Feature

Minorities are less likely than whites to receive needed mental health care, and the quality of care they do get tends to be less than good, says a Surgeon General report unveiled at APA's 2001 Annual Convention. The report, Mental Health: Culture, Race and Ethnicity, is a supplement to Mental Health: A Report of the Surgeon General, released in 1999.

"Disparities exist in access, utilization and quality of mental health services for racial and ethnic minorities," said U.S. Surgeon General David M. Satcher, MD, PhD, presenting the report to a packed room of more than 500 attendees.

In fact, he said, minorities experience "greater disability and greater burdens" due to mental illness than whites--"not necessarily because the illnesses are more severe...but because of the barriers they face in terms of access to care." Some of those barriers include cost and stigma. Failure to address these disparities, he said, is "playing out in human and economic terms on our streets, homeless shelters, foster-care systems and in our jails.

"That is why we say today, in a resounding fashion, that when it comes to mental health, culture counts," he said emphatically.

Satcher defined culture as a common set of norms, beliefs and values that influence mental health. "It can have an impact on how mental illness is perceived or diagnosed, how services are organized and how they're funded. It also affects how patients express their symptoms...and how they cope in the range of their community and family supports," he said.

Although no group in America has escaped being touched by mental disorders, he said, many ethnic groups share similar social and economic inequities, especially great vulnerability to racism, violence and poverty. And minority groups tend to be overrepresented in high-need populations but underrepresented among mental health professionals, Satcher said.

Harsh realities

The 200-page report broadly focuses on specific ethnic groups in the United States: African Americans, American Indians and Alaskan Natives, Asian Americans and Pacific Islanders, and Hispanic Americans.

Statistics about African Americans demonstrate the mental health needs they face. For example, while they make up only 12 percent of the population, about 22 percent of African-American families live in poverty. One in four African Americans is uninsured and only one-third receive care for mental disorders. They are more likely to use emergency services. And African Americans represent close to half of many high-need populations, such as the homeless, incarcerated, children in foster care and people exposed to violence. In fact, some studies report that more than 25 percent of African-American youth exposed to violence meet diagnostic criteria for post-traumatic stress disorder. "African Americans have problems with access, utilization and quality of mental health services," said Satcher.

The country's largest and fastest-growing minority group is the Hispanic and Latino population. Hispanic Americans have very limited access to ethnically or linguistically similar providers. Although about 40 percent of Hispanic Americans have limited English-language proficiency, relatively few mental health providers speak Spanish. Satcher noted this group is less likely than whites to receive mental health care but more likely, as are Asian American/Pacific Islanders, to seek care from folk healers.

Among America's rapidly growing Asian American/Pacific Islander population, "stigma and shame play a major role," Satcher said. "They have the lowest rate of utilization of mental health services of all minority groups." He called for more research about this population, adding that suicide in the Pacific Basin is becoming "an increasing concern for the public health service."

Although they comprise a much smaller portion of the American population--just 1 percent, American Indians and Alaskan Natives have a suicide rate that is 1.5 times the national average. "Tragically, males between the ages of 18 and 24 account for two-thirds of all American Indian/Alaskan Native suicides," noted Satcher. Drugs and alcohol are also common problems. In 1999, about 26 percent of this population lived in poverty. Only about 20 percent of American Indians and Alaskan Natives still live on reservations or trust lands. Yet since most health care has traditionally been provided through reservations, access is "a major problem."

Ensuring cultural care

The reality is that thousands of U.S. ethnic-minority citizens are not getting the mental health care they need, Satcher said. "The interaction of people of different cultures in the mental health arena tells us that there are many gaps and that we need more diversity in the mental health profession," said Satcher. "However, we can't wait."

"Providers must ensure the inclusion of the community in a community-based mental health system," he said.

He called for caregivers to recognize the role of folk healers and to accept the possibility of involving them in partnership and collaborative care. The community deserves a say in the development of its health-care program, he said. With community input, he hopes, "we could get rid of a lot of the stigma, because when the people have ownership they trust that program.

"We must continue the science, said Satcher. "We must expand the research. We must focus on improving the quality of mental health services.... The emphasis on cultural competence must begin now and must be a priority among all mental health professionals."

At the close of his presentation, Satcher brought the crowd to its feet to join in his rallying cry, "Culture counts. Culture counts. Culture counts."