Cultural Disparities in Mental Health Care: Closing the Gap

This article is the first in a series appearing in Psychiatric Times on Minority Mental Health. Topics will present different perspectives on efforts and directions for improving mental health among ethnocultural minorities. It is designed to illustrate challenges, promising approaches, and advances.

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In 2010, more than one-third of the US population identified themselves as members of racial or ethnic minority groups.¹ By 2050, it is projected that these groups will account for nearly half of the US population. The landmark report Culture, Race, and Ethnicity² documented the lack of access and the poor quality of mental health care among minorities-patients are less likely to receive diagnosis and treatment for a mental illness and are more likely to die by suicide; ethnic minority patients are even less likely to get help.

As ethnocultural diversity within the US grows, psychiatrists have a responsibility to evaluate a broad spectrum of attitudes, beliefs, and behaviors. Although ethnocultural consideration is an integral component of the biopsychosocial approach, cultural formulation is provided as a companion document in DSM, rather than the basis for all formulation interviews. Cultural awareness training has been identified as a key part of a psychiatrist’s education, with cultural competence required for psychiatric accreditation. However, what this entails and how it is accomplished varies tremendously. Given concerns about its purportedly atheoretical nature and limited empirical support, the construct of cultural competence generates controversy. Thus, alternative approaches to reduce disparities have been proposed.

Provider diversity can enhance cultural understanding. Between 1999 and 2006, professionals from ethnic minority groups increased from 17.6% to 21.4% in psychiatry, from 8.2% to 12.9% in social work, and from 6.6% to 7.8% in psychology.³ However, the lack of providers who speak the patient’s language can be a barrier to accessing and receiving mental health care. In addition, the number of culturally competent clinicians in some locations is too low to accommodate the di-verse populations. The shortage of specialists in minority communities means that finding a mental health practitioner may be a challenge. Greater exposure to primary care physicians and integration of behavioral health increases the chances of detecting mental illness and reducing disparities in access.

Cultural tailoring refers to the creation of interventions that use information about a given individual to determine what specific content he or she will receive, the contexts surrounding that information, by whom it will be presented, and the way it will be delivered. Overall, tailoring aims to enhance the relevance of the intervention and improve intervention response.

Use of cultural tailoring has grown exponentially since the 1990s, especially with chronic diseases and, to a lesser extent, with mental illness. More research is needed that compares the effectiveness of different models of care and culture. For tailoring to be successful, there must be a balance between fidelity for evidence-based treatment and culturally informed care.

Bernal and colleagues4 developed a framework with 8 dimensions as foci in the cultural tailoring programs: language, persons, metaphors, content, concepts, goals, methods, and context. In a critical review of tailoring interventions, Baker and colleagues⁵ found that interventions tailored to address barriers of existing practices may improve care and patient outcomes.

Although clinical research has made great strides in improving the criteria by which intervention programs and practices are deemed effective, current scientific progress has left many minority communities behind, essentially silencing cultural relevance. It is possible to demonstrate positive outcomes across ethnocultural groups, but this does not indicate that cultural relevance has been achieved. When clinicians adopt externally driven evidence-based practice in treating culturally diverse populations, patients may be further marginalized and their “ways of knowing” adversely affected.^6-8 Western scientific methodology essentially supersedes both indigenous inquiry and mental health context, minimizing the practices with ethnocultural roots.

Questions remain regarding the role of ethnicity in psychopharmacology.⁹ Research has demonstrated ethnic differences in the clinical presentation, treatment, clinical response, and outcome of mental illnesses. Some of these differences can be explained by genetic factors; others are influenced by culture. Pharmacogenomic and pharmocogenetic research aims to identify clinically meaningful predictors of drug efficacy and/or adverse-effect burden.¹⁰ While this is a promising approach, few studies in psychiatry have yielded compelling results.

Attention on the following is needed to close the gap:

• Increasing the availability of culturally relevant and informed mental health services accessible to minorities

• Increasing opportunities for training minority mental health professionals

• Ensuring implementation of culturally relevant, evidence-based prevention, early intervention, and treatment

• Developing and implementing services, programs, and policy to ensure minorities are empowered through culturally informed, practice-based evidence

• Developing better ways of defining and accurately measuring “ethnicity”

• Conducting studies that can guide psychopharmacological treatments for patients from different ethnocultural backgrounds

This article was originally posted on 7/23/2014 and has since been updated.

Disclosures:

Dr Goebert is Professor in the department of psychiatry at the University of Hawaii John A. Burns School of Medicine in Manoa. She is Director of National Center for Indigenous Hawaiian Behavioral Health and Hawaii’s Caring Communities Initiative for Youth Suicide Prevention. Dr Goebert receives funding from the Substance Abuse and Mental Health Services Administration (SAMHSA) through the Garrett Lee Smith Memorial Act for Youth Suicide Prevention (U79SM060394). The views represented in this article are solely the author’s and do not represent the views of SAMHSA.

References:

1. US Census Bureau. 2010 Census Data: 2010 Census Demographic Profiles. 2010. http://www.census.gov/2010census. Accessed July 23, 2014.

2. Satcher D. Mental Health: Culture, Race, and Ethnicity-A Supplement to Mental Health: A Report of the Surgeon General. 2001. http://www.ncbi.nlm.nih.gov/books/NBK44243. Accessed July 23, 2014.

3. Santiago CD, Miranda J. Progress in improving mental health services for racial-ethnic minority groups: a ten-year perspective. Psychiatr Serv. 2014;65:180-185.

4. Bernal G, Jiménez-Chafey MI, Domenech Rodríguez MM. Cultural adaptation of treatments: a resource for considering culture in evidence-based practice. Professional Psychol Res Pract. 2009;40:361-368.

5. Baker R, Camosso-Stefinovic J, Gillies C, et al. Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2010;(3):CD005470.

6. Cochran PA, Marshall CA, Garcia-Downing C, et al. Indigenous ways of knowing: implications for participatory research and community. Am J Public Health. 2008;98:22-27.

7. Smith LT. Decolonizing Methodologies: Research and Indigenous Peoples. New York: Zed Books; 1999.

8. Wendt DC, Gone JP. Rethinking cultural competence: insights from indigenous community treatment settings. Transcult Psychiatry. 2012;49:206-222.

9. Chaudhry I, Neelam K, Duddu V, Husain N. Ethnicity and psychopharmacology. J Psychopharmacol. 2008;22:673-680.

10. Malhotra AK, Zhang JP, Lencz T. Pharmacogenetics in psychiatry: translating research into clinical practice. Mol Psychiatry. 2012;17:760-769.