Reducing Mental Health Disparities (Text Version)

Slide presentation from the AHRQ 2010 conference.

On September 27, 2010, King Davis made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (442 KB). Free PowerPoint® Viewer (Plugin Software Help).


Slide 1

 Reducing Mental Health Disparities

Reducing Mental Health Disparities

King Davis, Ph.D.

Image: Seven overlapping statues are shown.

Slide 2

 What is the relationship between the mental health services system and help seeking behavior patterns of people of color?

What is the relationship between the mental health services system and help seeking behavior patterns of people of color?

Slide 3

What Causes the Problem: Either or Approaches/Answers  

What Causes the Problem: Either or Approaches/Answers

  • Service Delivery System.
  • Prevalence.
  • Incidence.
  • Help-Seeking Behaviors.

Slide 4

What is Help-Seeking?

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.

Slide 5

The Help-Seeking Paradox

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.

Slide 6

 Cultural Pathways to Help

Cultural Pathways to Help

  • Fear.
  • Embarrassment.
  • Language.
  • Trust.
  • Insurance.
  • MH Literacy.
  • Negative Experience.
  • Confidentiality.
  • Stigma.
  • Use of Pastoral Care.
  • Use of Native Healers.
  • Use of Emergency Rooms.
  • Family Support.
  • Episodic Use of Primary Care.
  • Advocacy Participation.
  • Lengthy Delay Post Onset.
  • Elastic Boundaries.

Snowden (2004); Neighbors (2007)

Slide 7

Status of Cultural Knowledge:

Status of Cultural Knowledge:

  • The Clinical Application of Cultural Competency is Relative.

Table shows a continuum from lowest (non English speaking) to highest (Anglo Americans)

Non English Speaking

  • Lowest Income.
  • Female & Male.

Native Americans

  • Asian/Pacific
  • Islanders & Indian/Pakistani.

African Americans

  • Mexican Immigrants.

Mexican Americans

  • Middle Income.
  • Women.

Anglo Americans

  • Highest Income.
  • Men.

Slide 8

 Working Definition of Disparity

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

Slide 9

 Mental Health Disparity

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.

Slide 10

 Elements in Disparities

Elements in Disparities

  • Service System.
  • Public Policies.
  • Academic Training & Education Programs.
  • Help-Seeking Behaviors.

Slide 11

Disparity

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

Slide 12

Slide 12. Train of Events

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 

Slide 13

Fragmentation  

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.

Slide 14

 Historical Research Hypotheses by Author and Chronological Period

Historical Research Hypotheses by Author and Chronological Period

Immunity
Hypothesis
1760-1864
Exaggerated Risk
Hypothesis
1865-1968
Null Hypothesis
1969-2009
Future
Cartwright (1851)
Galt (1840)
Jarvis (1842)
Jarvis (1844)
Smith (1851)
Va. General Assembly 1846
Va. General Assembly 1848
Va. General Assembly 1853
Va. General Assembly 1870
Va. General Assembly 1882
Andrews (1887)
Babcock (1895)
Bean (1906)
Bevis (1921)
Brody (1966)
Carothers (1947)
Conrad (1871)
Crawford (1960)
Denton (1960)
Deutsch (1944)
Drewry (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)
(1944 O'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

Slide 15

Examples of Disparities

Examples of Disparities

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

King Davis, 2009

Slide 16

Mental Health, Health, Mortality and Race

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?

Slide 17

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

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

YearAZMOOKRITXUT
1997 26.325.1 28.5 
1998 27.325.1 28.829.3
199932.226.826.3 29.326.9
200031.827.9 24.9  

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

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: http://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm.

Slide 18

Access and Quality of Care

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, fragmentation.

Joe Parks, MD, 2009

Slide 19

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

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

Race/Hispanic origin19902004
MaleFemaleMaleFemale
Black or African American485.4327.5342.1236.5
American Indian or Native264.1153.1182.7119.9
Asian or Pacific Islander220.7149.2146.596.1
Hispanic or Latino270.0177.2193.9130.0
White, not Hispanic or Latino413.6252.6268.7175.1

Slide 20

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

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

Causes of MortalityAfrican AmericanAmerican IndianAsian AmericanEuro-AmericanLatino American
1990200419902004199020041990200419902004
Heart Disease1144552233
Homicide1133455422
Suicide4533451122
Cerebrovascular
Disease
1155334422
Malignancy1155332244
Respiratory Disease2332451154
Influenza1133452254
Liver Diseases3411435522
Diabetes1122554433
HIV/AIDs1153453522
Accidents2311553432

Slide 21

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

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

 Cumulative Percentages
# years after disorder onset12510152030
Major Depression
   African American27.231.739.046.457.464.377.6
   White American39.544.451.158.264.770.378.0
Bipolar Disorder
   African American17.319.524.533.038.138.143.9
   White American40.544.349.858.270.571.379.4

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

Slide 22

Diagram

  • Cardiovascular Disease.
  • Depression.
  • Sickle Cell.
  • Schizophrenia.
  • Periodontal Disease.
  • Diabetes.
  • HIV.
  • Alcohol Abuse.
  • Cancer.
  • Obesity.
  • Bipolar.
  • Personality Disorder.
  • Dementia.
  • Homicides.
  • Domestic Violence.
  • Unemployment.
  • Sub-Prime Loans.
  • Low Birth Weight Babies.
  • Low Income.
  • Asset Accumulation.
  • Voting.
  • Political Office.
  • Sentencing.
  • Criminal Justice.
  • Cocaine Use/Sale.
  • Housing & Homelessness.
  • Nutrition.
  • Literacy.
  • Maternal/Infant Deaths.
  • Mental Retardation.
  • Uninsured.
  • Graduation Rates.
  • Crime Victims.
  • Capital Punishment.

King Davis, 2003

Slide 23

Why be Concerned: Multiple Costs

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

Slide 24

Path Dependence Analysis

Path Dependence Analysis

  • Fragmentation.
  • >Funding.
  • Increased Admissions.
  • Emergency Use.
  • Trauma.
  • FL. Statutes.
  • Stigma.
  • Beliefs.
  • Family Support.
  • >Illness.
  • Info.
  • Courts.
  • Fear.
  • Police/Sheriff.
  • Delayed Help.
  • Usage Rate.

Slide 25

Research Foci: Train of Events

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

Current as of December 2010
Internet Citation: Reducing Mental Health Disparities (Text Version). December 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2010/davis/index.html