Download Black and Blue: Depression in the African

Ethnic and Cultural Considerations
in the Clinical Management of
Mental Illness and Substance Abuse
Annelle B. Primm , MD, MPH
Medical Director
Johns Hopkins Community Psychiatry Program
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
Asian
American American
Indian
African 4%
2%
American
13%
Other
6%
White
75%
White
African American
Asian American
American Indian
Other
Hispanic - 13%
Source: US Census Bureau
Cultural 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 MH:
Race, Culture, and Ethnicity
 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
Barriers and Mediators to Equitable Health Care
for Racial and Ethnic Groups
Barriers
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
Use of Services
Visits
•
primary care
•
specialty
•
emergency
Procedures
•
preventive
•
diagnostic
•
therapeutic
Mediators
Quality of providers
•
cultural competence
•
communication skills
•
medical knowledge
•
technical skills
•
bias/stereotyping
Outcomes
Health Status
• mortality
• morbidity
• well-being
• functioning
Equity of Services
Appropriateness of care
Efficacy of treatment
Patient adherence
Patient Views of Care
• experiences
• satisfaction
• effective
partnership
Modified From Access to Health Care in America 10 , From Cooper LA, Hill MN, and Powe NR. JGIM 2002; 477-486
People of African Descent:
Mental 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 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 Alaskan,
Native Hawaiian Population:
Mental 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
Alaska 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 People:
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 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:
Mental 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
 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 on
Treatment Outcomes
Direct:
 Cultural
beliefs and preferences
 Pathoplasticity
 Ethnopsychopharmacology
Ethnic and Cultural Influences on
Treatment Outcomes
Indirect:
 Misinterpretation
of behavior and
belief
 Lack of symptom recognition
 Misdiagnosis and inappropriate
treatment
 Provider bias and stereotyping
Illicit Drug Use by Race/Ethnicity-2000
National Household Survey on Drug Abuse
%
16
14.8
12.6
14
12
10
8
6.4
6.4
6
5.3
2.7
4
2
0
White
Black
Hispanic
Am.
Indian
Asian
> one race
DSM-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
Acculturation
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 Symptoms



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 Complaints
Complaints
“nerves” and headaches
weakness, tiredness, “imbalance”
problems of the “heart”
“heartbroken”
anger, “evil”
Culture
Latino
Asian
Middle Eastern
American Indian
African American
Vicious Cycle
Medical and Behavioral
Problems
Mental Illness
Poverty and Social Problems
Substance Abuse
Incarceration
Violence
Therapeutic Relationship and Milieu
 “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 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 of 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 Techniques









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 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 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 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 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 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 Through the
Implementation of Cultural Competency
Diverse
Population
Cultural
Competency
• linguistically
• ethnically
• culturally
• effective
techniques
• sound
implementation
+
Source: Brach and Fraser, Cultural Competency; 2000
Appropriate
Services for Minority
Group Members
Improved Outcomes
for Minority Group
Members
• preventive
• screening
• diagnostic
• treatment
• health status
• functioning
• satisfaction
Reduction of
Health
Disparities
Health Disparities and Cultural
Competence Websites
 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