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NAMI CA 2014 Annual Conference “Growing Minds in Changing Times” Sergio Aguilar-Gaxiola, MD, PhD Professor of Clinical Internal Medicine Director, Center.

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Presentation on theme: "NAMI CA 2014 Annual Conference “Growing Minds in Changing Times” Sergio Aguilar-Gaxiola, MD, PhD Professor of Clinical Internal Medicine Director, Center."— Presentation transcript:

1 NAMI CA 2014 Annual Conference “Growing Minds in Changing Times” Sergio Aguilar-Gaxiola, MD, PhD Professor of Clinical Internal Medicine Director, Center for Reducing Health Disparities University of California, Davis Newport Beach, CA August 2, 2014 If You Build It, Will They Come? Addressing and Reducing Mental Health Treatment Gaps in Underserved Populations

2 I have no relevant financial interest/arrangement or affiliation with any organizations related to commercial products or services to be discussed at this presentation I have no relevant financial interest/arrangement or affiliation with any organizations related to commercial products or services to be discussed at this presentation Disclosure

3 Mental and/or substance abuse disorders are major drivers of suffering, disability, cost and are associated with poverty

4 4

5 The “Treatment Gap” Between 50 to 90% of people with serious mental disorders have not had received appropriate mental health care in the previous year

6 Treatment Gap in the U.S. n n Levels of unmet need (not receiving specialist or generalist care in past 12 months, with identified diagnosis in the same period) – –Hispanics – 70% – –African Americans – 72% – –Asian Americans – 78% – –Non-Hispanic Whites – 61% n n Levels of unmet need (not receiving specialist or generalist care in past 12 months, with identified diagnosis in the same period) – –Hispanics – 70% – –African Americans – 72% – –Asian Americans – 78% – –Non-Hispanic Whites – 61% Source: Alegria et al., 2006

7 Who Utilized Services? 38% of U.S. born received care 15% of immigrants received care 9% of migrant agricultural workers received care Mexican American Prevalence and Services Survey (MAPSS) Source: Aguilar-Gaxiola, Vega, et al., 2000

8 Treatment Gap: Is it Only in the U.S. Serious cases NOT receiving treatment during the past12 months Developed countriesDeveloping countries Lower rangeUpper rangeLower rangeUpper range 35% 61% 76% 85% Source: Saxena, 2011; Alegria, 2006; WHO World Mental Health Consortium, JAMA, June 2 nd, 2004

9 Why the Treatment Gap? ■ ■ Multiple barriers 1. 1.Individual level (e.g., stigma) 2. 2.Community level (e.g., Lack of culturally and linguistically appropriate services) 3.(e.g., Lack of social and economic resources and poor living conditions) 3.Systemic level (e.g., Lack of social and economic resources and poor living conditions) ■ ■ Lack of Engagement in Behavioral Healthcare ■ ■ Multiple barriers 1. 1.Individual level (e.g., stigma) 2. 2.Community level (e.g., Lack of culturally and linguistically appropriate services) 3.(e.g., Lack of social and economic resources and poor living conditions) 3.Systemic level (e.g., Lack of social and economic resources and poor living conditions) ■ ■ Lack of Engagement in Behavioral Healthcare

10 Workforce Challenges in Mental Health ■ ■ High caseloads, “burn out” ■ ■ Prescribers ■ ■ Lack of adequate training and graduate preparation programs ■ ■ Limited training in providing family- centered or recovery-oriented care ■ ■ Lack of positions in the public mental health system for consumers and family members ■ ■ Limited opportunities for advancement ■ ■ High caseloads, “burn out” ■ ■ Prescribers ■ ■ Lack of adequate training and graduate preparation programs ■ ■ Limited training in providing family- centered or recovery-oriented care ■ ■ Lack of positions in the public mental health system for consumers and family members ■ ■ Limited opportunities for advancement Source: Alonzo-Diaz. 2014

11 Latinos’ Lack of Engagement in Behavioral Healthcare as many as Latinos are more likely than non-Hispanic Whites to terminate treatment prematurely, with as many as 60-75% dropping out after just one session (McCabe, 2002) Mode number of visits is 1 median is 3 Mode number of visits is 1 and median is 3 to both psychiatrists and psychologists (Alegria, 2007) Action Needed: Consumer Engagement as many as Latinos are more likely than non-Hispanic Whites to terminate treatment prematurely, with as many as 60-75% dropping out after just one session (McCabe, 2002) Mode number of visits is 1 median is 3 Mode number of visits is 1 and median is 3 to both psychiatrists and psychologists (Alegria, 2007) Action Needed: Consumer Engagement

12 Untreated Mental Illness n n Intensify over time…can reduce life expectancy n n Causes intense and prolonged suffering to individuals and their families n n Limits individuals’ ability to reach social and educational normative goals n n Leads to expensive costs to individuals, families, and communities n n Intensify over time…can reduce life expectancy n n Causes intense and prolonged suffering to individuals and their families n n Limits individuals’ ability to reach social and educational normative goals n n Leads to expensive costs to individuals, families, and communities

13 Key Issues In Mental Health Care ■ ■ The 5 A’s: 1. 1.Accessibility 2. 2.Affordability 3. 3.Availability 4. 4.Appropriateness 5. 5.Advocacy ■ ■ The 5 A’s: 1. 1.Accessibility 2. 2.Affordability 3. 3.Availability 4. 4.Appropriateness 5. 5.Advocacy

14 How can we transform services and supports to prevent high risk behaviors and improve outcomes especially in underserved populations?

15 Going Beyond Services and Supports n n Integration of Primary and Behavioral Health Care n n Adaptations and Practice-based Evidence n n Community-based Partnerships n n Community Outreach and Engagement n n Prevention and Early Intervention and Health Promotion are Key n n Integration of Primary and Behavioral Health Care n n Adaptations and Practice-based Evidence n n Community-based Partnerships n n Community Outreach and Engagement n n Prevention and Early Intervention and Health Promotion are Key Source: Huang, 2007

16 “No mass disorder afflicting humankind has been eliminated or brought under control by attempts at treating the affected individual, nor by training large numbers of individual practitioners” George Albee Past President, American Psychological Association

17 Health care is not the primary determinant of health Improving health access is only part of the solution to improving health outcomes and reducing health disparities; There are three reasons why improving access to health care alone will not close the treatment gap: 1. 1.Clinical care treats one person at a time; 2. 2.Intervention often comes late; 3. 3.Clinical care is usually sought after people are sick (“fail first”). The Role of Prevention in Reducing the Treatment Gap Source: Mikkelsen, Cohen, Bhattacharyya, Valenzuela, Davis, & Gantz, 2002

18 Prevention and Early Intervention can make a vital contribution to current efforts to reduce disparities in health. By addressing the underlying factors that negatively influence health and mental health, prevention has the power to reduce the incidence of poor mental health and disability and premature death. The Role of Prevention in Closing the Treatment Gap Source: Mikkelsen, Cohen, Bhattacharyya, Valenzuela, Davis, & Gantz, 2002

19 IOM Public Briefing March 25, 2009 Washington DC Report of the Committee on the Prevention of Mental Disorders and Substance Abuse

20 Mental, Emotional and Substance Abuse Disorders Are Common and Costly Around 1 in 5 young people (14-20%) have a current disorder Estimated $247 billion in annual costs Costs to multiple sectors – education, justice, health care, social welfare Costs to the individual and family

21 Preventive Opportunities Early in Life Early onset (75% of adult disorders had onset by age 24; 50% by age 14) First symptoms occur 2-4 years prior to onset of a diagnosable disorder Common risk factors for multiple problems and disorders

22 Prevention Window

23 Core Concepts of Prevention 1. Prevention requires a change in thinking 2. Mental health and physical health are inseparable 3. Successful prevention is inherently interdisciplinary 4. Mental, emotional, and behavioral (MEB) disorders are developmental 5. Developmental perspective is key

24 Preventive Intervention Opportunities Parent hood

25 25 Two Approaches to Targeting Interventions Target specific disorders -- depression, substance abuse, schizophrenia Target risk and protective factors for multiple disorders -- poverty, maltreatment, family disruption, community and school risk factors

26 26 Impressive Evidence of Efficacy depression Interventions show effects on wide range of serious problems such as substance abuse, depression, antisocial behavior, child abuse Interventions improve positive outcomes such as school success, self-esteem Multi-year effects of some interventions

27 27 Evidence from Studies that Target Specific Disorders Indications that incidence of adolescent depression can be reduced Emerging evidence to prevent onset of full-blown schizophrenic episodes

28 28 Long-term Impact of Prevention Teacher training in classroom instruction and management, child social and emotional skill development and parent workshops were the intervention. A significant multi-varied effect across all 16 primary outcome indices were found. Specific effects included significantly better educational and economic attainment, mental health and sexual health by age 27 years. So prevention is possible. Hawkins JD, Kosterman R, Catalano RF, Hill KG, and Abbott RD. Effects of Social Development Intervention in Childhood 15 Years Later. Arch Pediatr Adolesc Med. 162(12), pp , 2008.

29 Community-Defined Solutions for Reducing Mental Health Disparities California Reducing Disparities Project

30  Main goal is to develop a Statewide Comprehensive Strategic Plan.  Identify community-defined promising practices, models, resources/approaches helpful for county program planners, practitioners, and policy makers in designing programs to better address the needs of these communities.  Contribute culturally relevant recommendations from each ethnic/cultural group to develop a comprehensive statewide strategic plan towards the reduction of mental health disparities Source: Guerrero, 2009

31 CA Reducing Disparities Project: Latino SPW The Latino Statewide Reducing Disparities Project started July 1, The main goal was to produce a community-defined, strength-based, culturally and linguistically appropriate report on reducing disparities in mental health services for Latinos. Identified and engaged a diverse range of Latino stakeholder representatives at the state, regional, and local levels. Stakeholders included consumers, providers, public agencies, and representatives of community interests, and have diversity in terms of gender, age, and mental health and health issues.

32 CA Reducing Disparities Project Latino SPW: Governance and Structure Southern Region (includes LA) Central Region Bay Area Region Northern California Region The Concilio

33 Latino Strategic Planning Workgroup – LATINO CONCILIO Website:

34 Forum Sites by City, Region & County Exhibit 5: Forum Sites by City, Region, and County

35 California Reducing Disparities Project Full report (PDF) available at: Spanish version will be soon available

36 Three Major Types of Barriers 1.Individual-Level Barriers – Stigma – Culture – Gender (masculinity) – Violence and trauma – Knowledge and awareness 2.Community-Level Barriers – Lack of culturally and linguistically appropriate services – Shortage of bilingual and bicultural mental health workers – Lack of school-based mental health programs – Organizational and systemic barriers 3.Systemic-Level Barriers – Lack of social and economic resources and poor living conditions – Inadequate transportation – Social exclusion

37 Strategic Directions to Improve Access, Availability, Appropriateness, Affordability, and Advocacy 1.School-based mental health programs; 2.Community-based organizations and co- location of resources; 3.Community and social media; 4.Culturally and linguistically appropriate treatment; 5.Workforce development to sustain culturally and linguistically competent workforce; 6.Community capacity building and community outreach and engagement.

38 Ventura County Strategic Directions: Reducing Disparities* * CRDP Latino Population Report, UC Davis Center for Reducing Health Disparities, 2012

39 Population 835,981 25% under 18 13% over 65 Median household income $76, % below poverty 1,774 estimated homeless in a day 41% Latino 48% Caucasian 7% Asian Pacific Islander 2% African American 37% use other language in home Ventura County Demographics

40 Faith-Based Collaborations Guadalupe Church, Project Esperanza St. Paul’s Baptist Church Word of Life: Community Coalition for Stronger Families Co-located Integrated Primary Care Health Care Agency: Fillmore, Oxnard, Santa Paula, Simi Valley, Thousand Oaks, Ventura Clinicas del Camino Real Strategic Direction #2: Community-Based Organizations and Co-Locating Resources

41 Mixteco Indigena Community Organizing Project (MICOP) Services: Community Coalition for Stronger Families (CCSF) Training - Mental health training for Mixteco Health Promotores to reduce stigma and other barriers to seeking services Outreach & Engagement – Sharing mental health education and raising awareness in Mixteco community Education – Presentation for partners and community agencies about Mixteco mental health needs, culture, and community Violence Prevention – Developed culturally appropriate training curriculum with The Partnership for Safe Families & Communities of Ventura County

42 Promotores and Promotoras Training Mixteco Engagement & Farm-worker Outreach & Treatment Project City Impact – Community Coalitions for Stronger Families Kids & Families Together – Foster Youth Kinship Project Strategic Direction #6: Community Capacity-Building and Outreach and Engagement

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45 Is it possible to improve community mental health by focusing primarily in access to care?

46 Source: Green LA, et al. N Engl J Med 2001;344: The “Ecology” of Medical Care

47 Source: Schroeder, 2007 “Even if the entire U.S. population had access to excellent medical care — which it does not — only a small fraction of these deaths could be prevented. The single greatest opportunity to improve health and reduce premature deaths lies in personal behavior. In fact, behavioral causes account for nearly 40% of all deaths in the United States” (p. 1222). Determinants of Health

48 48 Source: Miller, 2014

49 The Affordable Care Act (ACA) Source: Figueroa, 2013

50 Conclusions Mental health care disparities in access to care (for those who need treatment) exist in the U.S. They are a major public health problem at the national, state, and local levels. They lead to significant burden of unmet mental health needs. This translates into ill health, prolonged suffering, premature death, diminished productivity, and social and economic disparities. Mental health care disparities in access to care (for those who need treatment) exist in the U.S. They are a major public health problem at the national, state, and local levels. They lead to significant burden of unmet mental health needs. This translates into ill health, prolonged suffering, premature death, diminished productivity, and social and economic disparities.

51 51 Conclusions Globally and locally, most persons with mental substance use disorders and do not receive any specific health care. The challenges on delivery of effective interventions are large. We need to generate knowledge on scaling up effective care, especially in low-resource settings. People who are carrying the disease burden need help now! Will we respond? Source: Saxena, 2011

52 If You Build It, Will They Come? Well…It depends on: ■Who builds it ■How is it built ■Where is built ■Why is built

53 “Go in search of people. Begin with what they know. Build on what they have” Chinese proverb “Go in search of people. Begin with what they know. Build on what they have” Chinese proverb

54 We need to focus… NAMI CA can play a significant role closing the treatment gap NAMI CA can play a significant role closing the treatment gap


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