Surgeon General's Report Highlights Mental Health Problems Among Minorities

Words like depression and anxiety do not exist in certain American Indian languages, but the suicide rate for American Indian and Alaskan Native (AI/AN) males between the ages of 15 and 24 is two to three times higher than the national rate. The overall prevalence of mental health problems among Asian Americans and Pacific Islanders (AA/PIs) does not significantly differ from the prevalence rates for other Americans, but AA/PIs have the lowest utilization rates of mental health services among ethnic populations. Mexican Americans born outside the United States have lower prevalence rates of any lifetime disorders than Mexican Americans born in the United States, and 25% of Mexican-born immigrants show signs of mental illness or substance abuse, compared with 48% of U.S.-born Mexican Americans. Somatic symptoms are almost twice as likely to be found among African Americans than among white American populations.

There have been numerous efforts, both government- and privately-funded, to develop plans and policies to assist the mentally ill minorities in the United States. With the recent influx of immigrants to the United States from poorer countries, it is vital to address their mental health care needs.

A recently issued report from U.S. Surgeon General David Satcher, M.D., examined mental health care issues among minorities. "The cultures from which people hail affect all aspects of mental health and illness," wrote Satcher in Mental Health: Culture, Race and Ethnicity, a supplement to his 1999 Mental Health: A Report of the Surgeon General.

Culture affects the ways in which patients from a given culture communicate and manifest symptoms of mental illness, their style of coping, their family and community supports and their willingness to seek treatment, Satcher wrote. The cultures of the clinician and the service system influence diagnosis, treatment and service delivery, he added. Cultural and social influences are not the only determinants of mental illness and patterns of service use, but they do play important roles.

Two important points emerge from the supplement: there are wide disparities in the kinds of treatment available to members of ethnic minorities in the United States, and there are significant gaps in the available research about the way in which mental illness affects racial and ethnic groups.

Further, the report notes that wide differences exist within minority groups that are lumped together in statistical analyses and in many aid programs. American Indians and Alaskan Natives (AI/ANs), for example, include 561 separate tribes with some 200 languages recognized by the Bureau of Indian Affairs. Hispanic Americans come from cultures as diverse as Mexico and Cuba. Asian Americans and Pacific Islanders represent 43 separate ethnic groups from countries ranging from India to Indonesia. Fifty-three percent of African Americans live in the South and have different cultural experiences from those who live in other parts of the country. The report states:

Minorities are overrepresented among the Nation's vulnerable, high-need groups, such as homeless and incarcerated persons. These subpopulations have higher rates of mental disorders than people living in the community. Taken together, the evidence suggests that the disability burden from unmet mental health needs is disproportionately high for racial and ethnic minorities relative to whites.

The supplement consists of an overview of the collective mental health care needs of minority populations, followed by separate studies of each of four minority populations, including a historical perspective and analysis of the geographic distribution, family structure, education, income and physical health status of the group as a whole.

For example, African Americans are more likely to suffer from a broad range of physical diseases than are white Americans. Rates of heart disease, diabetes, prostate and breast cancer, infant mortality, and HIV/AIDS are all substantially greater for this group than for white Americans.

According to the report, American Indians "are five times more likely to die of alcohol-related causes than whites, but they are less likely to die from cancer and heart disease." The Pima tribe in Arizona, for example, has one of the highest rates of diabetes in the world. The incidence of end-stage renal disease, a known complication of diabetes, is higher among American Indians than for both white Americans and African Americans.

Satcher uses historical and sociocultural factors to analyze the particular mental health care needs of each minority group. Then, specific mental health care needs for both adults and children are discussed and attention is given to high-need populations and culturally-influenced syndromes within the group. Each chapter includes a discussion of the availability of care, the appropriateness of available treatments, diagnostic issues and best practices relating to the group.

Some factors relating to mental illness appear to be common to most ethnic and racial minorities. In general, according to the report, minorities "face a social and economic environment of inequality that includes greater exposure to racism, discrimination, violence and poverty. Living in poverty has the most measurable effect on the rates of mental illness. People in the lowest stratum of income...are about two to three times more likely than those in the highest stratum to have a mental disorder."

Stresses caused by racism and discrimination "place minorities at risk for mental disorders such as depression and anxiety." In addition, the report states, "The cultures of racial and ethnic minorities alter the types of mental health services they use. Cultural misunderstandings or communication problems between patients and clinicians may prevent minorities from using services and receiving appropriate care." Health care practitioners who are not attuned to racial differences may not be aware of unique physical conditions as well. For example, because of differences in their rates of drug metabolism, some AA/PIs may require lower doses of certain drugs than those prescribed for white Americans. African Americans also are found to metabolize antidepressants more slowly than white Americans and may experience serious side effects from inappropriate dosages.

Specific analyses for each ethnic group included a wide range of findings, including those outlined below.

African Americans

"Safety net" providers furnish a disproportionate share of the mental health care services, but the survival of these providers is threatened by uncertain sources of financing.

The stigma of mental illness prevents African Americans from seeking care. About 25% of African Americans are uninsured. Additionally, "many African Americans with adequate private insurance coverage are still less-inclined to use mental health services."

Only about one African American in three who needs care receives it. African Americans are also more likely than white Americans to terminate treatment early.

If African Americans do receive treatment, they are more likely to have sought help through primary care than through specialist services. As a result, they are frequently overrepresented in emergency departments and psychiatric hospitals.

For certain disorders (e.g., schizophrenia and mood disorders) errors in diagnosis are made more often for African Americans than for white Americans.

African Americans respond as well as white Americans to some behavioral treatments but were found to be less likely than white Americans to receive appropriate care for depression or anxiety.

American Indians and Alaskan Natives

Past attempts to eradicate native culture, including forced transfers of youngsters to government-run boarding schools away from their families and homes, have been associated with negative mental health consequences. American Indians and Alaskan Natives are also the most impoverished of today's minority groups. More than one-quarter live in poverty.

Certain DSM diagnoses, such as major depressive disorder, do not correspond directly to the categories of illness recognized by some American Indians.

Four out of five American Indians do not live on reservations, but most of the facilities run by the government's Indian Health Service are located on reservation lands.

One study found higher rates of posttraumatic stress disorder (PTSD) and long-term alcohol abuse among American Indian veterans of the Vietnam war than among their white American, African American or Japanese American counterparts.

In one study, American Indian youth were found to have rates of psychiatric disorders comparable to their white American counterparts, but "for white children, poverty doubled the risk of mental disorders, whereas poverty was not associated with increased risk of mental disorders among American Indian children." American Indian youngsters were also much more likely to be found suffering from attention-deficit/hyperactivity disorder and substance abuse or substance dependence disorders.

Twenty percent of American Indian elders who were studied in one urban clinic reported significant psychiatric symptoms.

While many AI/ANs prefer ethnically matched providers, only about 101 AI/AN mental health care professionals are available per 100,000 members of this ethnic group, compared with 173 per 100,000 for white Americans. In 1996, only an estimated 29 psychiatrists in the United States were of AI/AN heritage.

As many as two-thirds of AI/ANs continue to use traditional healers, sometimes in combination with mental health care providers.

Hispanic Americans

For Hispanic Americans, per capita income is among the lowest of the minority groups covered by this supplement. Additionally, they are the least likely ethnic group to have health insurance. Their rate of uninsurance is 37%, double that of white Americans.

About 40% of the Hispanic Americans in the 1990 census reported that they do not speak English well, but very few providers identify themselves as Hispanic or Spanish-speaking, limiting the opportunities for Hispanic American patients to match with providers who are ethnically or linguistically similar providers.

The suicide rate for Latinos is approximately half the rate of white Americans, but a national survey of over 16,000 high school students found that Hispanic Americans of both sexes reported more suicidal ideation and suicide attempts than African Americans and white Americans.

Many immigrants from Central American countries exhibit symptoms of PTSD. Overall, however, Latino immigrants have lower prevalence rates of mental illness than Hispanics born in the United States.

Asian Americans and Pacific Islanders

No study has addressed the rates of mental disorders for Pacific Islander American ethnic groups, and very few studies have been done on Hmong and Filipino ethnic groups.

When symptom scales are used, Asian Americans show an elevated level of depressive symptoms compared to white Americans, but these studies focus primarily on Chinese Americans, Japanese Americans and Southeast Asians. Additionally, relatively few studies have been conducted in the subjects' native language.

Asian Americans have lower rates of some disorders than white Americans, but higher rates of neuresthenia. Those who are less Westernized exhibit culture-bound syndromes more frequently.

Asian Americans and Pacific Islanders have the lowest rates of utilization of mental health services of any ethnic population. This is attributed to cultural stigmas and financial shortcomings. Overall poverty rates for AA/PIs are much higher than the national average.

Ethnic matching of AA/PI therapists and patients results in greater utilization of mental health care services.

(For more information on ethnicity and psychiatric diagnosis, please see related story, Effects of Ethnicity on Psychiatric Diagnosis: A Developmental Perspective -- Ed.)