Virginia Health Care Foundation’s Mental Health Roundtable Minority Mental Health Needs & Treatment in Virginia SJR 46 (2008) Patron: Senator Marsh Virginia Health Care Foundation’s Mental Health Roundtable May 15, 2009 Michele Chesser, PhD Senior Health Policy Analyst Joint Commission on Health Care

Prevalence of Mental Illness among Minority Populations Overall, Blacks, Hispanics, and Asians have lower rates of lifetime mental disorders than Whites. Compared to Whites, Blacks and Hispanics are more likely to have mental disorders that are persistent and severe. Blacks less likely to have depression, but when do, it is more persistent illness and they are more likely to rate their depression as very severe and disabling. Source: 4 studies funded by the National Institute of Mental Health, Consortium on Psychiatric Epidemiology Studies (2004)

Prevalence of Mental Illness among Minority Populations Native Americans have lower levels of risk for major depression than Whites, but are at higher risk for PTSD and alcohol dependence. Finally, minorities are more likely to be in high-need sub-populations (e.g. homeless or residing in an institution) whose rates of mental illness are higher and much less likely to be treated.

Race/Ethnic Mental Health Disparities Key Disparities: Access to quality services Help seeking and help utilization Negative experiences within the system Pervasiveness of stigma Lack of language and cultural competency among practitioners Lack of inclusion in research and clinical trials

Percentages of Adults Aged 18 or Older Reporting Receipt of Past Year Mental Health Treatment/Counseling Among Those with Serious Mental Illness, by Race/Ethnicity: 2001 51.4% 38.4% 26.6% Of those with SMI, fewer blacks and hispanics received treatment than whites This report uses data on adults aged 18 or older from the 2002 National Survey on Drug Use and Health (NSDUH). NSDUH is an annual survey of the civilian, noninstitutionalized population of the United States aged 12 or older. Prior to 2002, the survey was called the National Household Survey on Drug Abuse (NHSDA). NSDUH is the primary source of statistical information on the use of illegal drugs by the U.S. population. Conducted by the Federal Government since 1971, the survey collects data by administering questionnaires to a representative sample of the population through face-to-face interviews at the respondents' places of residence. The survey is sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA) and is planned and managed by SAMHSA's Office of Applied Studies (OAS). The data collection is conducted by RTI International. This section briefly describes the survey methodology. A more complete description is provided in Appendix A. NSDUH collects information from residents of households, noninstitutional group quarters (e.g., shelters, rooming houses, dormitories), and civilians living on military bases. Persons excluded from the survey include homeless persons who do not use shelters, military personnel on active duty, and residents of institutional group quarters, such as jails and hospitals. Source: SAMHSA, 2001 National Survey on Drug Use and Health (NSDUH).

Percentage of Adults Receiving Outpatient Mental Health Treatment in Past Year, by Race and Treatment Facility: 2000-2001 Other= outpatient medical clinic, partial day hospital or day treatment program, or some other place. Source: SAMHSA, Office of Applied Studies, National Household Survey on Drug Abuse, 2000 and 2001.

Percentage of Adults Receiving Outpatient Mental Health Treatment in Past Year, by Income and Treatment Facility: 2000-2001 much of the disparities are a result of socioeconomic status. Since many racial minority groups have higher levels of poverty/lower incomes, the two are highly correlated. Virginia poverty rates: Whites: 10% Blacks: 22% Hispanic: 22% Other= outpatient medical clinic, partial day hospital or day treatment program, or some other place. Source: SAMHSA, Office of Applied Studies, National Household Survey on Drug Abuse, 2000 and 2001.

Summary of Mental Health Disparities Racial/ethnic minorities are less likely to receive mental health treatment than Whites. Whites are more likely to receive outpatient treatment at a private therapist’s office whereas Blacks and Hispanics are more likely to receive care from a state mental health agency. Blacks are more likely to be hospitalized for mental illness than other racial/ethnic groups. Many racial/ethnic differences in mental health care are confounded by income differences.

Social Mechanisms Contributing to Mental Health Disparities Provider Bias and Stereotyping Provider Statistical Discrimination Provider and Geographic Differences Health Insurance Differences Source: McGuire, Thomas G. and Jeanne Miranda. 2008. “New Evidence Regarding Racial and Ethnic Disparities in Mental Health: Policy Implications.” Health Affairs, Vol. 27, No. 2, pgs 393-403.

Factors Influencing Consumer Treatment Decisions Fear Embarrassment Language Trust Income MH Literacy Negative Experience Confidentiality Beliefs Use of Pastoral Care Use of Native Healers Use of Emergency Rooms Use of Primary Care Family Support Delay of Treatment Source: Adapted (with revisions) from Snowden (2004) and Neighbors (2007)

Implications of Treatment Decisions & System Characteristics >Acute Episodes Chronic Conditions >Risk of Death >Uneven Utilization <Access & Availability <Quality of Care >Risk of Misdiagnosis >Inpatient Treatment >Use of Courts Source: Surgeon General (1999) and New Freedom Commission (2003)

Prescriptions for Change Interface of mental health care and general medicine The U.S. has “had a ‘system’ of care in which mental health has been set apart, separate from primary or general health care. Now that it is understood that mental and general health are inextricably linked, the two disciplines must be brought together.” (New Freedom Commission on Mental Health, 2003, p.v) Equalizing insurance coverage for mental and physical care Federal law takes effect January 1, 2010. Primary care providers need to be able to recognize mental illness and either treat or refer individuals to more specialized care. It is essential to facilitate access for persons with mh problems to high-quality, affordable, coordinated mental and general health care that is provided in a way that makes sense in their lives (including cultural sense). This will help reduce stigma in many ways: changing cultural beliefs at the societal level, patient does not have to go to different location to seek treatment, etc. Also greater affordability and therefore access to care.

Prescriptions for Change Support initiatives designed to address access and quality issues for all Virginians The Virginia Health Care Foundation’s New Mental Health Initiative: “A New Lease on Life: Health for Virginians with Mental Illness.” Grants will be awarded to health safety net organizations in the fall of this year to establish or expand: Basic mental health services and access to prescription medicines for uninsured patients. Primary medical care and access to prescription medicines for CSB clients with serious mental illness.

Prescriptions for Change Anti-stigma campaigns in minority communities Continued cultural competency training for mental health practitioners

Methods of Teaching Cultural Competency Material N=183 health profession degree programs at 44 institutions. Source: SCHEV report.

Prescriptions for Change Foster greater interest in the mental health care field among minority high school students Address social determinants of health inequities: poverty, shortage of affordable housing, lack of transportation in rural areas, and employment issues

Integrated Community Collaborative Care Primary Care Education / School Health Mental Health Care Community Care Housing/ Employment Justice/Courts Transportation