OVERVIEW OF CULTURAL DIVERSITY & MENTAL HEALTH SERVICES

Racial and ethnic minority groups are generally considered to be under-served by the mental health service system.  A constellation of barriers deters ethnic and racial minority group members from seeking treatment, and if individual members of groups succeed in accessing services, their treatment may be inappropriate to meet their needs. 

Research documents that many members of minority groups fear, or feel ill at ease with, the mental health system.  These groups experience it as the product of white, European culture, shaped by research primarily on white, European populations. 

Research and clinical practices have propelled advocates and mental health professionals to press for “linguistically and culturally competent services” to improve utilization and effectiveness of treatment for different cultures. 

INTRODUCTION TO CULTURAL DIVERSITY & DEMOGRAPHICS

Racial and ethnic populations differ from one another and from the larger society with respect to culture.  The term “culture” is used loosely to denote a common heritage and set of beliefs, norms, and values. 

The historical experiences of ethnic and minority groups in the Unites States are reflected in differences in economic, social, and political status.  The most measurable difference relates to income.  Many racial and ethnic minority groups have limited financial resources.  In 1994, families from these groups were at least three times as likely as white families to have incomes placing them below the federally established poverty line. 

Cultural identity imparts distinct patterns of belief and practices that have implications for the willingness to seek, and the ability to respond to mental health services.  These include coping styles and ties to family and community, discussed below. 

COPING STYLES

Cultural differences can be reflected in differences in preferred styles of coping with day-to-day problems.  Consistent with a cultural emphasis on restraint.  Asian American groups encourage a tendency not to dwell on morbid or upsetting thought.  They have little willingness to behave in a fashion that might disrupt social harmony.  Their emphasis on willpower is similar to the tendency documented among African Americans to minimize the significance of stress, and, relatedly, to try to prevail in the face of adversity through increased striving. 

Culturally rooted traditions of religious beliefs and practices carry important consequences for willingness to seek mental health services.  African Americans and a number of ethnic groups, when faced with personal difficulties, have been shown to seek guidance from religious figures. 

Many people of all racial and ethnic backgrounds believe that religion and spirituality favorably impact upon their lives and that well-being, good health, and religious commitment or faith are integrally intertwined.  

Cultural also imprints mental health by influencing whether and how individuals experience discomfort associated with mental illness.  When conveyed by tradition and sanctioned by cultural norms, characteristic modes of expressing suffering are sometimes called “idioms of distress”.  Idioms of distress often reflect values and themes found in the societies in which they originate. 

One of the most common idioms of distress is somatization, the expression of mental distress in terms of physical suffering.  Somatiazation is prevalent among person from a number of ethnic minority backgrounds.  Epidemiological studies have confirmed that there are relatively high rates of somatization among African Americans. 

Among culture-bound syndromes found among some Latino psychiatric patients is ataque de nevious, a syndrome of “uncontrollable shouting, crying, trembling, and aggressions” typically triggered by a stressful event involving family.  A Japanese culture-bound syndrome, Taijin kyofusho, is an intense fear that one’s body or bodily functions give offense to others.  Culture-bound syndromes sometimes reflect comprehensive systems of belief, typically emphasizing a need for balance between opposing forces or the power of supernatural forces.  Belief in indigenous disorders and adherence to culturally rooted coping practices are more common among older adults and among persons who are less acculturated. 

FAMILY & COMMUNITY AS RESOURCES

Ties to family and community, especially strong in African, Latino, Asian and Native American communities, are forged by cultural tradition and by the current and historical need to assist arriving immigrants, to provide a sanctuary against discrimination practiced by the larger society, and to provide a sense of belonging and affirming a central help-culture or ethnic identity. Family solidarity has been invoked to explain relatively low rates among minority groups of placing older people in nursing homes.  Families play an important role in providing support to individuals with mental health problems.  A strong sense of family loyalty means that, despite feelings of stigma and shame, families are an early and important source of assistance in efforts to cope, and that minority families may expect to continue to be involved in the treatment of a mentally ill member.  Investigators have demonstrated an association between family warmth and a reduced likelihood of relapse. 

EPIDEMIOLOGY & UTILIZATION OF SERVICES

One of the best ways to identify whether a minority group has problems accessing mental health services is to examine their utilization of services in relation to their need of services.  Some minority groups are underrepresented in the outpatient treatment population while, at the same time, over-represented in the inpatient population. 

AFRICAN AMERICANS

The prevalence of mental disorders is estimated to be the highest among African Americans than among whites.  This difference does not appear to be due to intrinsic differences between the races; rather, it appears to be due to socioeconomic differences.  When socioeconomic factors are taken into account, the prevalence difference disappears.  It is the lower socioeconomic status of African Americans that places them at a higher risk for mental disorders. 

African Americans are underrepresented in some outpatient treatment populations, but over-represented in public inpatient psychiatric care in relation to whites.  Their under-representation in outpatient treatment varies according to setting, type of provider, and source of payment.  The racial gap between African American and whites I utilization is smallest, if not nonexistent, in community-based programs and in its treatment financed by public sources, especially Medicaid.  The under-representation is largest in privately financed care, especially individual outpatient practice, paid for either by free-for-service arrangements, or managed care.  As a result, under-representation in the outpatient setting occurs more among working and middle class African Americans, who are privately insured, than among the poor.  This suggests that socioeconomic standing alone cannot explain the problems of under-utilization.  African Americans are over-represented in inpatient psychiatric care.  Their rate of utilization of psychiatric inpatient care is about double that of whites.  Over-representation is found in hospitals of all types except private psychiatric hospitals.  While difficult to explain definitively, the problem of over-representation in psychiatric hospitals appears to be rooted in poverty, disinclination to seek help, and lack of health and mental health services deemed appropriate, and responsive, as well as community support, are major contributors to delays by African Americans in seeking treatment until symptoms become so severe that they warrant inpatient care. 

Finally, African Americans are more likely than whites to use the emergency room for mental health problems.  Their over-reliance on emergency care for mental health problems is an extension of their over-reliance on emergency care for other health problems.  The practice of using the emergency room for routine care is generally attributed to a lack of health care providers in the community willing to offer routine treatment to people willing to offer routine treatment to people without insurance. 

ASIAN AMERICANS / PACIFIC ISLANDERS

Asian Americans are distinguished by extremely low levels at which specialty treatment is sought for mental health problems.  Asian Americans have proven less likely than whites, African Americans, and Hispanic Americans to seek care.  One national sample revealed that Asian Americans were only a quarter as likely as whites, and half as likely as African Americans and Hispanic American, to have sought outpatient treatment.  Asian Americans / Pacific Islanders are less likely than whites to be psychiatric inpatients.  The reason for the under-utilization of services include the stigma and loss of face over the mental health problem, limited English proficiency among some Asian immigrants, different cultural explanations for the problems, and the inability to find culturally competent services.  

HISPANIC AMERICANS

Several epidemiological studies revealed few differences between Hispanic Americans and whites in lifetime rates of mental illness.  Although rates of mental illness may be similar to whites in general, the prevalence of particular mental health problems, the manifestation of symptoms, and help-seeking behaviors within Hispanic subgroups need attention and further research.  For instance, the prevalence of depressive symptomatology is higher in Hispanic women (46%) than men (almost 20%); yet, the known risk factors do not totally explain the gender difference. 

Several studies indicate that Puerto Rican and Mexican American women with depressive symptomatology are underrepresented in mental health services and over-represented in general services.  

NATIVE AMERICANS

The indications are that depression is a significant problem in many American Indian / Alaska Native communities.  Alcohol abuse and dependency appear also to be especially problematic, occurring at perhaps twice the rate of occurrence found in any other population group.  Relatedly, suicide occurs at alarmingly high levels.  Among Native American veterans, post-traumatic stress disorder has been identified as especially prevalent in relation to whites.  Native Americans are over-represented in psychiatric inpatient care in relation to whites, with the exception of private psychiatric hospitals.

BARRIERS TO THE RECEIPT OF TREATMENT

The under-representation in outpatient treatment of racial and ethnic minority groups appears to be the result of cultural differences as well as financial organizational and diagnostic factors.  The service system has not been designed to respond to the cultural and linguistic needs presented by many racial and ethnic minorities. 

Among adults, the evidence is considerable that persons from minority backgrounds are less likely than whites to seek outpatient treatment in the specialty mental health sector.  This is not the case for emergency department care, from which African Americans are more likely than whites to seek care for mental health problems.  Language, like economic and accessibility differences, can play an important role in why people from other cultures do not seek treatment.   

MISTRUST

By comparison with whites, African Americans are more likely to give the following reasons for not seeking professional help in the face of depression: lack of time, fear of hospitalization, and fear of treatment.  Mistrust among African Americans may stem their experiences of segregation, racism, and discrimination.  African Americans have experienced racist slights in their contacts with the mental health system.  Some of these concerns are justified on the basis of research revealing clinician bias in over-diagnosis of schizophrenia and under-diagnosis of depression among African Americans. 

Lack of trust is likely to operate among other minority groups, according to research about their attitudes towards government-operated institutions rather than towards mental health treatment per se.  This is particularly pronounced for immigrant families with relatives who may be undocumented, and hence they are less likely to trust authorities for fear of being reported and having the family member deported. 

People from El Salvador and Argentina who have experienced imprisonment or watched the government murder family members and engage in other atrocities may have an especially strong mistrust of any governmental authority.  Within the Asian community, previous refugee experiences of groups such as Vietnamese, Indo-Chinese, and Cambodian immigrants parallel those experienced by Salvadoran and Argentine immigrants.  They too, experienced imprisonment, death of family members or friends, physical abuse, and assault, as well as new stresses upon arriving in the United States.  American Indians’ past experience in this country also imparted lack of trust of government.  Those living on Indian reservations are particularly fearful of sharing any information with white clinicians employed by the government.  As with African Americans, the historical relationship of forced control, segregation, racism, and discrimination has affected their ability to trust a white majority population. 

STIGMA

Both African American and other ethnic groups, report that embarrassment hinders seeking treatment.  African Americans tend to deny he threat of mental illness and strive to overcome mental health problems through self-reliance and determination.  Stigma, denial, and self-reliance are likely the explanation why other minority groups do not seek treatment.  Cultural factors tend to encourage the use of family traditional healers, and informal sources of care rather than treatment-seeking behavior. 

COST

Cost is yet another factor discouraging utilization of mental health services.  Minority persons are less likely to have private health insurance, but this factor alone may have little bearing on access.  Public sources of insurance and publicly supported treatment programs fill some of the gap.  Even among working class and middle-class African Americans who have private health insurance, there is under-representation of African Americans in outpatient treatment.  Much research remains to be performed on the relative importance of cost, cultural, and organizational barriers, and poverty and income limitations across the spectrum of racial and ethnic and minority groups. 

CLINICAL BIAS

Advocates and experts alike have asserted that bias in clinician judgment is one of the reasons for over-utilization of independent treatment by African Americans.  The strongest evidence of clinical bias is apparent for African Americans with schizophrenia and depression.  Several studies found that African Americans were more likely than whites to be diagnosed with schizophrenia, yet less likely to be diagnosed with depression.  In addition to problems of over-diagnosis or misdiagnosis, there may well be a problem of under-diagnosis among minority groups, such as Asian Americans, who are seen as “problem-free”. 

IMPROVING TREATMENT FOR MINORITY GROUPS

Under-utilization of treatment, less help-seeking behavior, inappropriate diagnosis, and other problems have beset racial and ethnic minority groups with respect to mental health treatment.  This kind of evidence has fueled the widespread perception of mental health treatment as being uninviting, inappropriate, or not as effective for minority groups as for whites.   

ETHNOPSYCHOPHARMACOLOGY

There is mounting awareness that ethnic and cultural influences can alter an individual’s responses to medication (pharmacotherapies).  Pharmacotherapies given by mouth usually enter the circulation after absorption from the stomach.  From the circulation they are distributed throughout the body (including the brain for psychoactive drugs) and then metabolized, usually in the liver, before they are cleared and eliminated from the body.  The rate of metabolism affects the amount of the drug in the circulation.  A slow rate of metabolism leaves more drug in the circulation.  A fast rate of metabolism, on the other hand, laves less drug in the circulation.  Too little drug in the circulation reduces effectiveness.  There is a wide racial and ethnic variation in drug-metabolizing, due to genetic variations in drug-metabolizing enzymes (which are responsible for breaking down drugs in the liver).  For example, 33 percent of African Americans and 37 percent of Asians are slow metabolizers of several antipsychotic medications and antidepressants.  This awareness should lead to more cautious prescribing practices, which usually entail starting patients at lower doses in the beginning of treatment.  Unfortunately, just the opposite typically had been the case with African America patients and antipsychotic drugs.  Clinicians in psychiatric emergency services prescribed more oral doses and more injections of antipsychotic medications to African American patients.  The combination of slow metabolism and over-medication of antipsychotic drugs in African Americans can yield very uncomfortable extrapyramidal side effects.  These are the kinds of experiences that likely contribute to mistrust of mental health services reported among African Americans.  Psychosocial factors also can play an important role in ethnic variation.  Compliance with dosing may be hindered by communication difficulties; side effects can be misinterpreted or carry different connotation; some groups may be more responsive to placebo and reliance on psychoactive traditional and alternative healing methods (such as medicinal plants and herbs) may result in interactions with prescribed pharmacotherapies.  Greater awareness of ethnopsychopharmacology is expected to improve treatment effectiveness for racial and ethnic minorities.