Conceptualizing Mental Health
Disparities in Communities of Color
May 19, 2005
King Davis, PhD, Executive Director
Hogg Foundation for Mental Health Services, Research, Policy & Education
Robert Lee Sutherland Chair in Mental Health & Social Policy
School of Social Work
The University of Texas at Austin
Austin, Texas
Purpose of the Presentation
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Conceptualize the term disparities
Place disparities in context
Link various types of disparities
Define key terms
Link health and mental health
disparities
Propose solutions and directions
Foci of the Presentation
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Disparities have an extensive history
Disparities are related to a perverse
conceptualization of people of color
This conceptualization pervaded clinical
practice, research, education & policy
Disparities are imbedded in differences
in income, access to information, and
cultural traditions & social structures
Conceptualizing Disparities
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Prevalence
Incidence
Services
Treatment
Prevention
Recovery
King Davis, 2003
Rehabilitation
Participation
Outcomes
Access
Quality
Use of Medication
DISPARITIES IN MENTAL HEALTH CARE
FOR RACIAL AND ETHNIC MINORITIES
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Minorities have less access to, and availability of, mental
health services
Minorities are less likely to receive needed mental health
services
Minorities in treatment often receive a poorer quality of
mental health care
Minorities are underrepresented in mental health research
Mental Health: Culture, Race, and Ethnicity, a Supplement to the Surgeon General’s Report
on Mental Health
Service Disparities
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Racial, ethnic, and cultural differences
in twenty characteristics designed to
define and describe the nature of
behavioral health service provision.
Source: K. Davis (2003)
Service Disparities 1760-2000
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>Frequency of Inaccurate Diagnosis
>Findings of Severe Mental Disorder
>Inpatient Hospitalization/LOS
>Involuntary Commitments
>Recidivism/Relapse
>Involvement in Criminal Justice System
>Mortality Rates (Primary Health Problems & Suicide)
<Recovery
>Uninsured/Underinsured
<Access to Outpatient/Early Access
<Access to Providers of Color
<Utilization of Cultural Competency in Service Design
<Participation in Behavioral Health Volunteer Organizations
<Access to Information about Behavioral Disorder/Services
<Family Support
Service Disparities
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>Delays in help seeking
<Housing alternatives
<Access to trained interpreters
<Inclusion in research/clinical trials
>Executions while mentally disabled
<Integrated behavioral health services
Expanded View of Disparities
Economic
Dental
Health
Political/
Legal
Mental
Health
Employment
Health
King Davis,
2003
Substance
Educational
Uninsured
Housing &
Homelessness
Voting
Sentencing
Political
Office
Asset
Accumulation
Graduation Low
Income
Rates
Homicides
Environmental
Pollution
Sickle
Diabetes Cell
Low Birth
Weight
Babies
HIV
Cardiovascular
Disease
Alcohol
Abuse
Cancer
Domestic
Violence
Depression Schizophrenia
Personality
Disorder
Dementia
Crime
Victims
Periodontal
Disease
Obesity
Cocaine
Use/Sale
Unemployment
King Davis, 2003
Nutrition
Literacy
Criminal
Justice
Maternal/
Infant
Deaths
Mental
Retardation
Bipolar
Capital
Punishment
Removal of Disparities
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Recent efforts at the federal (Clinton 1994)
presidential level are designed to eliminate
disparities in health and mental health by
2010;
President Bush (2003) has included this goal
in the recent report on mental health
Bush identifies cultural competence as the
vehicle for eliminating disparities in mental
health
Six Critical Goals
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Americans understand that mental health is
essential to overall health
Mental health is consumer and family driven
Disparities in mental health are eliminated
Early intervention is common
Excellent care is delivered and research is
accelerated
Technology is used to access mental health
care and information
Source: New Freedom Commission
Disparities in Mental Health
Services are Eliminated
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In a transformed mental health system,
all Americans will share equally in the
best available services and outcomes,
regardless of race, gender, ethnicity, or
geographic location.
Source: New Freedom Commission
Recommendations:
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Improve access to quality care that is
culturally competent
Improve access to quality care in rural
and geographically remote areas
Source: New Freedom Commission
Primary Strategy:
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How to develop & implement?
What are the key strategies?
What are the critical challenges?
State Mental
Health Plan
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The Challenge of Reform:
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Help seeking
Health
Insurance
Voluntary Participation
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System
Reform
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Private
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Sector
Human
Resources
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State
Government
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Disproportionate Poverty
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General Fund Pressure
State Policy Reform
Service Redesign: EBP
Federal Government
The Immunity Hypothesis
“Slaves are immune from stress and
from the subsequent risk of mental
illness because they do not own
property.”
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John Galt, M.D.(1840)
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Contextual Hypotheses
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Immunity Hypothesis 1763-1865
Exaggerated Risk Hypothesis -18651980
No-difference Hypothesis 1981-1990s
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Immunity Hypothesis Recycled 2001
Exaggerated Risk Hypothesis Recycled
2001
No-difference Hypothesis Recycled 2001
Historical Hypotheses
Historical Hypotheses - Continued
Multiple Costs
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Excess Preventable Deaths
Untreated Illness & Lower Lifetime
Achievement
Excess Hospital Admissions & Readmissions
Misdiagnosis & Inappropriate Care (LLOS)
Community Suspicion and Mistrust
Staff Division and Conflict
Absence of Scientific Knowledge & Theory
Ethical Conflict: Professional & Personal
Increased Taxes & Agency Budgets: Waste
Need for Behavioral Health Care
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African Americans:
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Overall rates of mental illness similar to nonHispanic whites
Differences in prevalence of specific illnesses
Suicide rates lower but on the rise
Environmental, economic and social factors
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Exposure to violence, homelessness,
incarceration, social welfare involvement
Less access to behavioral health services
Prospective Frequency Of Illness
Source: Davis, King., Johnson, Toni, & McClendon,A. (2002). Guidebook. Baltimore: Casey Foundation
Mental Health: A Report of the Surgeon General, DHHS, 1999.
Need for Behavioral Health Care
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American Indians and Alaska Natives
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Limited data on prevalence of MI
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One small study with 20 year follow-up found 70% lifetime
prevalence of MI
Increase rise of depression among older adults
Suicide rate 1.5xs national average with young males
accounting for 2/3 of suicides
2nd decade of life has highest mortality rate
Alcohol dependence, alcohol related deaths
Little information on service utilization patterns
Need for Behavioral Health Care
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Latinos/Hispanic Americans:
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Overall rates of MI similar to non-Hispanic whites
Higher rates of some disorders
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Higher rates of depression among elderly Latinos
Culture-bound syndromes:
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Anxiety-related and delinquency behaviors, depression and drug
use, more common among Latino youth
Susto (fright), nervios (nerves), mal de ojo (evil eye), and ataque
de nervios
Access to behavioral health services is limited
Need for Behavioral Health Care
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Asian Americans/Pacific Islanders
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Limited data on prevalence of MI
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Existing data suggests overall rates similar to whites
Higher rates of depression, PTSD
Somatic complaints of depression
Culture-bound syndromes
Lower suicide rates - except elderly women who have the
highest suicide rates in U.S.
Refugees with PTSD
Language barrier limits access to services
All Health Care is Cultural
Conceptualization
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Diagnosis
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Treatment
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Training
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Research
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Policy
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Help Seeking
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Compliance
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Participation
 Health Beliefs
 Expectations
 Employment
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Defining Cultural Competence
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Market-Based Definition
Cultural competence is the integration and
transformation of knowledge, information,
and data about individuals and groups of
people into specific clinical standards, skills,
service approaches, techniques, and
marketing programs that match the
individual’s culture and increase the quality
and appropriateness of health care and
outcomes (Davis, 1997).
Defining Cultural Competence
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Cultural competence is the conclusion
reached and shared by members of a
nation, community, group, organization,
business, or a board that constitutes
how the individual wants to be treated
with respect by others based on their
culture (T.Davis, 2002)
Status of Cultural Knowledge:
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The Clinical Application of Cultural
Competency is Relative
Non English
Speaking
Native
Americans
Lowest
Income
Asian/
Mexican
Pacific
Immigrants
Islanders &
Indian/Pakistani
Lowest
African
Americans
Mexican
Americans
Middle
Income
Anglo
Americans
Men
Highest
Elements of Cultural
Competence
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Attitudes of respect
Agency Evaluation
Beliefs
Agency Plan
Knowledge and Skills
Inclusion in Vision
Language and Communication
Community Analysis
Inclusion in
Services
Valuing Diversity
Outcomes
Cultural Self-Assessment Staffing
Figure 1.
Conceptual Framework
Individual
C. Individual &
Community
Factors
Professional:
Evidence
Based
Delayed
Help
Seeking
Self
Help
Church
Organizations
Degree of
Impairment
Practitioner:
Evidence Base
Family
Burden
Theory and
Model: Recovery
Community
Stigma
Consumer
Self help
DECISIONS TO
UTILIZE SOME
FORM OF HELP
COMMUNITIES
OF COLOR
PHASE 2
PHASE 3
Religious
Based
Help
PHASE 1
Family Choices/Actions
King Davis, Hogg
Foundation 2003
D.
Formal
Helping
System
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B. Number of Psychiatric Episodes
Social Marketing
Consideration and integration of social
variables in the design of plans and
policies in health care services
Study Culture:
Help Seeking
Definitions of Health/Illness
Information Use
Learning Style
Leadership
Family Systems
Media Outlets
Languages Spoken
Schools
Religious Ideas
Neighborhoods
General Conclusions
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Too much new information (format) to access/digest or use
Transformation cannot occur fully without addressing the
complex issue of disparities: knowledge, evidence, research,
participation, help seeking
Transformation comes at a time of significant reductions in state
budgets for human services;
Evidence based approaches must be expanded to include the 4
populations of color;
Cultural competence offers promise but requires national field
testing, cost estimation, educational trials, linkages to licensure,
accreditation, and further development;
Cultural competence must demonstrate outcome and cost
efficacy;
Poverty and related socio-economic issues will affect the
application of evidence based approaches;
New epidemiological studies are needed on the four populations
of color to increase knowledge of help seeking and utilization.