Ethnic and Cultural Ethnic and Cultural Considerations in the Considerations in the

Clinical Management of Clinical Management of Mental Illness and Mental Illness and Substance AbuseSubstance AbuseAnnelle B. Primm , MD, MPH

Medical DirectorJohns Hopkins Community Psychiatry

Program

Overview Overview

Population Trends Disparities among the 4 major

racial and ethnic minority groups Barriers to treatment DSM-IV Cultural Formulation Culturally appropriate care

US Population by Ethnicity 2000-Multiple Races

White75%

African American

13%

Asian American

4%American

Indian2% Other

6%White

African American

Asian American

American Indian

Other

Hispanic - 13%

Source: US Census Bureau

Cultural DivideCultural Divide

High likelihood of ethnic and cultural differences between health providers and patients

Limited training about the importance of cultural and ethnic factors in health care

Surgeon General’s Report on Surgeon General’s Report on MH: Race, Culture, and MH: Race, Culture, and EthnicityEthnicity

Mental Illness affects all Striking disparities in MH Care for

Minorities– Less likely to receive services– Poorer quality of care – Underrepresented in MH research

Disparities impose great disability burden on minorities

Lopez, 2002

Personal/Family

• acceptability

• cultural

• language/literacy

• attitudes, beliefs

• preferences

• involvement in care

• health behavior

• education/income

Structural

• availability

• appointments

• how organized

• transportation

Financial

• insurance coverage

• reimbursement levels

• public support

Visits• primary care• specialty• emergency

Procedures• preventive• diagnostic• therapeutic

Quality of providers• cultural competence• communication skills• medical knowledge• technical skills• bias/stereotyping

Appropriateness of care

Efficacy of treatment

Patient adherence

Health Status

• mortality

• morbidity

• well-being

• functioning

Equity of Services

Patient Views of Care

• experiences

• satisfaction

• effective partnership

BarriersBarriers

Use of ServicesUse of Services MediatorsMediators OutcomesOutcomes

Modified From Access to Health Care in America 10 , From Cooper LA, Hill MN, and Powe NR. JGIM 2002; 477-486

Barriers and Mediators to Equitable Health Care for Racial and Ethnic Groups

Barriers and Mediators to Equitable Health Care for Racial and Ethnic Groups

People of African Descent:People of African Descent:Mental Health CareMental Health Care Underuse of community outpatient care Later entry into treatment High drop-out rate Fewer treatment sessions High rates of inpatient care High rates of misdiagnosis High rates of severe mental illness

Cultural Competence Standards, 1997

African AmericansAfrican Americans

Concerns about “double”stigma Mistrust of health professionals Belief that prayer alone can heal Belief that suffering is a part of life

for Black people

American Indians, Native American Indians, Native Alaskan, Native Hawaiian Alaskan, Native Hawaiian Population:Population:Mental Health CareMental Health Care Appear to be at higher risk for mental disorders

High prevalence of depression, anxiety, substance abuse, violence, suicide

High rates of symptoms from family and interpersonal problems

Cultural Competence Standards, 1997

American Indians and American Indians and Alaska NativesAlaska Natives

Concerns about confidentiality - small, close community

Tendency to see the connection between mental illness and physical or spiritual illness

Use of both traditional and Western medicine

Asian and Pacific Islander Asian and Pacific Islander People:People: Mental Health Care Mental Health Care Shame & stigma associated with mental illness

High endurance of psychiatric distress Limited knowledge about mental health services Underutilization of mental health services Present for treatment in crisis High drop-out rate after initial contact Tendency to seek traditional healing Language barriers Cultural Competence Standards, 1997

Asian AmericansAsian Americans Symptoms are viewed as medical illness High prevalence of somatization

symptoms Difficulties in developing trust Hesitancy in opening up Tendency to give limited information Family is a key factor in treatment It is acceptable to disclose the diagnosis

to the family, but not to the patient

Latino Population:Latino Population:Mental Health CareMental Health Care

Early treatment drop-out Less access to full range of care Lower rates of voluntary hospitalization Use of crisis and other high cost

services Language barriers

Cultural Competence Standards, 1997

Latinos Latinos

Perception of mental illness as illness requiring medical intervention

Use of natural support systems Beliefs in the supernatural and use of

traditional healers Family needs prevail over individual Somatization of emotional states adapted from Alarcon,

2003

Ethnic and Cultural Influences Ethnic and Cultural Influences ononTreatment OutcomesTreatment Outcomes

Direct:

Cultural beliefs and preferences

Pathoplasticity

Ethnopsychopharmacology

Ethnic and Cultural Influences Ethnic and Cultural Influences ononTreatment OutcomesTreatment OutcomesIndirect:

Misinterpretation of behavior and belief

Lack of symptom recognition Misdiagnosis and inappropriate

treatment Provider bias and stereotyping

Illicit Drug Use by Race/Ethnicity-Illicit Drug Use by Race/Ethnicity-20002000National Household Survey on Drug National Household Survey on Drug AbuseAbuse

0

2

4

6

8

10

12

14

16

White Black Hispanic Am.Indian

Asian > one race

%

6.4 6.45.3

12.6

2.7

14.8

DSM-IV Cultural FormulationDSM-IV Cultural Formulation Cultural identity of the individual Cultural explanations of the individual’s

illness Cultural factors related to psychosocial

environment and levels of functioning Cultural elements of the relationship

between the individual and the clinician Overall cultural assessment for

diagnosis and care

AcculturationAcculturation

Acculturation describes the degree to which people from a particular cultural group display behavior that is like the more pervasive culture’s norms of behavior.

Recognition of Depressive Recognition of Depressive SymptomsSymptoms Using the CES-D, 47.3% of Latino and 41.6% of

Asian primary care patients had depressive symptoms indicative of psychiatric distress

PCPs identified psychiatric distress in 43.8% of Latinos and 23.6% of Asian patients

Higher acculturation status was significantly associated with overall diagnostic recognition as measured by PCP agreement with the CES-D

H Chung, et al, Depressive Symptoms and Psychiatric Distress in Low Income Asian and Latino Primary Care Patients: Prevalence and Recognition, Community Mental Health Journal, February, 2003

Depression Related Depression Related ComplaintsComplaints

Complaints Culture

“nerves” and headaches Latinoweakness, tiredness, “imbalance” Asianproblems of the “heart” Middle Eastern“heartbroken” American Indiananger, “evil” African American

Vicious CycleVicious CycleMedical and Behavioral

Problems

Mental Illness

Substance Abuse

Violence

Incarceration

Poverty and Social Problems

Therapeutic Relationship and Therapeutic Relationship and MilieuMilieu “Speak”, treat patients with respect,

Mr., Ms., honor privacy Show caring and empathic attitude Be there to intervene in crises Acknowledge importance of life events

– Abuse– Loss (illness, death, loss of housing, separation from

family)– Achievement

Be a part of the solution CSAT, 1999

Cultural CompetenceCultural Competence

A set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enable them to work effectively in cross-cultural situations.

Focal Point, vol. 3 #1, Fall, 1988

Culturally Competent System Culturally Competent System of Careof Care Importance of culture Assessment of cross-cultural

relations Vigilance towards the dynamics that

result from cultural differences Expansion of cultural knowledge Adaptation of services to meet

culturally-unique needs

Cultural Competence Cultural Competence TechniquesTechniques Bilingual/Bicultural providers Recruitment and Retention Training Coordinating with Traditional Healers Use of Community Health Workers Culturally Competent Health Promotion Including Family and/or Community Members Immersion into another Culture Administrative and Organizational

Accommodations Brach & Fraser, 2000

The Broadway Center Dual The Broadway Center Dual Diagnosis Service Diagnosis Service Use of structured diagnostic interview Pharmacologic management if needed Individual and group psychotherapy Case management services: housing,

vocational rehabilitation, jobs, literacy programs, and other social services

Key FeaturesKey Features Services provided regardless of

insurance status Availability of sample medications Coordination with primary care staff Empathic psychiatric therapist willing

to do outreach Word of mouth from patient-to-patient Creation of a culture in which mental

health is valued

Culturally Appropriate CareCulturally Appropriate Care

Services attended by members of the specific ethnic groups

Employment of appropriate ethnic staff at all levels

Involvement of professional and paraprofessional counselors from the recovering community

Cultural Issues in Substance Abuse Treatment CSAT, 1999

Culturally Appropriate CareCulturally Appropriate Care

Integrated Mental Health and Substance Abuse Treatment

Coordination with Systems (Corrections, Primary Care, Social Services)

Continuum of services (one-stop shop)- case management- medical care- social services

Culturally Appropriate CareCulturally Appropriate Care

Enlist people with mental illness and substance use disorders as advocates

Focus on Recovery Outreach, Education, Prevention

– use of culturally tailored educational videotape

Reducing Health Disparities Reducing Health Disparities Through the Implementation of Through the Implementation of Cultural CompetencyCultural Competency

Source: Brach and Fraser, Cultural Competency; 2000

Diverse Population

• linguistically• ethnically• culturally

Diverse Population

• linguistically• ethnically• culturally

Reduction of Health

Disparities

Reduction of Health

Disparities

Improved Outcomesfor Minority GroupMembers

• health status• functioning• satisfaction

Improved Outcomesfor Minority GroupMembers

• health status• functioning• satisfaction

Appropriate Services for MinorityGroup Members

• preventive• screening• diagnostic• treatment

Appropriate Services for MinorityGroup Members

• preventive• screening• diagnostic• treatment

Cultural Competency

• effective techniques• sound implementation

Cultural Competency

• effective techniques• sound implementation

+

Health Disparities and Health Disparities and Cultural Competence Cultural Competence WebsitesWebsites

IOM Report Unequal Treatment– www.nap.org

Surgeon General’s Supplement on Race Culture and Ethnicity– www.surgeongeneral.gov/library/mentalhealth/cre/

default.asp

Cultural Competence Standards– www.wiche.edu/MentalHealth/Cultural_Comp/ccstoc.htm

CLAS Standards (Culturally and Linguistically Appropriate Standards)– www.omhrc.gov/clas/cultural1a.htm