Special Programs and Initiatives

National Congress for Hispanic Mental Health

II. Executive Summary

The Issue...
The growth of the Hispanic population is enriching the diversity of the United States culture, while presenting unique challenges to health care systems that are not yet prepared to manage those differences. Hispanics are a broadly diverse population with many different histories and paths to the United States - from Central America, Cuba, Mexico, Puerto Rico, South America, the Caribbean, and elsewhere. Individual, family, and community experiences vary, even within the Hispanic community.

The Hispanic population, growing across the length and breadth of the United States, is projected to more than double in size in the United States, from just under 12 percent of the current U.S. population to almost 25 percent by the year 2050. In fact, Hispanics will soon become the largest minority population in the United States. Already, Hispanics are the youngest of America's racial and ethnic groups, with a mean age under 30 years.

As the population continues to grow, specific and unique health, social, economic, and educational needs will have more societal impact. Demographics currently report high levels of poverty and relatively low levels of educational attainment, which place many Hispanics at significant risk for health problems, including mental health problems, and may make it difficult to know how to access U.S. health care systems. This significant risk is further complicated by the low rate of health care insurance coverage. In fact, Hispanics have the lowest insurance coverage rates among the major U.S. ethnic groups. In 1998, 35 percent of working Hispanics were without insurance, and 44 percent of the Hispanic poor were without insurance. These facts are further complicated by cultural and language differences that the current health care system is not prepared to address appropriately.

Studies are showing that Hispanics with diagnosed mental disorders are receiving insufficient mental health care and have disparate access to and availability of services. It is not entirely surprising, then, that, of all Hispanic adults identified with mental disorders, fewer than 18 percent sought help from health care professionals - and fewer than half of those professionals were specialists in mental health care. Unfortunately, many mental health facilities are unsuccessful in reaching Hispanics.

The Call for Action...
Mental health problems exist in every racial and ethnic group and are a burden on the individuals who are ill, their families, and, ultimately, our society. In fact, mental illnesses such as depression and schizophrenia are among the most disabling of any health condition. The social, economic, familial, and personal costs of mental illness are too great to let any individuals suffering from mental illness go untreated.

The Hispanic population's growth and its concomitant need for appropriate mental health services led to a call for action from Hispanic community leadership across the country, including stakeholders, consumers, and providers. That call argued that the quality and availability of services must be improved, data collected, and programs validated and designed to address the unique needs of the Hispanic community. The community demanded that actions taken be appropriate to the diversity among Hispanics.

Answering the Call...
The voice of the Hispanic community has been heard by the U.S. government. In 1996, the Secretary of the Department of Health and Human Services (HHS), Donna Shalala, launched the HHS Hispanic Agenda for Action: Improving Services to Hispanic Americans. This Agenda called for improved health care delivery for Hispanic Americans. In 1998, President Clinton announced his Racial and Ethnic Health Disparities Initiative, calling for elimination of disparities in health status among racial and ethnic minorities by 2010. Following this announcement, the White House hosted the first ever Conference on Mental Health, providing the necessary leadership to place mental health on a level playing field with other serious, debilitating illnesses.

Following the White House Conference, the U.S. Surgeon General issued the first ever Report on Mental Health in 1999. The report described both the treatment opportunities and the gaps in access to and availability of treatment for mental illness. Emphasizing the importance of addressing disparities among ethnic and racial minorities, the Surgeon General announced the development of a supplemental report on racial and ethnic disparities in mental health, to be issued later this year. Finally, to provide support for these initiatives, the President's fiscal year 2001 budget proposal calls for special increases in Federal expenditures for mental health services and related activities that could benefit millions of Hispanics.

The Substance Abuse and Mental Health Services Administration (SAMHSA) is the designated lead for implementing the Administration's efforts to advance the Nation's mental health services, including the goals and objectives outlined in the 1996 HHS Hispanic Agenda for Action.

SAMHSA works to ensure that cultural, racial, and ethnic values and traditions guide the development and delivery of its programs and services. For the Hispanic community, SAMHSA has put understanding into action for the Hispanic communities it serves through the design of grant programs, through the nature of communications and outreach to the Hispanic community, and through its commitment to culturally competent prevention and treatment specialists at the local level. Specifically, through its many programs and activities, SAMHSA is working in partnership with the community to reach Hispanic female adolescents, target alcohol abuse among Hispanics, keep the workplace drug free, expand treatment capacity for Hispanic communities, serve seriously emotionally disturbed children and their families, develop standards of Hispanic mental health care, reach out to homeless Hispanic women and their children, and collect data through the National Household Survey on Drug Abuse to assess drug abuse and its co-occurring relationship with mental health.

Bringing the Community Together...
Recognizing the continuing need for targeted services and outreach to the Hispanic community, SAMHSA and its Center for Mental Health Services (CMHS) answered the call for action from the Hispanic community by bringing together a Steering Committee of Hispanic leaders to determine how best to improve mental health services for their community. The Committee envisioned an effective mental health care delivery system for Hispanic Americans guided by national, State, and local policy and action, developed under Hispanic leadership. Furthermore, the system envisioned would be community based, involving community leaders and community institutions, including schools, churches, social agencies, the justice system, consumers, and their families.

To achieve this vision, the Committee called for a summit of key Hispanic stakeholders to set an agenda for change and a plan for how to make that change happen. With SAMHSA/CMHS support, the National Congress for Hispanic Mental Health was held in March 2000.

Key stakeholders represented a broad spectrum of the mental health services community - from policymakers to consumers, service providers to researchers, faith community leaders to families. They worked in partnership with leaders from national organizations; Federal, State, and local government officials; representatives from foundations and universities; and political officials from State and national legislatures.

The Congress was driven by the consumer perspective, and this voice provided a framework for actions taken during the 2-day event. Consumers highlighted the following issues: education and understanding about mental health services, medical insurance coverage, funding for mental health services, culturally and linguistically appropriate services, discrimination and stigmatization within both the Latino community and mainstream society, leadership development in consumer-oriented organizations, representing the best interests of consumers, inclusion of consumers in community-based research projects and authority to make community assessments, and integration of consumers into the mental health profession.

Keynote presentations demonstrated senior leadership support for Hispanic mental health. Dr. David Satcher, U.S. Surgeon General, and Ms. Audrey Tayse Haynes, Chief of Staff to Mrs. Tipper Gore, provided their perspectives, along with the Honorable Grace Napolitano (D-CA, 34th District), U.S. House of Representatives, Dr. Nelba Chavez, Administrator of SAMHSA, and Dr. Bernard Arons, Director of CMHS, emphasized that mental health services for the Hispanic community must be more accessible, appropriate, and responsive to the needs of the community.

Consensus on an Agenda and an Action Plan...
Stakeholders and partners worked hard during the 2-day meeting in March, producing a comprehensive National Agenda for Hispanic Mental Health that established goals and recommendations to improve mental health services for the Hispanic community. The Agenda, supported by the consensus of the National Congress, provides a spring board for Hispanic leaders to change the face and character of mental health services in America.

The National Agenda for Hispanic Mental Health, included in its entirety later in this volume, documents the goals, key issues, and recommended objectives of the Hispanic Congress. The goal statements reflect the broad aspirations and expectations of the National Congress Participants for Hispanics who have mental health needs. The goals of the National Agenda are to:

Empower consumers, family members, Hispanic community-based organizations, and faith institutions to lead the mental health agenda to ensure cultural competency.
Develop an adequate cadre of culturally competent personnel to resolve the national crisis in mental health services for Hispanics.
Establish performance, outcome-based accountability across systems.
Improve prevention and early intervention services in the Hispanic community.
Improve mental health services and service outcomes for Hispanic consumers.
Improve Latino mental health and substance abuse services through research.

The Agenda's recommendations are premised on several fundamental conditions necessary to improve Hispanic mental health: identification of specific venues where Hispanic consumers, families, providers, and leaders must be engaged; creation of Hispanic-specific knowledge about prevalence and effective treatment; increasing accountable service capacity in Hispanic communities delivered by more Hispanic providers; and descriptions of the specific instances in which cultural competence standards must be used and enforced on behalf of Hispanic consumers and families. The Agenda raises expectations for Hispanics in specific, clearly defined ways.

The National Congress also took the next step of identifying a wide range of action items that would contribute to achieving the Agenda. The Action Plan, included in its entirety in later in these Proceedings, is the first iteration of an ongoing work in progress. It represents the National Congress's threshold effort to translate its visions and aspirations into concrete action steps. Workgroups took as many of the recommendations in the National Agenda as possible and did their best to answer the question, "Who can or should do what to make this recommendation a reality?" The result is a series of short- and long-term action items that will help make the National Agenda a reality.

The Action Plan is ambitious and designed to challenge the National Congress Participants and its current and future partners to reach toward goals that will make a difference for Hispanic Americans suffering from mental illness. It is also meant to be renewed and revised as Hispanic leaders forge new partnerships and strong commitments from others working for these goals. The Action Plan creates opportunities for increasing Hispanic representation in decision making and for ensuring the adoption of cultural competence standards throughout all levels of the mental health system. The Agenda and the Action Plan reflect the critical importance of consumer and family leadership in improving mental health services and in overseeing service system accountability to its customers, particularly those in Hispanic communities. The foundation is well laid.

Priorities for Action…
Four key priority themes emerged from the Agenda and Action Plan, focusing on access, research, training, education, and accountability:

Assuring Access to Mental Health Care and Supportive Services. National Congress participants identified a number of steps that can be taken to reduce barriers to care. Such steps can address health policy and institutional barriers. With regard to health policy barriers, health insurance that provides coverage for mental health services is imperative for Hispanics. Without such insurance, economic barriers will continue to prevent Hispanics from seeking care.

Health policies must ensure prevention and early intervention services across the life cycle that are responsive to the Hispanic community and culture, in order to improve mental health and reduce demands on the service systems.

With regard to institutional barriers, facilities must be operated in a manner that ensures that providers and all staff reach out to Hispanic consumers and their families within their communities and homes and across all service systems such as community health centers, substance abuse treatment services, welfare, criminal justice, and foster care, in order to treat persons from low income, low education, and low acculturation communities.

To further address institutional barriers, close gaps, and eliminate service disparities, cultural competence standards must be incorporated into all service systems, effectively making every door an open door to culturally relevant and appropriate care for all Hispanic subgroups.

Conducting Relevant Applied Research to Inform Service Delivery. National Congress participants recognized the considerable gains made in developing pharmacologic and psychosocial interventions for the general population. Further collaborative research efforts must be undertaken to ensure the effectiveness of these state-of-the-art treatments for Hispanics. With regard to psychosocial interventions, that is, those treatments in which patients and their families learn how to successfully address their illness, it is critical that such interventions can be validated both culturally and linguistically for Latinos. With regard to psychopharmacological treatment, clinical trials of existing and new medications must be carried out with Hispanics to ensure their effectiveness with this ethnic group.

Services exist to effectively treat a wide range of mental health problems. Validation of such treatments both culturally and linguistically is imperative for Hispanics. Additional efforts are needed to learn which specific interventions work best for Hispanics and the conditions and contexts under which best care is possible, from faith community and family to home and community.

Improving Human Resources and Training the Next Generation. The mental health service needs of a growing Hispanic community must be met with a significant infusion of culturally competent and linguistically appropriate personnel into community-based systems across the country. National Congress participants believed that, most importantly, Hispanics need to be appointed to key leadership positions at the national, State, and local levels, with a specific commitment to work toward a Federal Government workforce that is representative of the U.S. population. Hispanics must be recruited actively to work at all skill levels within the mental health workforce. Staff who are culturally and linguistically competent and are knowledgeable of the sociocultural basis of Hispanics' daily lives are essential. Initiatives should be undertaken to increase the numbers of bicultural and bilingual professionals. Furthermore, strategies must be developed to attract Hispanic youth to mental health careers.

Primary care providers - not just mental health professionals - must be trained to provide appropriate and regular screening for mental health disorders, using a strength-based, culturally competent approach. In addition, establishing collaborative relations between primary care providers and mental health specialists can increase accessibility to mental health care and improve consumers' mental health status. This is particularly critical because Hispanics with mental disorders are more likely to seek care from primary care providers than from mental health specialists.

Finally, cultural competence training should be a part of all training and educational curricula and a requisite for licensing and credentialing for all workers in the field of mental health.

Ensuring Accountability. Performance measures and outcome-based accountability across systems of care must be put into place to ensure that the Hispanic community's mental health needs are being met. Actions taken must ensure that mental health cultural competence standards and national performance measures are included in all regulations, professional accreditations, grants/contracts, State-based certifications, and college/university credits. Such accountability must extend beyond the mental health service system to other systems that interface with mental health, including justice, welfare, education, housing, and primary care.

Developing the Necessary Leadership...
National Congress participants recognized that identifying what needed to happen and how to make it happen was not enough. Leadership was necessary to carry it out. Knowing that the National Agenda and Action Plan was developed by a nationally representative group of leaders from the Hispanic community and key partners from all levels and sectors of society - national, State, and grassroots - the Hispanic stakeholders felt strongly that implementation of those plans must be carried out in a similar fashion. While SAMHSA/CMHS facilitated an opportunity for National Congress participants to create a vision for Hispanic mental health, consumers, providers, clergy, researchers, and leaders of national organizations must work in partnership with all Federal, State, and local leadership to affect change.

The consumers provided a strong and active voice throughout the planning of the National Congress, as well as during the Congress itself. Coming together as Tenemos Voz, or "We Have a Voice," representatives of the consumer community demonstrated their leadership effectiveness and understanding of the mental health needs of the Hispanic community. This group worked together and made plans to create a national consumer organization, building a movement to ensure coordinated and targeted education and advocacy around mental health and mental illness.

Similarly, the Steering Committee as a whole provided strong leadership in the planning and implementation of the National Congress. As a result, Congress participants called for creation of a national organization for Hispanic mental health, empowering the Steering Committee to take the necessary action to move forward with planning such an endeavor. This organization will serve as a point of contact for ensuring continued progress as a result of the National Congress.

Stakeholders from the Congress plan to move forward with their National Agenda for Hispanic Mental Health and Action Plan and welcome the opportunity to collaborate with others to respond to the mental health care needs of the Hispanic community.

In answering the call to action from the Hispanic community, SAMHSA/CMHS provided the support necessary to bring the key Hispanic stakeholders and partners together to create a vision for the future of Hispanic mental health. SAMHSA/CMHS is working with the community to put the words into action.

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