Download Stigma of Mental Illness Among Ethnic Minority Populations: African

Stigma of Mental Illness Among
Ethnic Minority Populations
African Americans
Lois Bolden, APRN, BC
June 27, 2004
This research is supported by
The Substance Abuse and Mental Health Services
Administration (SAMHSA)
Introduction

African Americans (AA) have high prevalence rates of
mental illnesses

They are less likely to receive treatment when compared
with other US groups

Stigma of mental illness is a barrier to prompt and effective
mental health treatment

Stigma influences patterns of mental health treatment
seeking behaviors
Chow, J., Jaffee, K. & Snowden, L. (2003). Racial/ethnic disparities in the use of mental health services in poverty areas. American Journal of Public
Health, 93(5), 792-797.
Wells, K., Klap, R., Koike, A. & Sherbourne, C. (2001). Ethnic disparities in unmet need for alcoholism, drug abuse, and mental health care. American
Journal of Psychiatry 15, (12), 2027-2032.
Williams, D. W. & Williams-Morris, R. (2000). Racism and mental health, The African American experience. Ethnicity and Health, 5(3/4), 243-268.
U.S. Department of Health and Human Services; Substance Abuse and Mental Health Services Administration, (1999) Mental Health: A Report of the
Surgeon General, Rockville, MD.
Essential Concepts
Stigma exists when individuals

Label persons as divergent

Use dominant cultural beliefs to connect labeled
person to unfavorable characteristics
Link, B. G. and. Phelan, J. A (2001). Conceptualizing stigma. Annual Review Sociology, 27, 363-385.
Essential Concepts

Place labeled person in a category that separates him or
her from mainstream society

Discriminate against the labeled person, leading to
compromised help seeking behaviors and negative
health outcomes
Link, B. G. and J. A. Phelan (2001). Conceptualizing stigma. Annual Review Sociology, 27, 363-385.
Impact of Stigma

Delay in mental health treatment seeking

Use of primary care and emergency rooms
services

Present for treatment with more severe symptoms;
they are more likely to be diagnosed as psychotic,
schizophrenic in particular
Kales, H., Blow, F., Bingham, C. R., Copeland, L. & Mellow, A. (2000). Race and inpatient psychiatric diagnosis among elderly veterans. Psychiatric
Services, 51, 795-800.
Minsky, S., William, V., Miskimen, Gara, M. & Escobar, J. (2003). Diagnostic patterns in Latino, African American and European American
psychiatric patients. Archives General Psychiatry, 60, 637-644.
U.S. Department of Health and Human Services; Substance Abuse and Mental Health Services Administration, (1999) Mental Health: A Report of the
Surgeon General, Rockville, MD.
Purpose
Explore the following questions

What are the demographic characteristics of African American people
who participated in the 2001 Nationwide Inpatient Data study (NIS)
and how do they compare with the other US groups?

Is there a difference between Length of Stay (LOS) among African
Americans and other US groups?

Is there a difference in the types of admissions of African Americans
and other US groups?

What are the three most prevalent psychiatric diagnoses among
African Americans who presented for treatment in emergency rooms?

What are the three most prevalent psychiatric diagnoses among
African American males between the ages of 18-30 who presented for
treatment in emergency rooms?
Methods

Secondary analyses of Healthcare Utilization Project
Nationwide Inpatient Sample, 2001

Setting




33 states
982 hospitals
5-8 million inpatient stays
Sample


547, 614 African Americans
Ages 18 and over
Methods

Exclusion Criteria:


Psychiatric hospitals, short term rehabilitation centers,
long term healthcare centers, alcoholism and chemical
dependency treatment facilities
Descriptive/Comparative Design
Results
(Table 1) Demographic Characteristics of The Nationwide Inpatient
Sample
Characteristics
N
African
Americans
Caucasians
Hispanics
*Asians/
Pacific
Islander
Native
Americans
576,737
3,322,677
459,507
96,481
19,330
50.95
19.97
60.42
20.45
45.86
21.01
52.51
21.61
51.33
20.16
Male (%)
36.60
40.65
31.64
32.05
36.10
Female (%)
63.40
59.35
68.36
67.95
63.90
Age
M
SD
Gender
*Categories for ethnic minority groups are those used in the NIS study
Results
(Table 2) Length of Stay for African Americans and Other US Groups
Characteristics
African
Americans
Caucasians Hispanics
Asians/
Pacific
Islanders
Native
Americans
Length of Stay
M
SD
*5.59
7.89
4.94
6.68
4.45
6.60
5.02
8.38
4.18
6.28
Results
(Table 3) A Comparison of Admission Types for African Americans with Other
US Groups
Characteristics
African
Americans
Caucasians
Hispanics
Asians/
Pacific
Islanders
Native
Americans
Emergency (%) *58.82
47.58
47.53
45.57
39.72
Urgent (%)
19.54
23.30
20.88
25.30
15.56
Elective (%)
21.37
29.07
31.56
29.10
44.70
Results
Three Most Prevalent Psychiatric Diagnoses for
African Americans
5.50%
22.20%
Psychosis
Alcohol/Drug Dependence
Depressive Neurosis
65%
Results
Three Most Prevalent Psychiatric Diagnoses for
African American Males (ages 18-30)
7%
15%
Psychosis
Alchohol/Drug
Dependence
Depressive Neurosis
78%
Discussion

The length of stays (LOS) were longer (5.59 days) for
African Americans (AA) than any other population

Perhaps they experienced delays in help seeking and are
more severely ill at the time they entered the health system

Most psychiatric admissions are from the emergency room
(58%)
Baker, F. & Bell C. (1999). Issues in the psychiatric treatment of African Americans. Psychiatric Services, 50, 362-368.
Chow, J., Jaffee, K. & Snowden, L. (2003). Racial/ethnic disparities in the use of mental health services in poverty areas.
American Journal of Public Health, 93(5), 792-797.
Minsky, S., William, V., Miskimen, Gara, M. & Escobar, J. (2003). Diagnostic patterns in Latino, African American and
European American psychiatric patients. Archives General Psychiatry, 60, 637-644.
Discussion
Three Most Common Psychiatric Diagnoses
 Psychosis
 Substance Abuse
 Depressive Neurosis

These findings are consistent with the literature suggesting that
AAs are more likely to be diagnosed with psychosis (67.8%)
rather than depressive neurosis (5.7%)

Substance abuse is also prevalent among AA males ages 18-30,
but the most frequent diagnosis in this group is PSYCHOSIS
Dixon, L., Paden-Green, L., Delahanty, J., Lucksted, A., Postrado, L., & Hall, J. (2001). Variables associated with disparities in treatment of patients with
schizophrenia and comorbid mood and anxiety disorders. Psychiatric Services 52(9), 1216-1222.
Kales, H., Blow, F., Bingham, C. R., Copeland, L. & Mellow, A. (2000). Race and inpatient psychiatric diagnosis among elderly veterans.
Psychiatric Services , 51, 795-800.
U.S. Department of Health and Human Services; Substance Abuse and Mental Health Services Administration, (1999) Mental Health: A Report of the Surgeon
General, Rockville, MD.
Limitations

Data were obtained from a large dataset with numerous
researchers and clinicians involved in the data collection
process; issues regarding cultural competence among
researchers and clinicians were not addressed

Potential for variability of data collection and interpretation
across sites

Inconsistencies regarding criteria for psychiatric diagnoses;
different criteria for classifying psychosis used by
International Classification of Diseases (ICD) and the
Diagnostic Related Groups (DRG)

Cultural competence was not addressed in the study as it
relates to African Americans and mental health and illness
Implications for Research

Future studies are needed that focus on the
impact of stigma on the “stigmatized individual”
in domains such as







Self-Esteem
Resilience
Health Outcomes
Family Relationship
Vocational Pursuits
Legal and Law Enforcement Policies and Practices
Parental Rights and Responsibilities
Link, B. G., Struening, E., Neese-Todd, S., Asmussen, S.& Phelan, J.A. (2001). The consequences of stigma for the selfesteem of people with mental illnesses. Psychiatric
Service, 52(12), 1621-1626.
U.S. Department of Health and Human Services; Substance Abuse and Mental Health Services Administration, (1999)
Mental Health: A Report of the Surgeon General, Rockville, MD.
Implications for Research

More research is needed to better understand the potential
overlap of cultural and folklore behaviors and beliefs that
could be misinterpreted as psychiatric symptoms by
clinicians and researchers who may not be culturally
competent

Exploration of the influence of culturally competent
African American providers in healthcare systems and
health outcomes of this population is not well researched;
stigma generated beliefs and practices within AA
communities should be systematically explored with
appropriate interventions and evaluations
U.S. Department of Health and Human Services; Substance Abuse and Mental Health Services Administration, (1999) Mental Health: A Report of the
Surgeon General, Rockville, MD.
Williams, D. W. & Williams-Morris, R. (2000). Racism and mental health, The African American experience. Ethnicity and Health, 5(3/4), 243-268.
Implications for Clinical Practice

It is imperative that clinicians are educated and trained in
cultural competence and the multitude of ways that
mental illness is expressed among different groups

Cultural diversity should be a major component of
education and continuing education for practitioners and
educators

More research is needed from the perspective of the
“stigmatized individual” and his/her sense of satisfaction
with treatment
Diala, C., Muntaner, C., Walrath, C., Nickerson, K., LaVeist, T., & Leaf, P. (2001). Racial/ethnic differences in attitudes toward seeking professional
mental health services. American Journal of Public Health, 91(5), 805-807.
Institute of Medicine (2001). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: The National Academies
Press.
Implications for Public Policy

Public Policy should address

The impact of stigma related to









Housing
Education
Employment Opportunities
Homelessness
Abandonment of Patient by the Family
Abandonment of Patient by the Practitioner
Patient in Clinical Research Trials
Continuity of Care
Aging and long term care
Corrigan, P., Thompson, V., Lambert, D. ,Sangster, Y., Noel, J., & Campbell, J. (2003). Perceptions of discrimination among persons with serious
mental illness. Psychiatric Services, 54(8), 1105-1110.
Hocking, B. (2003). Reducing mental illness stigma and discrimination-everybody's business. Medical Journal of Australia, 178(supplemental 5), 4748.
A comprehensive health care system could help
to assure a place in the community for
everyone
Thank You
References

Baker, F. & Bell, C. (1999). Issues in the psychiatric treatment of African Americans. Psychiatric
Services,
50(3), 362-368.

Chow, J., Jaffee, K. & Snowden, L. (2003). Racial/ethnic disparities in the use of mental health
services in poverty areas. American Journal of Public Health, 93(5), 792-797.

Copeland, L., Zeber, J., Valenstien, M., & Blow, F. (2003). Racial disparity in the use of atypical
antipsychotic medications among veterans. American Journal of Psychiatry, 160(10), 1817-1822.

Corrigan, P. P., D. (1999). Lessons from social psychology on discrediting psychiatric
American Psychologist, 54(9), 765-776.

Corrigan, P., Green, A. Lundin, Kubiak, M. & Penn, D. (2001). Familiarity with and social
distance from people who have serious mental illness. Psychiatric Services, 52(7), 953958.

Corrigan, P., Thompson, V., Lambert, D. ,Sangster, Y., Noel, J., & Campbell, J. (2003). Perceptions
of discrimination among persons with serious mental illness.
Psychiatric Services,
54(8), 11051110.
stigma.
References

Diala, C., Muntaner, C., Walrath, C., Nickerson, K., LaVeist, T., & Leaf, P. (2001).
Racial/ethnic differences in attitudes toward seeking professional mental health services.
American Journal of Public Health, 91(5), 805-807.

Dixon, L., Paden-Green, L., Delahanty, J., Lucksted, A., Postrado, L., & Hall, J. (2001).
associated with disparities in treatment of patients with schizophrenia and
mood and anxiety disorders. Psychiatric Services,
52(9), 1216-1222.

Hocking, B. (2003). Reducing mental illness stigma and discrimination-everybody's business.
Medical Journal of Australia, 178(supplemental 5), 47-48.

Institute of Medicine (2001). Unequal treatment: Confronting racial and ethnic disparities in
health care. Washington, DC: The National Academies Press.

Kales, H., Blow, F., Bingham, C. , Copeland, L. & Mellow, A. (2000). Race and inpatient psychiatric
diagnosis among elderly veterans. Psychiatric Services, 51, 795-800.

Kuno, E. & Rothbard, A. (2002). Racial disparities in antipsychotic prescription patterns
for patients with schizophrenia. American Journal of Psychiatry, 159(4), 567-572.

Link, B., Phelan, J., Bresnahan, M., Strueve, A. & Pescosolido, B. (1999). Public conceptions of
mental illness, label, causes, dangerousness, and social distance. American Journal of Public
Health, 89(9), 1328-1333.
Variables
comorbid
References

Link, B. G. & Phelan, J .A. (2001). Conceptualizing stigma. Annual Review Sociology, 27, 363-385.

Link, B. G., Struening, E., Neese-Todd, S., Asmussen, S.& Phelan, J.A. (2001). The
consequences of stigma for the self-esteem of people with mental illnesses. Psychiatric
Service, 52(12), 1621-1626.

Mann, C. H. & Himelein, M. (2004). Factors associated with stigmatization of persons with
mental illness. Psychiatric Services, 55 (2), 185-187.

Milligan, C., Nich, C., & Carroll, K. (2004). Ethnic differences in substance abuse
treatment, compliance, and outcome from two clinical trials. Psychiatric Services,
167-173.

Minsky, S., William, V., Miskimen, Gara, M. & Escobar, J. (2003). Diagnostic patterns
Latino, African American and European American psychiatric patients.
Archives General Psychiatry, 60, 637-644.

Neighbors, H., Trierweiler, S., Ford, B., & Muroff, J. (2003). Racial differences in DSM diagnosis
using a semi-structured instrument, The importance of clinical judgment in the
diagnosis of African Americans. Journal of Health and Social Behavior, 43(September), 237256.
55(2),
in
References
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Opolka, J., Rascati, K., Brown, C. & Gibson, P.J. (2004). Ethnicity and prescription
for haloperidol, risperidone, and olanzapine. Psychiatric Services 55(2), 151-156.
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
Perlick, D. (2001). Special section on stigma as a barrier to recovery, Introduction.
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
Pescosolido, B., Monahan, J., Link, B.G. Stueve, A. & Kikuzawa, S. (1999). The
public's
view of
the competence, dangerous, and need for legal coercion if persons with mental
health
problem. American Journal of Public Health, 89, 1339-1345.

Pyne, J. M., Kuc, E. J., Schroeder, P. J., Fortney, J. C., Edlund, M. & Sullivan, G. (2004).
Relationship between perceived stigma and depression severity. The Journal of Nervous and
Mental Disease, 192(4), 278-283.

Reardon, S. and Buka S. (2002). Differences in onset and persistence of substance abuse and
dependence among Whites, Blacks, and Hispanics. Public Health Report ,117(3), 51-60.

Sirey, J. A., Bruce, M., Alexopoulos, G. S., Perlick, D., Friedman, S., & Meyers, B. (2001).
Perceived stigma and patient-related severity of illness as predictors of antidepressant
drug adherence. Psychiatric Service, 52(12), 1615-1620.
References
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Snowden, L. R. (2001). Barriers to effective mental health services for African Americans. Mental
Health Services Research, 3(4), 181-187.

Stuart, H. A. & Arboleda-Florez, J F. (2001). A public health perspective on violent offences
among persons with mental illness. Psychiatric Services, 52(5), 654-659.

Takeuchi, D., & Mang-King, C. (1998). Coercive and voluntary referrals, How ethnic minority
adults get into mental health treatment. Ethnicity and Health, 3(3), 149-161.

U.S. Department of Health and Human Services; Substance Abuse and Mental Health Services
Administration, (1999) Mental Health: A Report of the Surgeon General, Rockville, MD.

Wang, P., Demier, O. & Kessler, R. (2002). Adequacy of treatment for serious mental illness in
the United States. American Journal of Public Health, 92(1), 92-98.

Wells, K., Klap, R., Koike, A. & Sherbourne, C. (2001). Ethnic disparities in unmet need for
alcoholism, drug abuse, and mental health care. American Journal of Psychiatry 15, (12), 20272032.

Williams, D. W. & Williams-Morris, R. (2000). Racism and mental health, The African American
experience. Ethnicity and Health, 5(3/4), 243-268.