NAMI CA 2014 Annual Conference
“Growing Minds in Changing Times”
If You Build It, Will They Come? Addressing
and Reducing Mental Health Treatment
Gaps in Underserved Populations
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
Disclosure
I have no relevant financial interest/arrangement
or affiliation with
any organizations related to
commercial products or services
to be discussed at this presentation
Mental and/or substance abuse
disorders are major drivers of
suffering, disability, cost and
are associated with poverty
4
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
Treatment Gap in the U.S.
 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
Mexican American Prevalence
and Services Survey (MAPSS)
Who Utilized Services?

38% of U.S. born received care

15% of immigrants received care

9% of migrant agricultural workers
received care
Source: Aguilar-Gaxiola, Vega, et al., 2000
Treatment Gap: Is it Only in the U.S.
Serious cases NOT receiving treatment during the past12 months
90
85%
80
76%
70
60
61%
50
40
30
35%
20
10
0
Lower range
Upper range
Developed countries
Lower range
Upper range
Developing countries
Source: Saxena, 2011; Alegria, 2006; WHO World Mental Health Consortium, JAMA, June 2nd, 2004
Why the Treatment Gap?
■
Multiple barriers
1. Individual level (e.g., stigma)
2. Community level (e.g., Lack of culturally
and linguistically appropriate services)
3. Systemic level (e.g., Lack of social and
economic resources and poor living
conditions)
■
Lack of Engagement in Behavioral
Healthcare
Workforce Challenges in Mental Health
■
■
■
■
■
■
High caseloads, “burn out”
Prescribers
Lack of adequate training and graduate
preparation programs
Limited training in providing familycentered 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
Latinos’ Lack of Engagement in
Behavioral Healthcare

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 and median is 3 to both
psychiatrists and psychologists (Alegria, 2007)

Action Needed: Consumer Engagement
Untreated Mental Illness
 Intensify
over time…can reduce
life expectancy
 Causes
intense and prolonged
suffering to individuals and their
families
 Limits
individuals’ ability to reach
social and educational normative
goals
 Leads
to expensive costs to
individuals, families, and
communities
Key Issues In Mental Health Care
■
The 5 A’s:
1. Accessibility
2. Affordability
3. Availability
4. Appropriateness
5. Advocacy
How can we transform services
and supports to prevent high
risk behaviors and improve
outcomes especially in
underserved populations?
Going Beyond Services and
Supports

Integration of Primary and Behavioral Health
Care

Adaptations and Practice-based Evidence

Community-based Partnerships

Community Outreach and Engagement

Prevention and Early Intervention and Health
Promotion are Key
Source: Huang, 2007
“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
The Role of Prevention in
Reducing the Treatment Gap
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. Clinical care treats one person at a time;
2. Intervention often comes late;
3. Clinical care is usually sought after people are sick
(“fail first”).
Source: Mikkelsen, Cohen, Bhattacharyya, Valenzuela, Davis, & Gantz, 2002
The Role of Prevention in
Closing the Treatment Gap

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.
Source: Mikkelsen, Cohen, Bhattacharyya, Valenzuela, Davis, & Gantz, 2002
Report of the Committee on the Prevention of
Mental Disorders and Substance Abuse
IOM Public Briefing
March 25, 2009
Washington DC
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
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
Prevention Window
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
Preventive Intervention Opportunities
Parent
hood
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
25
Impressive Evidence of Efficacy

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
26
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
27
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 1133-1141, 2008.
28
Community-Defined Solutions for
Reducing Mental Health Disparities
California Reducing Disparities Project
California Reducing Disparities
Project
 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
CA Reducing Disparities Project: Latino SPW
• The Latino Statewide Reducing Disparities Project
started July 1, 2010.
• 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.
CA Reducing Disparities Project
Latino SPW: Governance and
Structure
Southern
Region
(includes LA)
Northern
California
Region
The
Concilio
Bay Area
Region
Central
Region
Latino Strategic Planning Workgroup –
LATINO CONCILIO
Website: http://www.latinomentalhealthconcilio.org
Forum Sites by City, Region & County
Exhibit 5: Forum Sites by City, Region, and County
California Reducing Disparities Project
Full report (PDF) available at:
http://www.latinomentalhealthconcilio.org/mhsa/crdp-latino-population-report/
Spanish version will be soon available
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
Strategic Directions to Improve Access, Availability,
Appropriateness, Affordability, and Advocacy
1. School-based mental health programs;
2. Community-based organizations and colocation 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.
Ventura County
Strategic Directions: Reducing Disparities*
1. Academic
and SchoolBased Mental
Health
Programs
6. Community
Capacity-Building
and Outreach
and Engagement
2. Community-Based
Organizations
and Co-Locating
Resources
5. Culturally
and
Linguistically
Appropriate
Treatment
3. Community
and Social
Media
4. Workforce
Development
* CRDP Latino Population Report, UC Davis Center for Reducing Health Disparities, 2012
Ventura County
Demographics
37% use
other
language
in home
25% under
18
13% over
65
Median
household
income
$76,728
Population
835,981
41% Latino
48% Caucasian
7% Asian
Pacific Islander
2% African
American
9.9% below
poverty
1,774
estimated
homeless in
a day
Strategic Direction #2:
Community-Based Organizations and Co-Locating Resources
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
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
Strategic Direction #6:
Community Capacity-Building and Outreach
and Engagement
• 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
Is it possible to improve
community mental health
by focusing primarily
in access to care?
The “Ecology” of Medical Care
Source: Green LA, et al. N Engl J Med 2001;344:2021-5.
Determinants of Health
“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).
Source: Schroeder, 2007
Source: Miller, 2014
48
The Affordable Care Act
(ACA)
Source: Figueroa, 2013
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.
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:
51 Saxena, 2011
If You Build It, Will They Come?
Well…It depends on:
■ Who builds it
■ How is it built
■ Where is built
■ Why is built
“Go in search of people. Begin with
what they know. Build on
what they have”
Chinese proverb
We need to focus…
NAMI CA can play a significant
role closing the treatment gap