Minorities' Care for Mental Ills Is Called Inferior
Minorities in the United States, the surgeon general, Dr. David
Satcher, said, "suffer a disproportionate burden of mental illness"
because they often have less access to services than other Americans,
receive lower quality care and are less likely to seek help when they are
in distress. While serious mental disorders like depression, schizophrenia, panic
disorder, manic-depression and substance abuse occur in all races,
ethnicities and socioeconomic classes, Dr. Satcher said, minorities tend
to be overrepresented among those most vulnerable and in need of mental
health treatment, including the poor, the homeless, the institutionalized,
the incarcerated and the survivors of traumatic experiences. And because of the stigma attached to mental illness in some minority
cultures, he said, there is often a reluctance to use services even when
they are available. "We have got to find a way to bridge the gap between the need and the
access to services," Dr. Satcher said in a telephone interview before the
release of the report yesterday at a news conference at the American
Psychological Association's annual meeting in San Francisco. He called for more research in an area that is little studied and for
more cultural awareness on the part of mental health professionals. He
also recommended increased efforts to address the needs of minorities in
shaping the delivery of services, educating the public and integrating
mental health treatment with general medical care. As he has done in the
past, Dr. Satcher endorsed insurance coverage for mental illness
comparable to that for physical ills. The 200-page report, "Mental Health: Culture, Race and Ethnicity," is
based on peer-reviewed research from disciplines as varied as mental
health, history, sociology and anthropology. It examines virtually every
aspect of mental health, including the prevalence and diagnosis of
disorders, the services that are available, insurance issues and the
cultures of practitioners and patients. Individual chapters are devoted to
the mental health concerns of African-Americans; Hispanic- Americans;
Asian-Americans and Pacific Islanders; and American Indians and Alaska
Natives. The report is a supplement to the "Surgeon General's Report on
Mental Health," which Dr. Satcher issued in 1999. Dr. Renato D. Alarcˆn, the vice chairman of psychiatry at Emory
University, called the report "one more step, a big step." "Ethnic minorities benefit the least from the existing services," Dr.
Alarcˆn said, "and when they need them they might not have access to those
services." The report found that the disparities in care were, in part, a result
of fragmented, costly and inadequate mental health services and a lack of
insurance coverage in minorities. "Simply put, the nation's health systems must work to bring mental
health services to where the people are," the report summarized. But the problems for minorities, the report found, were also closely
tied to cultural differences that created barriers to treatment. "The main message of this supplement -- that culture counts -- should
echo through the corridors and communities of this nation," Dr. Satcher
said. Providers of mental health services, for example, often know little
about the cultural values and backgrounds of the patients they are
treating, or about the traditions of healing and the meaning of illness
within their cultures, the report said. Language differences may create further obstacles to effective
communication. There are few Spanish- speaking mental health
practitioners, the report noted, but up to 40 percent of Hispanics say
their proficiency in English is limited. In addition, the report found, racism and discrimination can lead to
errors in diagnosis or to inappropriate treatment. African-Americans, for
example, are more likely to receive misdiagnoses of schizophrenia and less
likely to be receive accurate diagnoses of depression or other mood
disorders. And while the rates of mental illness in Asian-Americans do not
differ significantly from those found in other groups, mental health
professionals may hold the stereotype that they are "mentally healthier,"
a bias that contributes to inadequate treatment and prevention. Compounding the problem, mental illness carries a greater stigma among
some ethnic and racial groups. Dr. Francis Lu, a professor of clinical psychiatry at the University of
California, San Francisco, who was a reviewer for the report, said that
for Asian-Americans, "the stigma factor is very intense." "We routinely see patients who delay treatment because the family has
tried to shelter the patients for months or years," Dr. Lu said. Among some minorities, the report said, distrust and fear of the mental
health system and mental health practitioners are common. And the symptoms
of illness may differ in different ethnic and racial groups. For example,
African-Americans, Asian-Americans and Hispanics are more likely than
non-Hispanic whites to express mental distress through physical symptoms
like stomachaches, chest pain, dizziness or other somatic complaints. Researchers have reported many "culture-bound syndromes" like "ataque
de nervios," a cluster of symptoms, including uncontrollable screaming and
attacks of crying, found mostly among Hispanics, particularly Caribbean
women. "If people are going to feel comfortable discussing mental disorders
they have to be talking to someone they trust, and to someone who
understands their culture and how things are expressed in their culture,"
Dr. Satcher said. He urged members of minorities to seek out help when they suffered from
"depression or anxiety or anything that interferes with one's ability to
function." He recommended the development of more mental health services tailored
for minorities and for training and support to increase their
representation in the mental health professions. And he raised the
possibility that the benefits in the long run might be worth the
short-term costs of "culturally appropriate" services, like outreach to
minorities in the community, increasing the number of bilingual community
health workers and working cooperatively with alternative medicine
practitioners. In some minorities, the report pointed out, traditional healers are the
first to be consulted. Dr. Alvin F. Poussaint, a professor of psychiatry
at Harvard and an author of "Lay My Burden Down: Suicide and the Mental
Health Crisis Among African-Americans," said, "We tend to dismiss a lot of
these cultural practices as quackery, further alienating the patient or in
fact not understanding the patient." Dr. Satcher and other experts who contributed to the report emphasized
the dearth of research on the effectiveness of different treatments,
including medication and psychotherapy, in different minority groups. And
they said that little was known about the prevalence of mental disorders
in many smaller racial and ethnic groups, including Asian- Americans,
Pacific Islanders, American Indians and Alaska Natives. For example, the report noted that there were no large published
studies of the prevalence of mental disorders among the 500 tribes that
make up the native population. Dr. Spero Manson, director of the division of American Indian and
Alaska Native programs at the University of Colorado's Health Sciences
Center and a science editor for Dr. Satcher's report, said that in a
review of the mental health literature, he found only 2,000 studies over
10 years, the bulk of them small and concerned primarily with alcohol and
drug abuse treatment. Yet the suicide rate among male Native Americans ages 15 to 24, the
report noted, is two to three times higher than in the general population,
and a 1997 study found that from 1979 to 1993, male Alaska Natives had
"one of the highest documented suicide rates in the world." Dr. Manson, who is conducting a large study of psychiatric disorders in
American Indians, is one of several researchers trying to fill the gap.
Similar projects are under way for Asian-Americans, Hispanics and
African-Americans and Caribbeans of African descent.
he
nation's ethnic and racial minorities face large and troubling disparities
in mental health care, the surgeon general said yesterday in a broad and
comprehensive report that offers a rare look at the mental- health needs
of four minority groups and the obstacles to treatment.
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