizing the role of culture, instead of appreciating its multifaceted roles across all mental disorders and cultures, including white American culture.

In recognition of the evolving nature of diagnosis, the American Psychiatric Association has an explicit revision process for DSM, which is updated roughly every 10 years to achieve greater objectivity, diagnostic precision, and diagnostic reliability in light of new empirical findings and field testing. Limitations of the current cultural formulation are expected to be addressed in future revisions of DSM. Interest in the role of culture in mental health and mental illness is consistent with the broader trend in neuroscience and genetics, integrative neuroscience. This field strives to explain the powerful effect of experience, in the broadest possible sense, on the structure and function of the brain. Leaders in the field envision that the study of genes and their interaction with the environment will yield new boundaries between mental disorders, which now are divided mostly on the basis of symptom clusters, course of illness, response to treatment, and family history (Hyman, 2000).

The Public Health Approach

The public health field in the United States traces its origins to attempts to control infectious diseases in the late 18th century (Mullan, 1989). Its expansion during the 19th and 20th centuries was tied to the growing awareness of the importance of income, employment, lifestyle, and diet in health and disease (Porter, 1997). The first reports on public health documented higher rates of disease in impoverished, overcrowded communities. The documented effects of population growth, migration to cities, and industrialization brought to light the roles of social forces and the environment in disease causation. By the mid-19th century, public health became a new field grounded in scientific observation and stunning developments in bacteriology (Institute of Medicine [IOM], 1988).

Today the public health approach underpins the Nation's commitment to health and medicine. This population-based approach is concerned with the health of an entire population, including its link to the physical, psychological, cultural, and social environments in which people live, work, and go to school (Chapter 2).

Public health focuses not only on traditional areas of medicine - diagnosis, treatment, and etiology or cause of an illness - but also on disease surveillance, health promotion, disease prevention, and access to and evaluation of services (Last & Wallace, 1992). The public health approach is premised on the conviction that it is inherently better to promote health and to prevent illness before it begins. Prevention also holds the promise of being more cost-effective.

Promoting Mental Health and Preventing Mental Disorders

The mental health field traditionally focused on mental illness in an attempt to serve individuals with the most severe disorders. As the field matures, however, it has begun to embrace activities that may promote mental health or prevent some mental illnesses and behavioral disorders. More specifically, it is employing the public health approach to identify problems and develop solutions for entire population groups. This approach:

  • Defines the problem using surveillance processes designed to gather data that establish the nature of the problem and the trends in its incidence and prevalence;
  • Identifies potential causes through epidemiological analyses that identify risk and protective factors associated with the problem;
  • Designs, develops, and evaluates the effectiveness and generalizability of interventions; and
  • Disseminates successful models as part of a coordinated effort to educate and reach out to the public Hamburg, 1998; Mercy et al., 1993.

Just as mental health and mental illness are points on a continuum, so too are the public health goals of mental health promotion and mental illness prevention. Promotion refers to active steps to enhance mental health, while prevention refers to active steps to protect against the onset of mental health problems or illnesses. 10

Promotion and prevention hinge on the identification of modifiable risk and protective factors, i.e., characteristics or conditions that, if present, increase or diminish, respectively, the likelihood that people will develop mental health problems or disorders (see full discussion in DHHS, 1999, p. 63-64). The modifiability of a risk or protective factor is a prerequisite for developing interventions targeted at these factors.

Risk and protective factors may be biological, psychological, or social in nature. They can operate within an individual, family, community, culture, or the larger society (Boxes 1-4, 1-5). A single risk or protective factor, in most cases, increases the probability, but is not necessarily the cause of a harmful or healthful effect. That is, one factor rarely is either necessary or sufficient to produce a given outcome. Each person is exposed to a unique constellation of risk and protective factors that act not in isolation, but rather through complex and often perplexing interactions. It is the accumulation and interaction of risk and protective factors that contribute to mental health, mental health problems, or mental illness, not a single risk or protective factor (IOM, 1994).

Risk and protective factors not only vary across individuals, but also across age, gender, and culture. A prime goal of the SGR was to sift through risk and protective factors affecting different age groups. This Supplement focuses on risk and protective factors that disproportionately affect racial and ethnic minorities. Such risk factors include poverty, immigration, violence, racism, and discrimination, whereas protective factors include spirituality and community and family support (Chapter 2).

Several well-designed studies have demonstrated that interventions can successfully reduce the severity of certain mental disorders and enhance mental health. Some of these studies have been conducted with ethnic and racial minority samples. For example, low-income minority adults at risk for depression participated in a course on cognitive-behavioral methods adapted to their culture to control their moods. At the end of the course and at 1-year followup, these adults showed fewer symptoms of depression than did a control group (Munoz et al., 1995). For low-income, Spanish-speaking immigrant families at risk for attachment disorders, a home visitor program for mothers and infants led to more secure attachments (Lieberman et al., 1991). These findings, while quite promising, must be understood in context: At this point, the mental health field does not have sufficient knowledge of causation to prevent the onset of major mental disorders like schizophrenia and bipolar disorder (DHHS, 1999).

The recently issued report, Youth Violence: A Report of the Surgeon General, spotlighted 27 effective interventions designed to prevent youth violence (DHHS, 2001). Many of these programs target high-risk racial and ethnic minority youth. Violence in youth not only produces injuries, disability, and death, but it also often has enduring negative consequences for the mental health of victims, perpetrators, their families, and their communities. There is little doubt that our poorest neighborhoods, where a disproportionate percentage of minorities live, are fraught with violence. Preventing violence is a vital public health goal with the potential to improve the mental health and overall health of our nation.

Box 1-4 Examples of Risk Factors Common to Mental Health Problems and Mental Disorders

Individual

  • Genetic vulnerability *
  • Gender
  • Low birth weight
  • Neuropsychological deficits
  • Language disabilities
  • Chronic physical illness
  • Below-average intelligence
  • Child abuse or neglect
Family
  • Severe marital discord
  • Social disadvantage
  • Overcrowding or large family size
  • Paternal criminality
  • Maternal mental disorder
  • Admission to foster care
Community or social
  • Violence
  • Poverty
  • Community disorganization
  • Inadequate schools
  • Racism and discrimination
* Genetic vulnerability varies by mental disorder

Sources: DHHS, 2001; DHHS, 1999; IOM, 1994

Box 1-5 Examples of Protective Factors Against Mental Health Problems and Mental Disorders

Individual

  • Positive temperament
  • Above-average intelligence
  • Social competence
  • Spirituality or religion
Family
  • Smaller family structure
  • Supportive relationships with parents
  • Good sibling relationships
  • Adequate rule setting and monitoring by parents
Community or social
  • Commitment to schools
  • Availability of health and social services
  • Social cohesion
Sources: DHHS, 2001; DHHS, 1999; IOM, 1994

Resilience

One area of mental health promotion that has received considerable attention in recent years is resilience, or the capacity to bounce back from adversity. Increasingly researchers emphasize that resilience is by no means a fixed trait of an individual.Rather, resilient adaptation comes about as a result of an individual's situation in interaction with protective factors in the social environment. Resilience research and programs take a "strengths-based approach" to human development and functioning: Rather than focusing on deficits and illnesses, they seek to understand and promote "self-righting tendencies" in individuals, families, and communities (Werner, 1989).

The formal study of resilience stems from research begun in the 1970s on children of parents with schizophrenia (Garmezy, 1971). The investigator found that having a parent with schizophrenia does indeed increase someone's risk for the illness, yet about 90 percent of the children in the study did not develop the illness. Further, most fared well in terms of peer relations, academic achievement, and other measures of mental health (Garmezy, 1971, 1991). This seminal research spawned a new line of investigations on children and other groups living in high-risk conditions such as poverty, war, and natural disasters.

Consistent with the public health approach, resilience research focuses on the promotion of protective factors. Key protective factors in racial and ethnic minority communities are supportive families, strong communities, spirituality, and religion.

Supportive Families and Communities

Researchers find that the support of other people is key to helping people cope with adversity. According to a nationally representative survey, families and friends are the first sources to which people say they will turn if they develop a mental illness (Pescosolido et al., 2000).

As early as 1983, researchers identified the following 10 characteristics of resilient African American families:

  1. Strong economic base
  2. Achievement orientation
  3. Role adaptability
  4. Spirituality
  5. Extended family bonds
  6. Racial pride
  7. Respect and love
  8. Resourcefulness
  9. Community involvement
  10. Family unity (Gary et al., 1983)

Other researchers have looked at the role of extended family members and other people in the community in helping children function well. A literature review on resilient African American children raised in inner-city neighborhoods concluded that "there was at least one adequate significant adult who was able to serve as an identification figure. In turn, the achieving youngsters seemed to hold a more positive attitude toward adults and authority figures in general" (Garmezy & Neuchterlein, 1972). In another study, African American children of low-income, divorced or separated parents were less likely to drop out of school if influenced by grandparents who provided continuity and support (Robins, et al., 1975). Similarly, for urban elementary students chronically exposed to violence, support of teachers enhanced their social competence in the classroom, as did support from peers and family. Family support was also critical in relieving the children's anxiety Hill & Madhere, 1996; Hill et al.,1996.

One ground-breaking ethnographic study focused on the children of Vietnamese refugees who were forced to leave Vietnam when Saigon fell in 1975. Many parents were subjected to severe trauma prior to immigration and then to the stress of resettlement in the United States. The children of these refugees showed remarkable resilience, at least in terms of school performance and academic ambitions. In an examination of Vietnamese students attending public high schools in a low-income resettlement area in New Orleans, approximately one-fourth of the students had an A average, and over half had a B average. Only 5 percent did not want to go to college. This study concluded that several factors contributed to the resilience of these children, including strong family and community ties, and "selective Americanization," i.e., integrating the best of American values while maintaining the best Vietnamese values (Zhou & Bankston, 1998).

For racial and ethnic minority groups, supportive families and communities help arriving immigrants with practical assistance in housing, transportation, and employment. In addition, they offer enduring emotional support and a haven against racism and discrimination. They also affirm cultural identity. The contributions of family and community are so ubiquitous and expected, that they only become obvious by their absence. A recurring theme of this Supplement is the essential nature of community and family support.

Spirituality and Religion

Spirituality and religion are gaining increased research attention because of their possible link to mental health promotion and mental illness prevention. Research findings, while somewhat equivocal, suggest that various aspects of religious practice, affiliation, and belief are beneficial for mental health. The findings are strongest for a link between spirituality and certain aspects of mental health, such as subjective well-being and life satisfaction e.g., Witter et al., 1985; Koenig et al., 1988; Ellison, 1991; Schumaker, 1992; Levin, 1994.

Research findings are somewhat contradictory about whether spirituality is associated with less psychological distress and fewer symptoms of depression in adults e.g., Idler, 1987; Williams et al., 1991. For prevention purposes, the role of spirituality may be tied to family relationships, as demonstrated by one recent, long-term study. It examined whether the mother's religious devotion was correlated with whether her children developed depression. The study found, over a 10-year period, that two factors were correlated with the children's not developing depression - the mother's religiosity and her having the same religious denomination as her children (Miller et al., 1997).

The association between religious involvement and mental health also has been studied directly in African Americans. Using data from five large national samples, researchers found that African Americans report significantly higher levels of subjective religiosity than do whites (Taylor et al., 1999). Other studies show that religious factors are strong predictors of life satisfaction for African Americans St. George & McNamara, 1984; Thomas & Holmes, 1992. Studies also find that public and private aspects of religious involvement are associated with improved self-perceptions and self-esteem Krause & Tran, 1989; Ellison, 1993.

Spirituality plays a prominent role in the lives of the majority of Americans, including many racial and ethnic minorities. For example, many American Indian and Alaska Native communities participate in spiritual and religious traditions, including the Native American Church, where Christian and Native beliefs coexist. Less is known about how these traditions relate to mental health. To study the relationship, researchers may need to develop new approaches and different types of out-come measures (The Fetzer Institute & National Institute on Aging, 1999).

How might spirituality and religion exert an influence on health? This provocative question has led to the development of theories to guide empirical research. Some hypotheses are that spirituality and religion influence health by adherence to health-related behaviors and lifestyles, by having an impact on marriage patterns and hence heritability, by providing social support, by psychophysiology via ritual, or by promoting healthy cognitions via belief or faith (Levin, 1996).

Organization of Supplement and Major Topics Covered

Chapter 2 lays the foundations for understanding the relationships between culture, mental health, mental illness, and mental health services. Chapters 3 through 6 provide information about each racial and ethnic minority group. Chapter 7 concludes with promising directions and courses of action to reduce disparities and improve the mental health of racial and ethnic minorities.

Each chapter concerning a racial or ethnic minority group follows a common format. The chapter begins with facets of the group's history in the United States and its demographic patterns, which include family structure, income, education, and health status. These factors are important for understanding contemporary ethnic identity issues and mental health, and the need for mental health services. The chapter then reviews the available scientific evidence regarding the need for mental health services (as measured by prevalence), the availability, accessibility, and utilization of services, and the appropriateness and outcomes of mental health services.

Need

In this Supplement, the need for mental health services is equated with prevalence, i.e., new and existing cases of mental disorders. Prevalence rates, however, are imperfect measures of need. A mental health problem may impair someone sufficiently to warrant treatment or other types of services (e.g., preventive care), while some milder forms of mental illness may not impair someone enough to warrant professional treatment. The problem is that the mental health field has not yet developed standard measures of "need for treatment" in the general population, much less for a given racial or ethnic group (DHHS, 1999). Where relevant, this Supplement also uses the diagnosis of a culture-bound syndrome as indicating a need for treatment.

This Supplement pays special attention to vulnerable, high-need populations, such as people who are homeless or incarcerated, or children in foster care. These are among the populations of most concern because they have the greatest need for services, defined by a higher risk for or prevalence of mental disorder than a relevant comparison population (Aday, 1994). Other populations, such as persons with co-occurring disorders or those living in migrant or rural communities, are also likely to be underserved or to have difficulty accessing needed treatment.

The chapters for each minority group vary some-what in terms of which high-need populations they cover. High-need populations were included in specific chapters on the basis of having overrepresentation by that particular minority group. For example, the chapter on Hispanic Americans covers refugees, whereas the chapter on American Indians and Alaska Natives covers children in foster care and people who abuse alcohol and drugs. The placements of these emphases should not be used to stereotype the group. High-need populations of all types exist in every group.

Availability

Availability of services refers to the number of providers in a given area and to whether these providers are able to offer mental health services that meet the needs of the population(s) they serve. The development of such services requires recognizing and responding to cultural concerns of racial and ethnic groups, including histories, traditions, beliefs, and value systems (U.S. Center for Mental Health Services [CMHS], 2000).

Accessibility

Access is defined as probability of use, given need for services. Because of the difficulty of operationalizing this definition, this Supplement relies on a commonly accepted measure of access, insurance status, i.e., whether or not people have private or public insurance to cover some or all of the cost of services (Brown et al., 2000). People with health insurance have greater access to services than those who do not (Newhouse, 1993). The nature of the coverage is also important - details such as coverage limits, deductibles, and the like - but few studies of minorities provide this level of specificity. Other cultural and organizational factors impede access, such as attitudes against treatment, mistrust, stigma, and fragmentation of services.

Utilization

Utilization of services is generally reported in this Supplement by rates of use of mental health services in any of the settings and sectors where they are provided. The chapters also provide some insight into more specific aspects of use such as intensity and duration of treatment, timing of care from first onset of symptoms, dropout rates, type of provider (e.g., specialist or primary care), sector, setting, and treatment modality. Many of these characteristics are described in the section on Service Settings (Chapter 2). Utilization is conceptualized as a combined function of all the previous topics - need, availability, and access.

Utilization is also reported for alternative or complementary sources of care including acupuncture, meditation, spiritual healing, herbal remedies, and/or traditional Chinese or American Indian medicine. The need to report these sources of care was prompted by the first national study of more than 16,000 people that found that about 10 percent of people reporting a mental condition used practitioner based alternative or complementary treatments. This rate of use was greater than that for people reporting a chronic medical condition (Druss & Rosenheck, 1999, 2000). The study also suggested that consumers 11 tend to use these therapies for milder mental health problems and continue to use mainstream medical services for more severe mental illnesses. Studies of the overall population in primary care clinics and in clinics specializing in complementary health care note that anxiety and depression are two of the disorders for which individuals use complementary care Elder et al., 1997; Davidson, et al., 1998; Eisenberg et al., 1998.

Appropriateness and Outcomes

Appropriateness is defined herein as receiving an accurate diagnosis or guideline-based treatment. An accurate diagnosis is one in which a careful evaluation of a patient's symptoms show that they correspond to diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorderspublished by the American Psychiatric Association. An appropriate treatment conforms to the treatment guidelines for that disorder published by professional mental health associations or evidence-based reports on healthcare outcomes (drawn from comprehensive syntheses and analyses of relevant scientific literature) supported by government agencies.

Outcomes of treatment ordinarily refer either to the efficacy or effectiveness of treatment. Efficacy is whether treatment works in highly controlled research settings, whereas effectiveness is whether treatment works in clinical practice settings. Common outcomes that are measured are improved mortality and morbidity - such as less suicide or a reduction in symptoms or levels of distress - and improvement in mental health. Outcomes also cover improvements in disability, work performance, and other functional measures. Outcomes are studied in relation to any type of treatment, including those that are culturally responsive.

Science Base

Standards of Scientific Evidence

This Supplement draws on the best available science coming from many disciplines - mental health, health services, history, sociology, and anthropology. The statements made in this Supplement are documented by reference to studies published in the professional literature. Publications are first required to be peer-reviewed by fellow experts to ensure their quality. Quality depends on scientifically rigorous methods of data collection, analysis, and interpretation.

No single study, regardless of the quality of its design, is sufficient by itself to serve as the basis for a conclusion in this Supplement. Findings must be replicated in several studies, and findings must be consistent. The strength or degree of evidence amassed for any conclusion is referred to as the level of evidence.

Assessing the level of evidence is often difficult when findings transcend disciplinary boundaries. Distinct disciplines formulate questions differently. This, in turn, dictates different approaches to designing and conducting research, and the approach often determines how researchers report their findings and conclusions. Even when approaches are similar, investigators in different disciplines frequently employ different terms to describe similar concepts. In seeking to apply scientific standards consistently across the many fields of research reviewed, this Supplement emphasizes two criteria: rigorous methods of inquiry and sufficient data to support major conclusions.

Methodological Issues in Studying Minorities

Because race and ethnicity are hard to define, many scientists discourage the use of these terms in the analysis of disease, unless there is reason to suspect, based on other sources of evidence, that a relationship exists. In general, cause and effect relationships between health status and race and ethnicity have been rare, and when they have been found, they are usually related to lifestyle or other behavioral factors that tend to correlate with racial and ethnic categories. Observed differences between racial and ethnic groups are less likely to be caused by underlying biological differences but rather by factors that co-vary with race, such as income, education, or environment. Even central tendency differences in metabolic rates are overshadowed by the complete overlap in the distribution of metabolic rates across American racial and ethnic groups. Some editors of scientific journals actively discourage presentation of racial and ethnic data unless there is a specific rationale for such analyses.

NIH insists that clinical trials to test treatments include a strongly diverse population of volunteers. This diversity is necessary to ensure that the results of the trials will apply broadly to all populations, including minority groups. According to the theory of clinical trials, it is not necessary to separately analyze subpopulations unless there are empirically based hypotheses about group differences.

Still, the study of mental health in minorities is flourishing, even though researchers face methodological hurdles that make these studies more complex, costly, and difficult to conduct than similar types of investigations in predominantly white communities.

One major consideration is related to the measurement of mental disorders. For example, even when using the DSM system to establish the criteria for different mental disorders and a standardized instrument such as the Composite International Diagnostic Interview Schedule (CIDI) to measure disorders, cultural factors affect how individuals define, evaluate, seek help for, and present their health problems to family members, friends, and service providers. Considering culture in a standardized measure of mental disorders is reliant on at least three types of equivalence: conceptual, scale, and norm. Conceptual equivalence refers to similarities in the meaning of concepts used in assessment: e.g., Do minorities and whites think of well-being, depression, or self-esteem in the same way? Scale equivalence refers to the use of standard formats in questionnaire items that are familiar to all groups. Western-educated people of all groups are familiar with responding to questions that have choices such as "strongly agree," "agree," and so on, or a true-false dichotomy. Recent immigrants, particularly individuals who have not been educated in the Western system, may not understand this format. Accordingly, their answers to questions using these response options may not be valid or reliable. Norm equivalence refers to the application of standard norms developed in one sample and used with another group. Because population or sub-population statistics form one standard by which we judge normal and abnormal or high and low functioning, it is important to understand whether the population on which the norms are based is similar to the study group.

Over the past decade, social scientists have used focus groups, ethnographies, and detailed interviews to help modify standardized measures to make them more equivalent for use with racial and ethnic minority groups. Although refining instruments for different racial and ethnic minorities has been made more systematic and efficient, making measures equivalent remains a time-consuming process.

For researchers who use surveys to collect data, a major methodological hurdle is the issue of sampling. Compared with interviewing all members living in a geographic area, sampling is a scientific and cost-effective means to estimate the rates of mental disorder and use of services for a particular group or community. Because ethnic and racial minority groups are relatively rare in most communities, it is difficult to recruit adequate samples for any one particular study. When a study requires large samples of a specific ethnic group, the screening time to locate respondents is quite high. For example, in a study in Los Angeles, nearly 17,000 households were approached to secure a final sample size of 1,747 Chinese American respondents (Takeuchi et al., 1998). If the study design looks for certain sub-groups (e.g., adults, children, and older adults), the cost and time for screening individuals can become even higher.

Another potential obstacle is that racial and ethnic minorities may be reluctant to participate in research studies. For some, like American Indians and African Americans, research raises past breaches of ethics and harm to individuals (Krieger, 1987). For others, like recent Asian or Latino immigrants, participation in research may be a strange concept, and recruitment may be difficult.

In addition to the difficulties of recruiting individual respondents, some racial and ethnic minority communities may resist being part of a research study. Researchers often conduct studies in minority communities because they want their work to have an impact in resolving social problems, guiding policy, or serving as a basis for programs that will improve the quality of life in the community. These investigations can provide communities with needed data to secure resources for new programs, assess interventions that may be useful in the community, or identify high-risk groups. To conduct studies, however, investigators must rely on community cooperation to help identify people and encourage participation. Frequently, an uneasy tension exists between researchers and the communities they study. Community leaders may see researchers as exploitative and divorced from real issues and real-life problems, while researchers view community leaders as compromising research methods and thereby diminishing out-comes, which would have eventually benefited the community. Such tensions can hinder the initiation of research projects in both white and nonwhite communities.

Preparation of the Supplement

In February 2000, the Surgeon General commissioned this Supplement to examine racial and ethnic minority mental health. Accordingly, it selectively expands on parts of the main report, Mental Health: A Report of the Surgeon General (DHHS, 1999).

As was the case with that report, the Office of the Surgeon General, with the approval of the Secretary of the Department of Health and Human Services, authorized the Substance Abuse and Mental Health Services Administration (SAMHSA) to serve as the lead operating division for preparing the Supplement. SAMHSA's Center for Mental Health Services worked in consultation with the National Institute of Mental Health (NIMH) of the National Institutes of Health to develop this Supplement under the guidance of the Surgeon General, Dr. David Satcher.

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Footnotes

1

This Supplement uses the term "whites" to denote non-Hispanic white Americans.

2

Disability is measured in terms of lost years of healthy life from either disability or premature death.

3

Disability is self-reported and defined as having a level of functional impairment sufficient to restrict major life activities.

4

Most epidemiological studies using disorder-based definitions of mental illness are conducted in community household surveys. They fail to include nonhousehold members, such as persons without homes or persons residing in institutions such as residential treatment centers, jails, shelters, and hospitals.

5

This Supplement defines vulnerable, high-need groups as any population subgroup (such as children or adults who are homeless, incarcerated, or in foster care) which has (1) a higher risk for mental illness, (2) a higher need for mental health services, or (3) a higher risk for not receiving mental health services.

6

In recognition of the limitations of the broad groupings, a major revision occurred with the 2000 census. The revision allows individuals to identify with more than one group (OMB, 2000). The U.S. Census Bureau anticipates that this change will result in approximately 63 different categories of racial and ethnic identifications.

7

Wherever possible, this Supplement uses the most recent data from the 2000 census. However, because of the recency of results, more specialized analyses have yet to be performed. Therefore, this Supplement also draws on analyses of previous census data.

8

Reasons behind growth in income inequality include the reduction in blue-collar jobs in manufacturing and less reliance on uneducated workers (Mishel & Bernstein, 1992). Also, there was a shift to technical service, information technology, and management Drucker, 1993; U.S. Census Bureau, 2000.

9

Except as noted in Chapter 2 regarding the lack of data for some ethnic groups.

10

This definition technically refers to primary prevention, i.e., prevention of a disorder before its initial onset. Secondary prevention refers to the prevention of recurrences or exacerbations of already diagnosed disorders. Tertiary prevention refers to the prevention or reduction of disability caused by a disorder. There also are other ways to define comprehensive efforts at prevention (IOM, 1994).

11

Although a number of terms identify people who use or have used mental health services (e.g., mental health consumer, survivor, expatient, client), the terms "consumer" and "patient" will be used interchangably throughout this Supplement.

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