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Johns Hopkins Community Psychiatry Program
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
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Overview Population Trends
Disparities among the 4 major racial and ethnic minority groups Barriers to treatment DSM-IV Cultural Formulation Culturally appropriate care
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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
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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
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Barriers and Mediators to Equitable Health Care for Racial and Ethnic Groups
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 Mediators Outcomes Visits primary care specialty emergency Procedures preventive diagnostic therapeutic Quality of providers cultural competence communication skills medical knowledge technical skills bias/stereotyping Appropriateness of care Efficacy of treatment Patient adherence Health Status mortality morbidity well-being functioning Equity of Services 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;
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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
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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
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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
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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
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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
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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
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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
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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
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Ethnic and Cultural Influences on Treatment Outcomes
Direct: Cultural beliefs and preferences Pathoplasticity Ethnopsychopharmacology
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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
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Illicit Drug Use by Race/Ethnicity-2000 National Household Survey on Drug Abuse
14.8 % 12.6 6.4 6.4 5.3 2.7
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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
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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.
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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
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Depression Related Complaints
Complaints Culture “nerves” and headaches Latino weakness, tiredness, “imbalance” Asian problems of the “heart” Middle Eastern “heartbroken” American Indian anger, “evil” African American
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Vicious Cycle Medical and Behavioral Problems Mental Illness
Poverty and Social Problems Substance Abuse Incarceration Violence
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Reducing Health Disparities Through the Implementation of Cultural Competency
Diverse Population linguistically ethnically culturally Reduction of Health Disparities Improved Outcomes for Minority Group Members health status functioning satisfaction Appropriate Services for Minority Group Members preventive screening diagnostic treatment Cultural Competency effective techniques sound implementation + Source: Brach and Fraser, Cultural Competency; 2000
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Health Disparities and Cultural Competence Websites
IOM Report Unequal Treatment Surgeon General’s Supplement on Race Culture and Ethnicity Cultural Competence Standards CLAS Standards (Culturally and Linguistically Appropriate Standards)
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