1. 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

2. Overview l Population Trends l Disparities among the 4 major racial and ethnic minority groups l Barriers to treatment l DSM-IV Cultural Formulation l Culturally appropriate care

4. Cultural Divide l High likelihood of ethnic and cultural differences between health providers and patients l Limited training about the importance of cultural and ethnic factors in health care

5. Surgeon General’s Report on MH: Race, Culture, and Ethnicity l Mental Illness affects all l Striking disparities in MH Care for Minorities –Less likely to receive services –Poorer quality of care –Underrepresented in MH research l Disparities impose great disability burden on minorities Lopez, 2002

6. 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 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 Barriers Use of Services Mediators Outcomes Modified From Access to Health Care in America 10, From Cooper LA, Hill MN, and Powe NR. JGIM 2002; 477-486 Barriers and Mediators to Equitable Health Care for Racial and Ethnic Groups

7. People of African Descent: Mental Health Care l Underuse of community outpatient care l Later entry into treatment l High drop-out rate l Fewer treatment sessions l High rates of inpatient care l High rates of misdiagnosis l High rates of severe mental illness Cultural Competence Standards, 1997

8. African Americans l Concerns about “double”stigma l Mistrust of health professionals l Belief that prayer alone can heal l Belief that suffering is a part of life for Black people

9. American Indians, Native Alaskan, Native Hawaiian Population: Mental Health Care l Appear to be at higher risk for mental disorders l High prevalence of depression, anxiety, substance abuse, violence, suicide l High rates of symptoms from family and interpersonal problems Cultural Competence Standards, 1997

10. American Indians and Alaska Natives l Concerns about confidentiality - small, close community l Tendency to see the connection between mental illness and physical or spiritual illness l Use of both traditional and Western medicine

11. Asian and Pacific Islander People: Mental Health Care l Shame & stigma associated with mental illness l High endurance of psychiatric distress l Limited knowledge about mental health services l Underutilization of mental health services l Present for treatment in crisis l High drop-out rate after initial contact l Tendency to seek traditional healing l Language barriers Cultural Competence Standards, 1997

12. Asian Americans l Symptoms are viewed as medical illness l High prevalence of somatization symptoms l Difficulties in developing trust l Hesitancy in opening up l Tendency to give limited information l Family is a key factor in treatment l It is acceptable to disclose the diagnosis to the family, but not to the patient

13. Latino Population: Mental Health Care l Early treatment drop-out l Less access to full range of care l Lower rates of voluntary hospitalization l Use of crisis and other high cost services l Language barriers Cultural Competence Standards, 1997

14. Latinos l Perception of mental illness as illness requiring medical intervention l Use of natural support systems l Beliefs in the supernatural and use of traditional healers l Family needs prevail over individual l Somatization of emotional states adapted from Alarcon, 2003

15. Ethnic and Cultural Influences on Treatment Outcomes Direct: l Cultural beliefs and preferences l Pathoplasticity l Ethnopsychopharmacology

16. Ethnic and Cultural Influences on Treatment Outcomes Indirect: l Misinterpretation of behavior and belief l Lack of symptom recognition l Misdiagnosis and inappropriate treatment l Provider bias and stereotyping

17. Illicit Drug Use by Race/Ethnicity-2000 National Household Survey on Drug Abuse % 6.4 5.3 12.6 2.7 14.8

18. DSM-IV Cultural Formulation l Cultural identity of the individual l Cultural explanations of the individual’s illness l Cultural factors related to psychosocial environment and levels of functioning l Cultural elements of the relationship between the individual and the clinician l Overall cultural assessment for diagnosis and care

19. 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.

20. Recognition of Depressive Symptoms l Using the CES-D, 47.3% of Latino and 41.6% of Asian primary care patients had depressive symptoms indicative of psychiatric distress l PCPs identified psychiatric distress in 43.8% of Latinos and 23.6% of Asian patients l 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

21. 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

22. Vicious Cycle Medical and Behavioral Problems Mental Illness Substance Abuse Violence Incarceration Poverty and Social Problems

23. Therapeutic Relationship and Milieu l “Speak”, treat patients with respect, Mr., Ms., honor privacy l Show caring and empathic attitude l Be there to intervene in crises l Acknowledge importance of life events –Abuse –Loss (illness, death, loss of housing, separation from family) –Achievement l Be a part of the solution CSAT, 1999

24. 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

25. Culturally Competent System of Care l Importance of culture l Assessment of cross-cultural relations l Vigilance towards the dynamics that result from cultural differences l Expansion of cultural knowledge l Adaptation of services to meet culturally-unique needs

26. Cultural Competence Techniques l Bilingual/Bicultural providers l Recruitment and Retention l Training l Coordinating with Traditional Healers l Use of Community Health Workers l Culturally Competent Health Promotion l Including Family and/or Community Members l Immersion into another Culture l Administrative and Organizational Accommodations Brach & Fraser, 2000

27. The Broadway Center Dual Diagnosis Service l Use of structured diagnostic interview l Pharmacologic management if needed l Individual and group psychotherapy l Case management services: housing, vocational rehabilitation, jobs, literacy programs, and other social services

28. Key Features l Services provided regardless of insurance status l Availability of sample medications l Coordination with primary care staff l Empathic psychiatric therapist willing to do outreach l Word of mouth from patient-to-patient l Creation of a culture in which mental health is valued

29. Culturally Appropriate Care l Services attended by members of the specific ethnic groups l Employment of appropriate ethnic staff at all levels l Involvement of professional and paraprofessional counselors from the recovering community Cultural Issues in Substance Abuse Treatment CSAT, 1999

30. Culturally Appropriate Care l Integrated Mental Health and Substance Abuse Treatment l Coordination with Systems (Corrections, Primary Care, Social Services) l Continuum of services (one-stop shop) - case management - medical care - social services

31. Culturally Appropriate Care l Enlist people with mental illness and substance use disorders as advocates l Focus on Recovery l Outreach, Education, Prevention –use of culturally tailored educational videotape

32. Reducing Health Disparities Through the Implementation of Cultural Competency Source: Brach and Fraser, Cultural Competency; 2000 Diverse Population linguistically ethnically culturally Diverse Population linguistically ethnically culturally Reduction of Health Disparities Reduction of Health Disparities Improved Outcomes for Minority Group Members health status functioning satisfaction Improved Outcomes for Minority Group Members health status functioning satisfaction Appropriate Services for Minority Group Members preventive screening diagnostic treatment Appropriate Services for Minority Group Members preventive screening diagnostic treatment Cultural Competency effective techniques sound implementation Cultural Competency effective techniques sound implementation +

33. Health Disparities and Cultural Competence Websites l IOM Report Unequal Treatment – www.nap.org l Surgeon General’s Supplement on Race Culture and Ethnicity – www.surgeongeneral.gov/library/mentalhealth/cre/default.asp l Cultural Competence Standards – www.wiche.edu/MentalHealth/Cultural_Comp/ccstoc.htm l CLAS Standards ( Culturally and Linguistically Appropriate Standards) – www.omhrc.gov/clas/cultural1a.htm