Mental Health in Latinos Along Mental Health in Latinos Along the US-Mexico Borderthe US-Mexico Border

Francisco Moreno, MDFrancisco Moreno, MDProfessor of PsychiatryProfessor of Psychiatry

Deputy Dean for Diversity and InclusionDeputy Dean for Diversity and Inclusion

University of Arizona College of MedicineUniversity of Arizona College of Medicine

OverviewOverview

Demographics of Border StatesDemographics of Border States Challenges for Mental Health Care Challenges for Mental Health Care

Along the Border Along the Border Approaches to Minimize Mental Approaches to Minimize Mental

Health Care DisparitiesHealth Care Disparities Primary Care Services and Integrated Primary Care Services and Integrated

Care approachCare approach

Profile of Latinos in the USProfile of Latinos in the US

Census 2010 and 2000:Census 2010 and 2000: Percent Hispanic Along Border Percent Hispanic Along Border

StatesStates

Latinos in the US CensusLatinos in the US Census

52 million Latinos (16.7% of US 52 million Latinos (16.7% of US population)population)

76% speak other than English at home76% speak other than English at home 35% state they are not fluent in English35% state they are not fluent in English 62% have a HS diploma vs. 91% of NHW62% have a HS diploma vs. 91% of NHW 13% have a BA or higher vs. 31% of NHW13% have a BA or higher vs. 31% of NHW 24.8% live in poverty vs. 10.6% of NHW24.8% live in poverty vs. 10.6% of NHW 30.7% are uninsured vs. 11.7% of NHW30.7% are uninsured vs. 11.7% of NHW

Social Determinants of Social Determinants of Mental HealthMental Health

Social Issue Level of Evidence

Low SES Very convincing

Low education Very convincing

Unemployment or underemployment Very convincing

Food insecurity and early deficiency Strong

Gender inequity Strong

Low income Strong

Social DeterminantsSocial Determinants Mental health prevention and intervention Mental health prevention and intervention

efforts concentrate overwhelmingly on efforts concentrate overwhelmingly on affecting individual, family and/or affecting individual, family and/or community changecommunity change

Broader social, political and economic Broader social, political and economic conditions determine the determinants.conditions determine the determinants.

Heterogeneity of Hispanic Heterogeneity of Hispanic AmericansAmericans

BirthplaceBirthplace AcculturationAcculturation LanguageLanguage LiteracyLiteracy GeneticsGenetics RaceRace EducationEducation SESSES Urbanicity, region, Urbanicity, region,

etc.etc.Pew Research Center

Risk Factors for Mental Risk Factors for Mental IllnessIllness

Medical conditions: Diabetes, obesity, Medical conditions: Diabetes, obesity, painpain

Domestic violence, Domestic violence, ““MachismoMachismo”” effects on effects on gender equity, parenting, help seekinggender equity, parenting, help seeking

Certain family dynamicsCertain family dynamics AcculturationAcculturation Early life traumaEarly life trauma Financial challengesFinancial challenges RacismRacism Physical environmentPhysical environment

Migration Related StressMigration Related Stress Failure to succeed in the country of originFailure to succeed in the country of origin Immigration ExperienceImmigration Experience Adaptation Process:Adaptation Process:

Limited ResourcesLimited Resources Restricted MobilityRestricted Mobility Marginalization and isolationMarginalization and isolation Blame/stigmatization and guilt/shameBlame/stigmatization and guilt/shame Vulnerability/exploitabilityVulnerability/exploitability Fear and fear-based behaviorsFear and fear-based behaviors Family stress: Role and tradition Family stress: Role and tradition

changeschanges

““Fronterizo” Related StressFronterizo” Related Stress Contrasting cultures separated by Contrasting cultures separated by

language, religion, race, philosophy, language, religion, race, philosophy, historyhistory

Separation from the heartland areasSeparation from the heartland areas Physical isolationPhysical isolation Frontier conditionsFrontier conditions Transnational frictionsTransnational frictions Ethnic rivalriesEthnic rivalries

(Riding 1984; Martinez (Riding 1984; Martinez 1994)1994)

IMMIGRANT SOCIAL ADAPTATION IMMIGRANT SOCIAL ADAPTATION AND VULNERABILITY TO MH AND VULNERABILITY TO MH

PROBLEMSPROBLEMSContext of Exit

Developmental Stage

Family circumstances prior to migration

Family Stress

Loss of traditional family customs

Family Acculturation stress

Family role changes

Immigration Experience

Circumstances of exit

Circumstances of entrance

Acculturation Stress

Adolescent acculturation stress

Parental acculturation stress

Acculturation Process

Family Acculturation

Adolescent acculturation

Segmented Assimilation

Assimilation into local environment

VULNERABILITY TO MH PROB.

Serious Psychological Serious Psychological DistressDistress

18 y/o or older (2009-2010)18 y/o or older (2009-2010)

Hispanic Mexican American

NHW Mexican/NHW Ratio

Hispanic/NHW Ratio

3.6 2.8 3.1 0.9 1.2

NHW= Non-Hispanic Whites

Latino nativity differencesLatino nativity differences

Higher rates of mental illness among the Higher rates of mental illness among the native born and long-term U.S. residentsnative born and long-term U.S. residents

Replicated in Mexican immigrants and Replicated in Mexican immigrants and Puerto Rico Islanders. Also replicated in US-Puerto Rico Islanders. Also replicated in US-Mexico Border for Depression, Anxiety, Sub. Mexico Border for Depression, Anxiety, Sub. AbuseAbuse

Exceptions include Central American Exceptions include Central American immigrants often exposed to trauma and immigrants often exposed to trauma and Cuban Americans in FloridaCuban Americans in Florida

National Council of La Raza Institute for Hispanic Health 2005

Serious Psychological Serious Psychological DistressDistress

Percent of PovertyPercent of Poverty

Hispanic NHW Hispanic/NHW Ratio

Below 100% 6.4 10.1 0.6

100% - 200% 4.1 5.5 0.7

200% - 400% 2.6 3.2 0.8

NHW= Non-Hispanic Whites

Percentage feeling Percentage feeling depressive symptoms all depressive symptoms all

the time 2010the time 2010

Hispanic NHW Hispanic/NHW Ratio

Sadness 4.6 2.8 1.6

Hopelessness 3.3 2.0 1.7

Worthlessness 2.3 1.7 1.6

Everything is an effort

6.5 5.6 1.2

NHW= Non-Hispanic Whites

Percentage feeling anxious Percentage feeling anxious symptoms most the time symptoms most the time

20102010

Hispanic

NHW Hispanic/NHW Ratio

Nervousness all or most the time

5.4 4.9 1.1

Restlessness all or most the time

5.6 6.4 0.9

NHW= Non-Hispanic Whites

Death Rates for Suicide by Death Rates for Suicide by Sex and Ethnicity Sex and Ethnicity (by 100,000)(by 100,000)

Hispanic NHW Hispanic/NHW Ratio

Male 9.8 23.2 0.4

Female 2.0 6.0 0.3

Total 5.9 14.3 0.4

NHW= Non-Hispanic Whites

Suicidal Attempts in HS Suicidal Attempts in HS StudentsStudents

Hispanic NHW Hispanic/NHW Ratio

Male 6.9 4.6 1.5

Female 13.5 7.9 1.7

Total 10.2 6.2 1.6

NHW= Non-Hispanic Whites

Percentage receiving Percentage receiving counseling / medication in counseling / medication in

20082008

Hispanic NHW Hispanic/NHW Ratio

Male 5.2 / 4.0 10.8 /9.1 0.5 / 0.4

Female 8.4 / 6.5 20.8 / 18.3

0.4 / 0.4

Total 6.8 / 5.2 16.0 / 13.9

0.4 / 0.4

NHW= Non-Hispanic Whites

Some Common Issues in Some Common Issues in Latino Mental HealthLatino Mental Health

Latino children with developmental and Latino children with developmental and mental disorders remain largely undiagnosedmental disorders remain largely undiagnosed

Latino children are treated more frequently Latino children are treated more frequently than other groups but adults are not than other groups but adults are not (US-SG 01)(US-SG 01)

Latinos are identified as a high risk group for Latinos are identified as a high risk group for depression, anxiety, and substance abuse depression, anxiety, and substance abuse (National Alliance for Hispanic Health 2001)(National Alliance for Hispanic Health 2001)

Ineffective coping and increased stress may Ineffective coping and increased stress may lead to higher suicidal ideation and behaviorlead to higher suicidal ideation and behavior

Latinos Health SeekingLatinos Health Seeking

What do I have? Why do I have it? What do I have? Why do I have it? What is going to help? Who do I go to?What is going to help? Who do I go to?

<1/11 Latinos seek Mental Health Tx<1/11 Latinos seek Mental Health Tx <1/5 Latinos seek general medical care<1/5 Latinos seek general medical care <1/20 immigrants seek Mental Health Tx<1/20 immigrants seek Mental Health Tx <1/10 immigrants seek general medical Tx<1/10 immigrants seek general medical Tx

Reasons provided by Reasons provided by patients for not seeking patients for not seeking

helphelp Lack of knowledge of where to seek Lack of knowledge of where to seek

carecare Lack of proximity to treatment centersLack of proximity to treatment centers Transportation problemsTransportation problems Lack of Spanish speaking providers who Lack of Spanish speaking providers who

are culturally and linguistically trainedare culturally and linguistically trained

““La ropa sucia se lava en casa…”La ropa sucia se lava en casa…”(Aguilar-Gaxiola et al, 2002)

Latino Mental Health CareLatino Mental Health Care

Twice as likely to seek health care in PCP Twice as likely to seek health care in PCP clinics, faith based organizationsclinics, faith based organizations

PCPs prescribe 67% of psychotropics and PCPs prescribe 67% of psychotropics and 80% of antidepressants (Chapa, 2004)80% of antidepressants (Chapa, 2004)

We have 20 Latino Mental Health We have 20 Latino Mental Health Professionals per 100,000 Latinos in the Professionals per 100,000 Latinos in the USUS

Mexican American Prevalence and Services Survey (MAPSS)

Language BarriersLanguage Barriers

Patients report more symptoms during Spanish Patients report more symptoms during Spanish interviews interviews (Price and Cuellar 1981) (Price and Cuellar 1981)

Clinicians detect higher symptom severity in Clinicians detect higher symptom severity in Hispanic patients with schizophrenia and Hispanic patients with schizophrenia and depression during bilingual interviews followed depression during bilingual interviews followed by Spanish, and lowest in English. by Spanish, and lowest in English. (Malgady and (Malgady and Costantino 1998)Costantino 1998)

Nearly half Spanish speaking Latinos report Nearly half Spanish speaking Latinos report trouble communicating with their physicians trouble communicating with their physicians and understanding information about and understanding information about medication and written instructions medication and written instructions (The (The Commonwealth Fund 2003)Commonwealth Fund 2003)

Family Domain

SocioculturalDomain

PersonalDomain

AccessDomain

Provider Domain

Beliefs andAttitudes

Impairment, History ofTx and Dx, Self Rated Mental Health Status,Self-defined Problem,

Insurance andTreatment Exper.

Information about MHProblem IdentificationStigmaSupport for treatment

SES, Nativity.Age,Ethnicity, Accul.

Referral sourceStaff CourtesyTransportationWork ObligationsEligibility for Services

Appropriateness of careTimely Appointments

PREDISPOSING NEED ENABLING OUTCOMES

OPERATIONALIZATION OF A SOCIOBEHAVIORAL MODEL OF HELP SEEKING

PersistenceSatisfaction

TreatmentEffectiveness

NOTE: MODEL FOR GENERATING TESTS OF HYPOTHESES AND MULTIVARIATE MODELS

Mental Illness:Mental Illness: In the context of In the context of CultureCulture

Expression: Consistent with self, Expression: Consistent with self, family, society.family, society.

Assessment: Related to perceived Assessment: Related to perceived experience and assigned rationale.experience and assigned rationale.

Treatment: Congruent to notion of Treatment: Congruent to notion of illness and its cause.illness and its cause.

Institute for Healthcare Institute for Healthcare Improvement (Triple Aim)Improvement (Triple Aim)

1.1. Improve the Improve the healthhealth of the population of the population

2.2. Enhance the patient experience of Enhance the patient experience of carecare (including quality, access, and (including quality, access, and reliability)reliability)

3.3. Reduce, or at least control, the per Reduce, or at least control, the per capita capita costcost of care. of care.

Border Area Latino:Border Area Latino:Access to Mental HealthcareAccess to Mental Healthcare

Increased number of uninsured and Increased number of uninsured and underinsuredunderinsured

Geographic accessibility concernsGeographic accessibility concerns Specialty services limitationsSpecialty services limitations Linguistic and cultural incongruenceLinguistic and cultural incongruence Decrease utilization of government Decrease utilization of government

programs (Medicare, VA)programs (Medicare, VA) Sick time benefitsSick time benefits Schedule flexibilitySchedule flexibility Immigration issuesImmigration issues

A method for improving cultural A method for improving cultural

congruence:congruence: The Cultural FormulationThe Cultural Formulation

Systematic assessment of Systematic assessment of cultural factors impacting Dx and cultural factors impacting Dx and Tx (1994)Tx (1994)

A.A. Cultural identityCultural identity

B.B. Cultural explanations of illnessCultural explanations of illness

C.C. Cultural factors related to psycho-Cultural factors related to psycho-social environment and functionsocial environment and function

D.D. Physician patient relationshipPhysician patient relationship

E.E. Overall Cultural AssessmentOverall Cultural Assessment

CLAS standardsCLAS standards

The collective set of “Culturally and The collective set of “Culturally and Linguistically Appropriate Services” (CLAS Linguistically Appropriate Services” (CLAS Mandates US-DHHS-OMH 2001) intended Mandates US-DHHS-OMH 2001) intended to guide, inform, and facilitate required to guide, inform, and facilitate required and recommended practices related to and recommended practices related to culturally and linguistically appropriate culturally and linguistically appropriate health services.health services.

http://minorityhealth.hhs.gov/assets/pdf/checked/executive.pdfhttp://minorityhealth.hhs.gov/assets/pdf/checked/executive.pdf

D: Cultural Elements of the D: Cultural Elements of the Clinician-Patient RelationshipClinician-Patient Relationship

•Differences in culture, social status or role Differences in culture, social status or role between the clinician and patientbetween the clinician and patient

•Communicating with a professional in a Communicating with a professional in a field unknown to the patient in his/her own field unknown to the patient in his/her own culture.culture.

•Communicating with a figure of the Communicating with a figure of the establishment or authority information that establishment or authority information that may be damaging to an immigration claim, may be damaging to an immigration claim, insurance, probation, etc.insurance, probation, etc.

•Negotiating levels of intimacy and rapport Negotiating levels of intimacy and rapport with members of a different race, religion or with members of a different race, religion or profession.profession.

Some Elements of Cultural Some Elements of Cultural CongruenceCongruence

Language of interview, communication Language of interview, communication adequacyadequacy

Nature of work-up and interpretation of Nature of work-up and interpretation of symptomssymptoms

Role assigned to precipitants/stressors and their Role assigned to precipitants/stressors and their interaction with individual/social vulnerabilitiesinteraction with individual/social vulnerabilities

Treatments offered and outcomes expectedTreatments offered and outcomes expected Attitudes towards inclusion of family, social Attitudes towards inclusion of family, social

networks, including spiritual communitiesnetworks, including spiritual communities Addressing stigmaAddressing stigma Healthcare accessHealthcare access

Cultural Sensitivity: Cultural Sensitivity: Ten CommandmentsTen Commandments

1.1. Respect all culturesRespect all cultures

2.2. Understand your own cultural identityUnderstand your own cultural identity

3.3. Find out each patient’s cultural identificationFind out each patient’s cultural identification

4.4. See patients in a culturally comfortable environmentSee patients in a culturally comfortable environment

5.5. Conduct culturally sensitive evaluationsConduct culturally sensitive evaluations

6.6. Elicit patient (family) expectations, preferences, and prior Elicit patient (family) expectations, preferences, and prior attempts to get help.attempts to get help.

7.7. Adapt treatment techniques to cultural values of the Adapt treatment techniques to cultural values of the patientpatient

8.8. Determine your cultural effectivenessDetermine your cultural effectiveness

9.9. Understand broader societal influences on cultural groups.Understand broader societal influences on cultural groups.

10.10. Advocate for institutional policies and practices of cultural Advocate for institutional policies and practices of cultural competence.competence.

Dealing with Stress (Really?)Dealing with Stress (Really?)

Adapted Interventions: Adapted Interventions: BalanceBalance

Go to bed earlier, enjoy your partner and restGo to bed earlier, enjoy your partner and rest Avoid drinking excessively, or using drugsAvoid drinking excessively, or using drugs Enjoy family and friendsEnjoy family and friends Walk/run in a safe and pleasant environmentWalk/run in a safe and pleasant environment Go to church, read that helpful bookGo to church, read that helpful book Worry about what you need to, onlyWorry about what you need to, only Celebrate your strengths/gifts, share themCelebrate your strengths/gifts, share them Take parenting classes, join marital groupsTake parenting classes, join marital groups

Screening and TreatmentScreening and Treatment

Early detection, meet them where they areEarly detection, meet them where they are Any clinic registration, PCP, OBGYN, Peds, Any clinic registration, PCP, OBGYN, Peds,

Geriatrics, Cancer Clinics, Pain Clinics, Geriatrics, Cancer Clinics, Pain Clinics, RehabRehab

PHQ-9 PHQ-9 (2)(2) GAD-7GAD-7 TMAP algorithm TMAP algorithm Realistic referral optionsRealistic referral options

Integrated Mental Health Integrated Mental Health CareCare

Integrating mental health services Integrating mental health services into primary care services and into primary care services and integrating primary care services into integrating primary care services into mental health and substance abuse mental health and substance abuse care settings to improve quality of care settings to improve quality of care.care.

Example of Academic and Example of Academic and Community CollaborationsCommunity Collaborations

A study proposing to compare the A study proposing to compare the acceptability and effectiveness of acceptability and effectiveness of depression treatment for Hispanic depression treatment for Hispanic patients provided by a psychiatrist patients provided by a psychiatrist through internet videoconferencing through internet videoconferencing (webcam) with treatment as usual (webcam) with treatment as usual with the primary care provider (TAU). with the primary care provider (TAU).

College of MedicineCollege of Medicine

Mission: To continually Mission: To continually improve health care for improve health care for all Arizonans through all Arizonans through education, research and education, research and clinical care.clinical care.

Services: Among its 20 Services: Among its 20 departments and 8 departments and 8 interdisciplinary centers interdisciplinary centers includes the includes the Arizona Hispanic Center Arizona Hispanic Center of Excellence; Arizona of Excellence; Arizona Telemedicine ProgramTelemedicine Program

The University of ArizonaHealth Sciences Center

FOUNDED 1962FOUNDED 1962Mission of caring for the Mission of caring for the

uninsured and underserved for uninsured and underserved for 48 years in Tucson and 48 years in Tucson and

Southern ArizonaSouthern Arizona

Purpose and RationalePurpose and Rationale Our Our broad long-term objectivebroad long-term objective is to improve the is to improve the

quality of care to underserved Hispanics affected quality of care to underserved Hispanics affected with depressive disorders using health with depressive disorders using health information technology.information technology.

This technology can be used to provide This technology can be used to provide appropriate patient centered care, with culturally appropriate patient centered care, with culturally and linguistically congruent providers.and linguistically congruent providers.

Results from this study may help inform the Results from this study may help inform the manner in which quality and specialized manner in which quality and specialized psychiatric care can be delivered using real time psychiatric care can be delivered using real time video communication through the internet video communication through the internet (webcam), a medium that is now readily and (webcam), a medium that is now readily and economically available.economically available.

SubjectsSubjects

N= 150 Self identified as Hispanics, age N= 150 Self identified as Hispanics, age ≥ 18 ≥ 18 y/oy/o

MINI based DSM-IV diagnosis of Major MINI based DSM-IV diagnosis of Major Depressive Disorder (MDD)Depressive Disorder (MDD)

Excluded: bipolar disorder, schizophrenia, Excluded: bipolar disorder, schizophrenia, dementia, active substance dependence; dementia, active substance dependence; requiring inpatient or residential treatment; requiring inpatient or residential treatment; serious medical illness; lacking capacity to serious medical illness; lacking capacity to consent; pregnant or lactating women; and consent; pregnant or lactating women; and people with safety concerns (DTS, DTO). people with safety concerns (DTS, DTO).

Webcam InterventionWebcam Intervention

Webcam InterventionWebcam Intervention Patients receive services on site at SEHC and Patients receive services on site at SEHC and

will be oriented and ushered by study will be oriented and ushered by study personnel.personnel.

Psychiatric visits include a 45-60 minute full Psychiatric visits include a 45-60 minute full psychiatric interview, informed consent and psychiatric interview, informed consent and treatment planning procedures treatment planning procedures (American Psychiatric (American Psychiatric

Association Treatment Guidelines)Association Treatment Guidelines). In addition to . In addition to pharmacotherapy, other aspects of care may pharmacotherapy, other aspects of care may include psychoeducation, and brief eclectic include psychoeducation, and brief eclectic interventions as appropriate.interventions as appropriate.

Follow up visits will take place monthly for 20-Follow up visits will take place monthly for 20-30 minutes, for rapport maintenance, progress 30 minutes, for rapport maintenance, progress and safety monitor, treatment adjustment if and safety monitor, treatment adjustment if needed.needed.

After hour coverage will be provided through After hour coverage will be provided through the Psychiatry Research Clinician on call at UMCthe Psychiatry Research Clinician on call at UMC

Treatment as Usual by PCPTreatment as Usual by PCP

Treatment as UsualTreatment as Usual Depression treatment will be obtained Depression treatment will be obtained

from the patientfrom the patient’’s PCP as it is normally s PCP as it is normally done at SEHC.done at SEHC.

TAU often includes antidepressants, in TAU often includes antidepressants, in adherence to AHCPR treatment adherence to AHCPR treatment guidelines.guidelines.

Patients who require additional mental Patients who require additional mental health care are referred to behavioral health care are referred to behavioral health services or community mental health services or community mental health agencies. health agencies. (patients with specific psychosocial (patients with specific psychosocial issues, safety concerns, evident need for couples or family therapy)issues, safety concerns, evident need for couples or family therapy)

Crisis services related to depression are Crisis services related to depression are provided through standard clinic provided through standard clinic protocols.protocols.

Data Collection Tools Data Collection Tools ScheduleSchedule

MiMinn

RaterRater BasBase-e-

lineline

Mo Mo 11

Mo Mo 22

Mo Mo 33

Mo Mo 4 4

Mo Mo 55

Mo Mo 66

PHQ-9PHQ-9 22 SelfSelf XX XX XX

MINIMINI 3030 ClinClin XX

Q-LES-QQ-LES-Q 55 SelfSelf XX XX XX

SF-8SF-8 55 SelfSelf XX XX XX

MADRSMADRS 1515 ClinClin XX XX XX

VSQ-9VSQ-9 22 SelfSelf XX XX XX XX XX XX XX

WAI-S-WAI-S-C+TC+T

55 Self/Self/ClinClin

XX XX XX

ARSMA-IIARSMA-II 1010 SelfSelf XX XX XX

Baseline/ Baseline/ Other InfoOther Info

55 SelfSelf XX XX XX

CompliancCompliance ratinge rating

11 Self Self /Clin/Clin

XX XX XX XX XX XX

Depression Outcome Depression Outcome MADRSMADRS

Time Effect: p<.01 Treatment Interaction: p <.05 Time Effect: p<.01 Treatment Interaction: p <.05

MADRS: Categorical MADRS: Categorical OutcomeOutcome

Depression Outcome PHQ-9Depression Outcome PHQ-9Time Effect: p<.01 Treatment Interaction: p <.05Time Effect: p<.01 Treatment Interaction: p <.05

Quality of Life OutcomeQuality of Life OutcomeTime Effect: p<.01 Treatment Interaction: p <.05Time Effect: p<.01 Treatment Interaction: p <.05

Disability OutcomeDisability OutcomeTime Effect: p<.01 Treatment Interaction: p <.05Time Effect: p<.01 Treatment Interaction: p <.05

Patient Doctor RelationshipPatient Doctor Relationship(Patient Ratings)(Patient Ratings)

Time Effect: p<.01 Treatment Interaction: p <.05Time Effect: p<.01 Treatment Interaction: p <.05

Overall Visit SatisfactionOverall Visit SatisfactionTime Effect: p<.01 Treatment Interaction: p >.1Time Effect: p<.01 Treatment Interaction: p >.1

SummarySummary US-Mexico Border Mental Health is associated US-Mexico Border Mental Health is associated

with unique stressors related to immigration, with unique stressors related to immigration, acculturation, and common socioeconomic acculturation, and common socioeconomic issuesissues

Providing screening and treatment requires Providing screening and treatment requires cultural, linguistic, and literacy sensitivitycultural, linguistic, and literacy sensitivity

PCPs (non-psychiatrists) are an important PCPs (non-psychiatrists) are an important source of adequate mental health caresource of adequate mental health care

Specialized care is sparse yet effective when Specialized care is sparse yet effective when accessed and properly delivered. accessed and properly delivered.

AcknowledgementsAcknowledgements