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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 7 A Vision for the Future

Introduction

The extensive evidence reviewed in this supplemental report to Mental Health: A Report of the Surgeon General (1999) supports the conclusion that mental illnesses are serious and disabling disorders affecting all populations, regardless of race or ethnicity. This Supplement also concludes that culture and social context influence mental health, mental illness, and mental health services in America. Despite the existence of effective treatments, disparities lie in the availability, accessibility, and quality of mental health services for racial and ethnic minorities. As a result, these populations bear a disproportionately high disability burden from mental disorders. This Supplement underscores the recommendation of the original Surgeon General's Report on Mental Health: People should seek help if they have a mental health problem or if they think they have symptoms of a mental disorder. In addition, the literature reviewed herein suggests that mental health researchers, policymakers, and service providers must be more responsive to the social contexts, cultural values, and historical experiences of all Americans, including racial and ethnic minorities.

Lack of information regarding the mental health needs of many racial and ethnic minorities is also a critical disparity. Too often, the best available research on racial and ethnic minorities consists of small studies that cannot be generalized to today's increasingly diverse communities. While the research reported in this Supplement is the best science available, it represents a science base that is incomplete.

To better address the dynamic impact of culture, race, and ethnicity on mental health and mental illness, more research is needed on how to prevent and treat mental illness and to enhance the mental health of all racial and ethnic groups. Following an extensive consultation process with public health experts, service providers, and consumers, the Surgeon General released Healthy People 2010 in early 2000 as a challenge to the Nation to address disparities in health care access and outcomes. For the first time, among the 10 "leading indicators" of the Nation's health on which progress will be regularly monitored is one mental health goal: increasing treatment of depression for underserved minority groups. This national agenda encourages the field to strive toward the highest possible quality of health care and health outcomes, with equally high standards of care across groups.

A public health approach to reducing mental health disparities will require a national commitment, bringing together the best of the public and private sectors, individuals and communities, Federal, State, and local governments, universities, foundations, mental health researchers, advocates, health service providers, consumers, and their families. Through active partnership, these stakeholders can generate the knowledge and resources necessary to improve mental health services for racial and ethnic minorities in this country. This chapter highlights promising courses of action that can be used to reach the ambitious goals of reducing barriers and promoting equal access to effective mental health services for all persons who need them.

Continue to Expand the Science Base

The mental health knowledge base regarding racial and ethnic minorities is limited but growing. Because good science is an essential underpinning of the public health approach to mental health and mental illness, systematic work in the areas of epidemiology, evidence-based treatment, psychopharmacology, ethnic- and culture-specific interventions, diagnosis and assessment, and prevention and promotion needs to be developed and expanded.

Epidemiology

In March 1994, the policies of the National Institutes of Health (NIH) regarding inclusion of racial and ethnic minorities in study populations were significantly strengthened (NIH Guidelines, 1994, p. 14509). This change requires inclusion of ethnic minorities in all NIH-funded research. The results of this policy will be apparent in the coming years as studies funded during this era begin to be published.

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 specific racial and ethnic groups.

The National Institute of Mental Health (NIMH) recently funded a collaborative series of projects that will make great strides in psychiatric epidemiology nationwide. The National Survey of Health and Stress (NSHS) will interview a nationally representative sample of adolescents and adults to estimate the prevalence of mental disorders in the United States. Although the NSHS will interview nearly 20,000 adolescents and adults, its samples of specific racial and ethnic minority groups will be proportionate to their size in the Nation's population, and, thus, not very large. To complement the NSHS, NIMH has funded the National Survey of American Lives (NSAL) and the National Latino and Asian American Study (NLAAS), which will include large samples of different racial and ethnic minorities. In the NSAL, approximately 9,000 African American adolescents and adults will be interviewed; about a quarter of them will be immigrants to the United States. In the NLAAS, a total of about 8,000 Latino and Asian American adults from a few specific ethnic groups will be interviewed about their mental health and service use patterns. Project investigators have made a substantial portion of the NSHS, NSAL, and NLAAS surveys similar to facilitate cross-study comparisons. Taken together, these studies will permit the most comprehensive assessments to date of symptom patterns, prevalence rates of disorders, access to services, and functioning for different racial and ethnic minority groups.

In addition, a major effort to examine the psychiatric epidemiology and the use of mental health services by American Indians has recently been completed. The American Indian Services Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project (AI-SUPERPFP), sponsored by NIMH and conducted by the National Center for American Indian and Alaska Native Mental Health Research, is a large-scale, multi-stage study of prevalence and utilization rates among over 3,000 individuals in two large American Indian communities, a Southwestern tribe and a Northern Plains tribe. In this study, mental disorders are diagnosed in a manner that is culturally relevant, using methods similar to those employed by the National Comorbidity Survey. The results of this study will be available in 2002 and will add greatly to our understanding of the need for mental health care among American Indians.

The National Household Survey on Drug Abuse (NHSDA) is conducted annually by the Substance Abuse and Mental Health Services Administration (SAMHSA) and interviews approximately 70,000 respondents each year. The NHSDA conducts interviews in both Spanish and English and has generated samples of white Americans, African Americans, and Hispanic Americans large enough to allow separate data analyses by racial or ethnic group. Through this annual survey it will be possible to track changes in the prevalence of substance abuse and dependence, as well as certain mental health problems for several racial and ethnic groups.

It is important that findings from these studies serve as a basis for improving mental health services for all groups.

Evidence-Based Treatment

Research reviewed in the previous chapters provides evidence that ethnic minorities can benefit from mental health treatment. While the Surgeon General's Report on Mental Health contained strong and consistent documentation of a comprehensive range of effective interventions for treating many mental disorders (DHHS, 1999), most of the studies reporting findings for racial and ethnic minorities had small samples and were not randomized controlled trials. As discussed in Chapter 2, the research used to generate professional treatment guidelines for most health and mental health interventions does not include or report large enough samples of racial and ethnic minorities to allow group-specific determinations of efficacy (see Appendix A). In the future, evidence from randomized controlled trials that include and identify sizable racial and ethnic minority samples may lead to treatment improvements, which will help clinicians to maximize real-world effectiveness of already-proven psychiatric medications and psychotherapies.

At the same time, research is essential to examine the efficacy of ethnic- or culture-specific interventions for minority populations and their effectiveness in clinical practice settings. A good example of a well-designed study addressing these issues is the WE Care Study (Women Entering Care), a major effort to examine treatment for depression in low-income and minority women. Funded by NIMH, this study examines the impact of evidence-based care for depression on a large sample (N = 350) of white, African American, and Latina women who are poor. This randomized controlled trial is not only examining the impact of treatment for depression on this group of women, but it will also determine whether providing treatment to women who are mothers results in improvements in the mental health and functioning of their children.

Psychopharmacology

Some of the variability in people's responses to medications is accounted for by factors related to race, ethnicity, and lifestyle. Information about race and ethnicity, as well as factors such as age, gender, and family history, may provide a starting point for medical research aimed at developing and testing drug therapies tailored to individual patients. Identifying the various mechanisms responsible for differential pharmacological response will aid in predicting an individual's likely response to a medication before it is prescribed.

A few studies have examined racial and ethnic differences in the metabolism of clinically important drugs used to treat mental illnesses. As the evidence base grows, improved treatment guidelines will help clinicians be aware that differences in metabolic response, as well as differences in age, gender, family history, lifestyle, and co-occurring illnesses, can alter a drug's safety and efficacy. For example, clinicians are becoming sensitized to the possibility that a significant proportion of racial and ethnic minority patients will respond to some common medications at lower-than-usual dosages. Care must be taken to avoid overmedicating patients, because over-medication can lead to adverse effects or toxicity. However, because each racial and ethnic population contains the full range of drug metabolic activity across its membership, a clinician should not come to firm conclusions about higher or lower metabolic rates based on an individual's race or ethnicity alone.

Currently, there is little empirical evidence around improving systems of care for racial and ethnic minorities. To reduce disparities in quality of care, research is needed on strategies to improve the availability and delivery of evidence-based treatments, including state-of-the-art medications and psychotherapies. Consumers, communities, mental health services researchers, and Federal agencies have an opportunity to work together toward the development and dissemination of evidence-based treatment information to improve quality of care for racial and ethnic minorities. In particular, studies are needed that identify effective interventions for minority subpopulations, such as children, older adults, persons with co-occurring mental and physical health conditions, and persons who are living in rural areas.

Ethnic- or Culture-Specific Interventions

Clinicians' awareness of their own cultural orientation, their knowledge of the client's background, and their skills with different cultural groups may be essential to improving access, utilization, and quality of mental health services for minority populations. While no rigorous, systematic studies have been conducted to test these hypotheses, evidence suggests that culturally oriented interventions are more effective than usual care at reducing dropout rates for ethnic minority mental health clients. While the efficacy of most ethnic-specific or culturally responsive services is yet to be determined, models already shown to be useful through research could be targeted for further efficacy research and, ultimately, dissemination to mental health providers.

Because stigma and help-seeking behaviors are two culturally determined factors in service use, research is needed on how to change attitudes and improve utilization of mental health services. Some promising areas of study in racial and ethnic minority communities are reducing stigma associated with mental illness, encouraging early intervention, and increasing awareness of effective treatments and the possibility of recovery. These messages should be tailored to the languages and cultures of multiple racial and ethnic communities. Communities that can incorporate evidence-based knowledge about disease and treatments will have a health advantage.

Diagnosis and Assessment

Though the major mental illnesses are found worldwide, manifestations of these and other health conditions may vary with age, gender, race, ethnicity, and culture. Research reported in this Supplement documents that minorities tend to receive less appropriate diagnoses than whites. Further study is needed on how to address issues of clinician bias and diagnostic accuracy, particularly among those providers working with racial and ethnic minority consumers.

As noted in Chapter 1, the DSM-IV marked a new level of acknowledgment of the role of culture in shaping the symptoms and expression of mental disorders. The inclusion of a "Glossary of Culture-Bound Syndromes" and the "Outline for Cultural Formulation" for clinicians was a significant step forward in recognizing the impact of culture, race, and ethnicity on mental health. Further study is needed, however, to examine the relationship between culture-bound syndromes and existing disorders and the connection of culture-bound syndromes with underlying biological, social, and cultural processes. Examining the extent to which culture-bound syndromes are unique idioms of distress for some groups or variants of existing syndromes or disorders is particularly important.

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, now under development, will extend and elaborate concepts introduced in DSM-IV regarding the role and importance of culture and ethnicity in the diagnostic process. While striving to understand the processes that underlie disorders and syndromes, it is also critical to examine how clinicians apply cultural knowledge in their clinical evaluations. Further research is needed on the impact of culture in interview-based diagnosis and assessment techniques, as well as in the use and interpretation of formal psychological tests. Quality mental health assessment and treatment rely on understanding local representations of illness and distress for all populations.

Prevention and Promotion

Preventive interventions have the potential to decrease the incidence, severity, and duration of certain mental disorders or behavioral problems, e.g., depression, conduct disorder, or substance abuse. In addition, promotive interventions, such as increasing healthy thinking patterns or improving coping skills, may be integral to fostering the mental health of the nation. Unfortunately, only a handful of interventions to promote mental health, reduce risk, or enhance resiliency have been empirically validated for racial and ethnic minorities. As part of a public health approach to mental health and mental illness for all Americans, the growing knowledge base for preventive interventions must include racial and ethnic minorities.

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 to ameliorate negative health outcomes.

Study the Roles of Culture, Race, and Ethnicity in Mental Health

How do racial and ethnic groups differ in their manifestations and perceptions of mental illness and their attitudes toward and use of mental health services? What is it about race and ethnicity that helps explain these differences? The mental health community will benefit from a better understanding of how factors such as acculturation, help-seeking behaviors, stigma, ethnic identity, racism, and spirituality provide protection from or risk for mental illness in racial and ethnic minority populations. While no single study can shed light on all these issues simultaneously, scientific research will advance knowledge, increase our ability to prevent or treat mental illness, and promote mental health.

New studies will advance our knowledge about the social and cultural characteristics of racial and ethnic minority groups that correlate with risk and protective factors for mental health. As described earlier, researchers involved in the NSHS, NSAL, NLAAS, and AI-SUPERPFP large-scale epidemiological studies have collaborated on a set of core questions that will facilitate comparisons across populations. For example, across all four studies, it will be possible to assess how socioeconomic status, wealth, education, neighborhood context, social support, religiosity, and spirituality relate to mental illness among African Americans, Latinos, Asian Americans, American Indians, and whites. Similarly, it will be possible to assess how acculturation, ethnic identity, and perceived discrimination affect mental health outcomes for the four underserved racial and ethnic groups. These types of analyses go beyond straightforward epidemiological comparisons; 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.

Improve Access to Treatment

Race, ethnicity, culture, language, geographic region, and other social factors affect the perception, availability, utilization, and, potentially, the outcomes of mental health services. Therfore the provision of high-quality, culturally responsive, and language-appropriate mental health services in locations accessible to racial and ethnic minorities is essential to creating a more equitable system.

Improve Geographic Access

Racial and ethnic minorities have less access than white Americans to mental health services. Minorities are more likely to be poor and uninsured. Many live in areas where general health care and specialty mental health services are in short supply. An increasingly distressed safety net of community health centers, rural and migrant health centers, and community mental health agencies provides physical and mental health care services to racial and ethnic minorities in medically underserved areas (IOM, 2000). 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.

Integrate Mental Health and Primary Care

Many racial and ethnic minority consumers and families prefer to receive mental health services through their primary care physicians. Explanations of this preference may be that members of minority groups fear, feel ill at ease with, or are unfamiliar with the specialty mental health system. Community health centers as well as other public and private primary health settings provide a vital frontline for the detection and treatment of mental illnesses and the co-occurrence of mental illnesses with physical illnesses.

The Federal Government, in collaboration with the private sector, is working to bring mental health care to the primary health care system. A variety of demonstration and research 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. Developing strong links between primary care providers and community mental health centers will also assure continuity of care when more complex or intensive mental health services are warranted.

For example, the Chinatown Health Center in New York City, a Health Resource Services Administration (HRSA)-funded community health center, participates in two important Federal projects. The first is a study of whether it is more effective to treat older Chinese American health center patients with mental illnesses in an integrated primary and behavioral health program or to have the primary care physician refer them to specialty mental health services. The second project is part of a "Breakthrough Collabrative" series co-sponsored by the Institute for Healthcare Improvement, the Robert Wood Johnson Foundation, and several Federal agencies. This intensive quality improvement program is aimed at transforming the way the health center treats patients with depression. These Breakthrough Collaboratives are changing the way safety net health providers engage and treat their patients who may have chronic physical health conditions as well as mental health problems.

Ensure Language Access

A major barrier to effective mental health treatment arises when provider and patient do not speak the same language. The DHHS Office of Civil Rights has published guidance on this subject for health and social services providers (DHHS, 2000). All organizations or individuals receiving Federal financial assistance from DHHS, including hospitals, nursing homes, home health agencies, managed health care organizations, health and mental health service providers, and human services organizations have an obligation under the 1964 Civil Rights Act to ensure that persons with limited English proficiency (LEP) have meaningful and equal access to benefits and services. As outlined in the guidance, satisfactory service to LEP clients includes identifying and documenting the language needs of the individual provider and the client population, providing a range of translation options, monitoring the quality of language services, and providing written materials in languages other than English wherever a significant percentage of the target population has LEP. Efforts such as these will help ensure that limited English skills do not restrict access to the fullest use of services for a significant proportion of racial and ethnic minority Americans.

Coordinate and Integrate Mental Health Services for High-Need Populations

The Nation is struggling to meet the needs of its most vulnerable individuals, such as those in foster care, jails, prisons, homeless shelters, and refugee resettlement programs. Accordingly, the attention being given to the development and provision of effective, culturally responsive mental health services for these populations is increasing. Because racial and ethnic minorities are over-represented among these vulnerable, high-need populations, the introduction, expansion, and improvement of mental health services in settings where these groups are is critical to reducing mental health disparities. Another promising line of research is the role of mental health treatment in preventing individuals from falling into these vulnerable populations.

One innovative Center for Mental Health Services (CMHS) demonstration program to reduce homelessness integrates housing supports with medical and mental health services. This program has successfully brought adults with serious mental illness off the streets and helped them stay in housing, reduced their illicit drug use, decreased minor crime, and increased their use of outpatient mental health services. It has also shown that it is possible for organizations with very different missions and funding streams to work together to deliver effective, integrated services when they are focused on a common goal: to meet the real and complex needs of vulnerable people. These grants have helped several thousand homeless adults with severe mental illness (over 50 percent of whom were racial or ethnic minorities) to move off the streets and into stable housing (CMHS, Rosenheck et al., 1998). Because of the over-representation of ethnic minorities among persons who are homeless, such programs may play an important role in reducing racial and ethnic disparities in access to the mental health system.

Reduce Barriers to Treatment

Organization and financing of services have impeded access and availability for racial and ethnic minorities. Therefore, reducing financial barriers and making services more accessible to minority communities should be aims within any effort to reduce mental health disparities. Shame, stigma, discrimination, and mistrust also keep racial and ethnic minorities from seeking treatment when it is needed. Therefore, effective efforts to increase utilization will target social factors as well as quality of services.

Racial and ethnic minorities do not use mental health services at rates comparable to those of whites or in proportion to the prevalence of mental illness in either minority populations or the general population. The reasons for lower rates of utilization are complex. Research suggests that cost and lack of health insurance, fragmentation of services, culturally mediated stigma or patterns of help-seeking, mistrust of specialty mental health services, and the insensitivity of many mental health care systems, all discourage racial and ethnic minorities' use of mental health care. Opportunities exist to remove barriers and to promote consumers' access to needed services.

Ensure Parity and Expand Public Health Insurance

Minorities are less likely than whites to have health insurance and to have the ability to pay for mental health services. Across racial and ethnic groups, lack of health insurance is a significant financial barrier to getting needed mental health care. Even for people with health insurance, whether public or private insurance, there are greater restrictions on coverage for mental disorders than for other illnesses. This inequity, known as lack of parity in mental health coverage, needs to be corrected. The original Surgeon General's Report on Mental Health made clear that parity in mental health coverage is an affordable and effective objective for the Nation.

Another important step toward removing the financial barriers that contribute to unequal access to needed mental health care is the extension of publicly supported health care coverage to children who are poor and near poor. Federal legislation has created prospects for significantly expanding mental health coverage for the nation's 10 million uninsured children. The State Children's Health Insurance Program is a federally funded program enacted in 1997 that provides $24 billion over five years to ensure health care coverage for children in low-income families who are not eligible for Medicaid. If this program were modified to ensure adequate coverage for mental health and substance abuse disorders, it might substantially reduce the financial barriers to treatment and enhance access to health care for millions of children from all racial and ethnic backgrounds.

Extend Health Insurance for the Uninsured

Approximately 43 million Americans have no health insurance. Federal and State parity laws and steps to equalize health and mental health benefits in public insurance programs will do little to reduce barriers for the millions of working poor who do not qualify for public benefits, yet do not have private insurance. Today, the Nation's patchwork of health insurance programs leaves more than one person in seven with no means to pay for health care other than by out-of-pocket and charity payments. The consequences of the patchwork are many holes in the health care system through which a disproportionately greater number of poor, sick, rural, and distressed minority families frequently fall.

Efforts are currently underway to create more systematic approaches for States and local communities to extend health and mental health care to their uninsured residents. In 2000 and 2001, HRSA awarded planning grants to communities in 20 States to develop strategies to extend health coverage to their uninsured. Recipients of the grants will receive technical assistance to ensure that mental health needs of their uninsured residents are met in equal measure with other health needs. The program is modeled on a Robert Wood Johnson Foundation program, Communities in Charge, which is assisting 20 cities to stretch a safety net of health care insurance for people who have no health coverage. This and other efforts will have a significant impact on many racial and ethnic minority individuals who are uninsured.

Examine the Costs and Benefits of Culturally Appropriate Services

The burden of untreated mental illness is costly for all Americans. As the Nation looks into ways to remove financial barriers to mental health and addictions treatment, it is also important to look at the long-term cost-effectiveness of offering culturally appropriate services. Engaging and treating racial and ethnic minority children, adults, or older adults by reaching out to family members and other social supports may require a greater initial investment of resources, but it may also result in substantial decreases in disability burden. In addition, undertaking other case management services that do not involve direct client contact, such as discussing a coordinated treatment plan with a traditional healer, may not be payable through insurance. Nevertheless, such "ancillary" services may be essential to ensuring that those in need of services will enter and stay in treatment long enough to get help that is effective.

Similarly, bilingual or bicultural community health workers may be needed to bridge the gap between the formal health care system and racial and ethnic minority communities. Funds to support these community workers are scarce, and in the bottom-line environment of managed care, often nonexistent. Yet studies across many areas of health have shown that community health workers- neighborhood workers, indigenous health workers, lay health advisers, consejera, promotora-can improve minorities' access to and utilization of health care and preventive services Krieger et al., 1999; Witmer et al., 1995. These community health workers can also bridge language differences that create communication barriers for a substantial proportion of racial and ethnic minority Americans receiving health care Commonwealth Fund, 1995; President's Advisory Commission on Asian Americans and Pacific Islanders, 2001.

Many Americans, including members of racial and ethnic minorities, use alternative or complementary health care. The findings from a study of American Indian veterans' use of biomedical and alternative mental health care suggest that medical need drives service use, but the physical, financial, and cultural availability of services may influence the form that such service use assumes (Gurley et al., 2001). Research is needed to fully understand the effects of complementary care and their interactions with standard mental health interventions. In the meantime, it is important that mental health systems create avenues for working with complementary care providers to foster greater awareness, mutual understanding, and respect. Consumers and families may be more likely to take advantage of effective mental health treatments if both the formal mental health and complementary care systems work together to ensure that individuals with mental illness receive coordinated, and truly complementary, treatments.

Although providing services to meet the cultural and linguistic needs of more diverse populations may demand more of an initial investment than continuing services as usual, cost-effectiveness studies will help to examine the benefits of providing (or the costs of failing to provide) culturally appropriate services.

Reduce Barriers in Managed Care

Evidence cited in this Supplement suggests that managed mental health care is perceived by some racial and ethnic minorities as creating even greater barriers to treatment than fee-for-service plans. However, more systematic assessment of the treatment experiences, quality, and out-come of racial and ethnic minorities in managed care may help to identify opportunities for using this mechanism to improve access and quality of services. Because managed care organizations contract to provide all necessary services to beneficiaries at a fixed cost, managed care offers a potential means for increasing providers' flexibility to reach out and engage minority populations. For example, a health maintenance organization (HMO) might be able to support more outreach and engagement to people of color living in rural communities by removing inflexible billing methods based on individual office visits.

Overcome Shame, Stigma, and Discrimination

Shame, stigma, and discrimination are major reasons why people with mental health problems avoid seeking treatment, regardless of their race or ethnicity. The effects of negative public attitudes and behaviors toward people with mental illness may be even more powerful for racial and ethnic minorities than for whites (Chapter 2). For example, in some Asian American communities, the shame and stigma associated with the mental illness of one family member can affect the marriage and employment potential of other relatives. More research is needed to develop effective methods of overcoming this powerful barrier to getting people with mental health problems the help they need. Public education efforts targeting shame, stigma, and discrimination are likely to be more effective if they are tailored to the languages, needs, and cultures of racial and ethnic minorities.

Build Trust in Mental Health Services

Mistrust of mental health services deters many individuals from seeking treatment for mental illness. Although there are undoubtedly myriad complex reasons for this lack of trust, one of its major sources for racial and ethnic minorities may be their past negative experiences with the mental health treatment system. Mistrust is understandable in light of research findings that minorities receive a higher proportion of misdiagnoses, experience greater clinician bias, and have lower access to effective treatments that are evidence-based, as compared with whites. As detailed in the next section, one of the most essential steps to building trust in mental health services is reducing racial and ethnic disparities in the quality of available services. Minority communities also need more information about the effectiveness of treatment and the possibility of recovery from mental illness.

Improve Quality of Care

This Supplement identified racial and ethnic disparities in the quality of mental health services people receive. Therefore, the provision of high-quality services in settings where there is an appreciation for diversity and its impact on mental health is a priority for meeting current and future needs of diverse racial and ethnic populations.

Ensure Evidence-Based Treatment

As noted earlier, the recommended treatments available for all patients are those based on a strong and consistent evidence base and tailored to the age, race, gender, and culture of the individual. It is clear that the Nation's mental health service system needs to ensure that all Americans receive the highest standard of care. This Supplement finds that racial and ethnic minorities are less likely than whites to receive effective, state-of-the-art treatments. Therefore, frontline providers need incentives and opportunities to participate in quality improvement activities that will help them better manage medications and provide effective psychosocial treatments to racial and ethnic minority consumers, children, and families in ways that are both culturally and linguistically appropriate and consistent with practice standards.

Develop and Evaluate Culturally Responsive Services

Culture and language affect the perception, utilization, and, potentially, the outcomes of mental health services. Therefore, the provision of culturally and linguistically appropriate mental health services is a key ingredient for any programming designed to meet the needs of diverse racial and ethnic populations. This programming should include:

  1. language access for persons with limited English proficiency;
  2. services provided in a manner that is congruent, rather than conflicting, with cultural norms; and
  3. the capacity of the provider to convey understanding and respect for the client's worldview and experiences.

The refinement and study of cultural competence may reveal a mechanism for helping mental health organizations and providers deliver culturally appropriate services. This approach underscores the recognition of cultural differences in consumers and families and then develops a set of skills, knowledge, and policies in an effort to deliver services more effectively. There have been, however, few direct empirical studies of cultural competence. Research is needed to determine its key ingredients and what influence, if any, they have on improving service delivery, utilization, treatment response, adherence, outcomes, or quality for racial and ethnic minorities.

Engage Consumers, Families, and Communities in Developing Services

One way to ensure that mental health services meet the needs of racial and ethnic minority populations is to involve representatives from the community being served in the design, planning, and implementation of services. Modeled on primary health care programs that successfully target recent immigrants and refugees, some minority-oriented mental health programs appear to succeed by maintaining active relationships with community institutions and leaders. These programs do aggressive outreach, furnish a familiar and welcoming atmosphere, and identify and encourage styles of practice tailored to racial and ethnic minority groups.

State, county, and local communities carry the primary responsibility for developing, organizing, and operating their own mental health services. Their leaders are frequently in the position to determine the investment of Federal, State, and local mental health resources. It is incumbent upon those who control the organizational structure of local programs to engage consumers, families, and other community members in the process of reducing mental health service disparities.

One organization that is successfully reaching out is the Feather River Tribe of California. With Federal seed-grant funds, this tribe has developed a plan for serving tribal children with serious emotional problems that is based on community members' assessment of needs and expectations from mental health treatment. Their effort has engaged tribal members so successfully that, through their own fundraising efforts, they have netted sufficient tribal, State, foundation, and Federal resources to implement a comprehensive, community-based children's services program. As a result, this community feels ownership and commitment to its mental health service delivery system, and Feather River children are receiving more and better quality services.

Support Capacity Development

Minorities are underrepresented among mental health providers, researchers, administrators, policymakers, and consumer and family organizations. Furthermore, many providers and researchers of all backgrounds are not fully aware of the impact of culture on mental health, mental illness, and mental health services. All mental health professionals are encouraged to develop their understanding of the roles of age, gender, race, ethnicity, and culture in research and treatment. Therefore, mental health training programs and funding sources that work toward equitable representation and a culturally informed training curriculum will contribute to reducing disparities.

Train Mental Health Professionals

Racial and ethnic minorities continue to be badly under-represented, relative to their proportion of the U.S. population, within the core mental health professions - psychiatry, psychology, social work, counseling, and psychiatric nursing. Although it is certainly not the case that only minorities can understand or treat persons of like race or cultural background, minority providers treat a higher proportion of minority patients than do white providers. There is also evidence that ethnic match between provider and client encourages consumers to enter and stay in treatment.

The ability to reduce health disparities through the research proposed in the NIH 2001 Health Disparities Plan requires a strong commitment to training and supporting investigators in this area. Not only are there disparities in the number of studies that analyze their findings by race or ethnicity, but there are also disparities in the number of racial and ethnic minority investigators applying for and receiving grants to pursue mental health research.

Without concerted efforts by policymakers, educational institutions, and senior researchers, the shortage of providers and researchers equipped to address the needs of minority populations will contribute to the disproportionate burden of mental illness on racial and ethnic minorities. Programs that encourage students who are committed to serving racial and ethnic minority communities to enter the field of mental health will help to reduce the mismatch between needs and capacity. Furthermore, it is important that professional training programs include curricula that address the impact of culture, race, and ethnicity on mental health, mental illness, and mental health services. Hence, there is a need to encourage targeted Federal training or grant programs, educational programs for high school, college, and graduate students, outreach by graduate and professional schools, and continuing education by accrediting professional organizations.

Encourage Consumer and Family Leadership

Whereas the movement to give voice and leadership to the recipients of mental health services - consumers and family members - has been growing rapidly over the past 20 years, racial and ethnic minorities continue to be underrepresented in this arena. Although there have been recent Federal, State and local efforts to develop networks and leadership among minority consumers and families, concerted efforts are needed to give voices to these relatively unheard stakeholders of the mental health system.

Promote Mental Health

Mental health promotion and mental illness prevention can improve the mental health of a community. Therefore, dedicated efforts should investigate avenues for reducing the effects of historical social inequities and for promoting community and family strengths.

Address Social Adversities

Mental health is adversely affected by chronic social conditions that disproportionately affect America's poor and its racial and ethnic minority groups. These conditions include poverty, community violence, racism, and discrimination. The reduction of social adversities, while a formidable task, may be vital to improving the mental health of racial and ethnic minorities. Although there is substantial literature on the damaging effects of poverty on mental health, there is less empirical evidence for the effects of exposure to racism, discrimination, and community violence. As these relationships are examined, it is in the Nation's interest to reduce the impact of such social problems, as well as to promote respect and understanding among Americans of all backgrounds.

Build on Natural Supports

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 for both ameliorating risk and fostering resilience. Furthermore, culturally appropriate efforts are needed to educate families and communities about mental health, mental illness, treatment effectiveness, the possibility of recovery, and the availability of services in their area.

Strengthen Families

Families are the primary source of care and support for the majority of adults and children with mental health disorders or problems. Given the important role of family in the mental health system, it is essential that efforts to reduce racial and ethnic disparities include strategies to strengthen families to function at their fullest potential and to mitigate the stressful effects of caring for a relative with mental illness or serious emotional disturbance. Furthermore, strong families are better equipped to cope with adversity and to provide mentally healthy environments for their children. As with mental health interventions, family support and family strengthening efforts need to be tailored to the linguistic and cultural needs of racial and ethnic minorities.

Conclusions

Mental Health: Culture, Race, and Ethnicity presents compelling evidence that racial and ethnic minorities collectively experience a disproportionately high disability burden from unmet mental health needs. Despite the progress in understanding the causes of mental illness and the tremendous advances in finding effective mental health treatments, far less is known about the mental health of African Americans, American Indians and Alaska Natives, Asian American and Pacific Islanders, and Hispanic Americans.

The Nation has far to go to eliminate racial and ethnic disparities in mental health. While working toward this goal, the public health system must support the strength and resilience of America's families. The demographic changes anticipated over the next decades magnify the importance of eliminating differences in mental health burden and access to services. Ethnic minority groups are expected to grow as a proportion of the total U.S. population. Therefore, the future mental health of America as a whole will be enhanced substantially by improving the health of racial and ethnic minorities.

It is necessary to expand and improve programs to deliver culturally, linguistically, and geographically accessible mental health services. Financial barriers, including discriminatory health insurance coverage of treatment for mental illness, need to be surmounted. Programs to increase public awareness of mental illness and effective treatments must be developed for racial and ethnic minority communities, as must efforts to overcome shame, stigma, discrimination, and distrust. The time is right for a commitment to expand or redirect resources to support evidence-based, affordable, and culturally appropriate mental health services for racial and ethnic minorities, particularly in settings where those with the highest need are not being adequately served, such as jails, prisons, homeless shelters, and foster care.

Clinical practice guidelines and program standards for culturally competent mental health services should be subject to rigorous empirical study. If they are found to be effective for racial and ethnic minorities, such standards should be disseminated and implemented with fidelity. For state-of-the-art, evidence-based interventions, it is critical that quality improvement processes be inaugurated, so that clinicians and programs actually use them and use them appropriately.

Building capacity for research, training, and community leadership is essential to meet the needs of racial and ethnic minorities in the 21st century. Where gaps exist in the evidence base about the prevalence, perception, course, detection, and treatment of mental illness in racial and ethnic minority populations, individuals must be trained and supported to carry out systematic programs of research. Where shortages of accessible services are evident, both mainstream and bilingual-bicultural providers and administrators must learn to create culturally appropriate and evidence-based systems of care. Where leadership is lacking in consumer and family groups, encouraging grassroots efforts will help to strengthen the voices of racial and ethnic minorities.

Accountability for making progress and providing state-of-the-art services will help to reduce disparities in the mental health and health care systems. This Supplement sets a foundation for national efforts to provide racial and ethnic minorities affected by mental disorders with effective and affordable treatments tailored to their specific needs. Public reports throughout the decade will provide excellent opportunities to gauge successes, evaluate directions, and chart necessary changes. Addressing disparities in mental health is the right thing to do for all Americans.

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