Reducing Mental Health Disparities

King Davis, Ph.D.

What is the relationship between the mental health services system and help seeking

behavior patterns of people of color?

Service Delivery System

Incidence

Prevalence

Help-Seeking Behaviors

What Causes the Problem: Either or Approaches/Answers

What is Help – Seeking?• Help-seeking involves a number of pro-active steps

that take a person, family, or community from the point of recognizing a problem exists to using [entrusting] an external resource to solve, lessen, or cure the problem.

The Help Seeking Paradox

• Although there are reportedly minimal differences in rates, there are marked differences in help seeking by race, ethnicity, language, gender, residence, and other identifiable characteristics.

Use of Pastoral CareUse of Native Healers

Use of Emergency RoomsFamily Support

Episodic Use of Primary Care

>Advocacy ParticipationLengthy Delay Post Onset

Elastic Boundaries

Cultural Pathways to Help

FearEmbarrassmentLanguageTrustInsuranceMH LiteracyNegative ExperienceConfidentialityStigma

Snowden (2004); Neighbors (2007)

Status of Cultural Knowledge:

• The Clinical Application of Cultural Competency is Relative

Non EnglishSpeaking

Native Americans

Lowest IncomeFemale & Male

Asian/PacificIslanders &Indian/Pakistani

AfricanAmericans

MexicanImmigrants

MexicanAmericans

MiddleIncomeWomen

AngloAmericans

Men

Lowest Highest

Working Definition of Disparity

• Measurable, not assumed, differences between two or more objects, groups, people, or an absence of parity or equality between them. Unlike health disparities, mental health disparities are mainly in service patterns rather than rates of morbidity.

King Davis, 2009

Mental Health Disparity

Principally, a measurable difference in services [clinical choices and decisions], risk, help seeking, outcome, prevalence/incidence, and/or mortality by race, culture, ethnicity, language, gender, or any other identifiable characteristic.

Help-Seeking Behaviors

Elements in Disparities

Service System

Public Policies

AcademicTraining & EducationPrograms

Disparity

“…should be viewed as a train of events leading to a difference in:– Access to, utilization of, or quality of care– Health status, or– Health outcome

….that deserves scrutiny.”

Pearcy & Keppel 2009

Train of Events Family/Community

Help Seeking

Stigma

Religious Based

Family Burden(?)

Vol. Participation

Myth & Fear

Cultural Beliefs

Discrimination

MH Literacy

History/Memory

Provider System

Workforce Diversity

Fragmentation

Ethics/IRB Issues

Commitment

Resources/Costs

Availability/Access

Location/Hours

Service Design

EBPs/PBEs

Courts/Police

Knowledge Base

Conceptualization

Problem Formulation

Theory/Hypotheses

Research Methods

Sampling Bias

Community Involvement

Public Policy Impact

University Education

Media Portrayals/Stigma

Cultural Competence

Comparative Outcomes

Davis 2009; IOM 2005; HHS 2001

FRAGMENTATION

• The U.S. health, mental health and substance abuse treatment systems have developed independent of each other and of primary care. They typically are operated separately, without regard for the reality that physical and behavioral health are linked if not the same.

• Training programs reflect the same fragmentation.

Historical Research Hypotheses byAuthor and Chronological Period

ImmunityHypothesis1760 - 1864

Exaggerated RiskHypothesis1865 – 1968

Null Hypothesis1969 - 2009

Future

Cartwright (1851)Galt (1840)

Jarvis (1842)Jarvis (1844)Smith (1851)

Va. General Assembly 1846Va. General Assembly 1848 Va. General Assembly 1853Va. General Assembly 1870Va. General Assembly 1882

Andrews (1887); Babcock (1895); Bean (1906); Bevis (1921) Brody (1966); Carothers (1947)Conrad (1871); Crawford (1960)Denton (1960); Deutsch (1944Drewry (1916); Evarts (1914)Faris (1939); Fischer (1943)Focault (1965); Goffman (1961)Green(1914); Greenblatt (1955)Grossack (1963); Hansen (1959)Hollingshead(1958); Hurd (1916)Ivins(1950); Jaco (1960)Kardineer (1962); Keeler (1963)Kleiner (1959); Lewis (1931)Malzberg (1953); McClean (1914)(1944O’Malley); Pasamanick (1959)Parker (1966); Postell (1951)Reissman (1964); Ripley (1947)Schermerhorn(1956); Srole (1962)St. Clair (1951); US Census (1888)Williams (1949); Witner (1891)

Adebimpe (1981); Allen (1982)Alvarez (1976); Autunes (1974)Baker (1999); Bell (1980)Broman (1987) Brown (1990)Carter Com (1978); Collins (1980)Fabrega (1988); Fischer (1969)Flaskerud (1992); Gary (1978)Grob (1994); Gould (1981)Gullattee (1972); Jackson (1976)Jackson (1992); Jones (1982)Kessler (1994); Kramer (1980)Lawson (1994); Lindsey (1989)Manderscheid(1985); McCandless (1996); McCulloch (1995)Milstein (1995); Mollica (1980)Neighbors (1987); Poussaint (1998)Rack (1982); Ramm (1989)Regier (1993); Robins (1991)Rothman(1970); Ruiz (1990)Simon (1973); Snowden (1990)Thomas (1972); Warheit (1998)Wexberg (1998); Williams (1986)Willie (1973)

Bernal (2007)Brown (2007)Davis (20007)IOM(2007)Jackson (2007)Kessler (2007)Lawson (2007)Lopez (2007)Lu (2007)Miranda (2007)Neighbors (2007)Snowden (2007)Wang (2007)Whaley (2007)WHO (2007)Williams (2007)Zane (2007)

King Davis, 2007

Examples of Disparities

• Admissions Involuntary Commitments• Length of Stay Access to Service • Recidivism RatesDiagnosis of SMI• Use of Police Quality of Care• Homelessness Use of Medication - EBPs• Mortality Rates Accuracy of Diagnosis

King Davis, 2009

Mental Health, Health, Mortality and Race

• Individuals with a diagnosis of severe mental illness die an average of 25-32 years earlier than individuals without mental illness.

• What are the implications for people of color with severe mental illness?

• What solutions can be offered to prevent or reduce the rate of deaths?

Mortality Associated with Mental Disorders: Mean Years of Potential Life Lost

Compared with the general population, persons with major mental illness lose 25-30 years of normal life span

Year AZ MO OK RI TX UT

1997 26.3 25.1 28.5

1998 27.3 25.1 28.8 29.3

1999 32.2 26.8 26.3 29.3 26.9

2000 31.8 27.9 24.9

Lutterman, T; Ganju, V; Schacht, L; Monihan, K; et.al. Sixteen State Study on Mental Health Performance Measures. DHHS Publication No. (SMA) 03-3835. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 2003. Colton CW, Manderscheid RW. Prev Chronic Dis. Available at: ttp://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm.

Access and Quality of Care• SMI may be a health risk factor because of:

– Patient factors, e.g.: amotivation, fearfulness, homelessness, victimization/trauma, resources, advocacy, unemployment, incarceration, social instability, IV drug use, etc

– Provider factors: Comfort level and attitude of healthcare providers, coordination between mental health and general health care, stigma,

– System factors: Funding, fragmentationJoe Parks, MD 2009

1990 2004Male Female Male Female

Black or African American 485.4 327.5 342.1 236.5American Indian or Native 264.1 153.1 182.7 119.9Asian or Pacific Islander 220.7 149.2 146.5 96.1Hispanic or Latino 270.0 177.2 193.9 130.0

White, not Hispanic or Latino 413.6 252.6 268.7 175.1

Table 19. Death rates for diseases of heart, by race and Hispanic origin 1990 and 2004

Causes of Mortality African American1990 2004

American Indian1990 2004

Asian American1990 2004

Euro-American1990 2004

Latino American1990 2004

Heart Disease 1 1 4 4 5 5 2 2 3 3Homicide 1 1 3 3 4 5 5 4 2 2Suicide 4 5 3 3 4 5 1 1 2 2CerebrovascularDisease

1 1 5 5 3 3 4 4 2 2

Malignancy 1 1 5 5 3 3 2 2 4 4Respiratory Disease 2 3 3 2 4 5 1 1 5 4

Influenza 1 1 3 3 4 5 2 2 5 4Liver Diseases 3 4 1 1 4 3 5 5 2 2Diabetes 1 1 2 2 5 5 4 4 3 3HIV/AIDs 1 1 5 3 4 5 3 5 2 2Accidents 2 3 1 1 5 5 3 4 3 2

Table 2. Changes in Ranking of mortality by race, Hispanic origin, and year

Neighbors, Baser & Martin (2007). unpublished data from the National Survey of American Life

Cumulative Percentages

# years after disorder onset 1 2 5 10 15 20 30

Major Depression African American 27.2 31.7 39.0 46.4 57.4 64.3 77.6

White American 39.5 44.4 51.1 58.2 64.7 70.3 78.0

Bipolar Disorder

African American 17.3 19.5 24.5 33.0 38.1 38.1 43.9

White American 40.5 44.3 49.8 58.2 70.5 71.3 79.4

Black-White Comparison of Cumulative Proportions of Cases making Treatment Contact by Selected Years

After Disorder Onset

CardiovascularDisease

Depression

Sickle Cell

Schizophrenia

PeriodontalDisease

Diabetes

HIV

Alcohol Abuse

Cancer Obesity

BipolarPersonalityDisorder Dementia

HomicidesDomestic Violence

Unemployment

Sub-Prime Loans

Low BirthWeightBabies

Low Income

AssetAccumulation

VotingPoliticalOffice

SentencingCriminalJustice

Cocaine Use/Sale

Housing &Homelessness

NutritionLiteracy

Maternal/Infant Deaths

MentalRetardation

Uninsured

GraduationRates

CrimeVictims

CapitalPunishment

King Davis, 2003

Why be Concerned: Multiple Costs• Excess Preventable Deaths• Untreated Illness & Lower Achievement• Excess Hospital Admissions & Readmissions• Misdiagnosis & Poor Application of EBPs• Community Suspicion and Mistrust• Staff Division and Conflict• Absence of Scientific Knowledge & Theory• Ethical Conflict: Professional & Personal• Increased Direct and Indirect Costs: Tremendous Waste• Loss of Input from Special Markets: Volunteers/Policy• Clinical Dropouts• Cultural Malpractice• Public Customers are Disproportionately Persons of Color!

King Davis, 2008

Path Dependence Analysis

Fragmentation

>Funding

Trauma

UsageRate

EmergencyUse

Beliefs InfoIncreased Admissions Stigma

Family SupportDelayed Help

Courts

Police/Sheriff

Fear

>Illness

FL. Statutes

Research Foci: Train of Events Family/Community

Help Seeking

Stigma

Religious Based

Family Burden(?)

Vol. Participation

Myth & Fear

Cultural Beliefs

Discrimination

MH Literacy

History/Memory

Provider System

Workforce Diversity

Fragmentation

Ethics/IRB Issues

Commitment

Resources/Costs

Availability/Access

Location/Hours

Service Design

EBPs/PBEs

Courts/Police

Knowledge Base

Conceptualization

Problem Formulation

Theory/Hypotheses

Research Methods

Sampling Bias

Community Involvement

Public Policy Impact

University Education

Media Portrayals/Stigma

Cultural Competence

Comparative Outcomes

Davis 2009; IOM 2005; HHS 2001