CHAPTER 1

Introduction

Organization of Supplement and Major Topics Covered

Chapter 2 lays the foundations for understanding the relationships between culture, mental health, mental illness, and mental health services. Chapters 3 through 6 provide information about each racial and ethnic minority group. Chapter 7 concludes with promising directions and courses of action to reduce disparities and improve the mental health of racial and ethnic minorities.

Each chapter concerning a racial or ethnic minority group follows a common format. The chapter begins with facets of the group’s history in the United States and its demographic patterns, which include family structure, income, education, and health status. These factors are important for understanding contemporary ethnic identity issues and mental health, and the need for mental health services. The chapter then reviews the available scientific evidence regarding the need for mental health services (as measured by prevalence), the availability, accessibility, and utilization of services, and the appropriateness and outcomes of mental health services.

Need

In this Supplement, the need for mental health services is equated with prevalence, i.e., new and existing cases of mental disorders. Prevalence rates, however, are imperfect measures of need. A mental health problem may impair someone sufficiently to warrant treatment or other types of services (e.g., preventive care), while some milder forms of mental illness may not impair someone enough to warrant professional treatment. The problem is that the mental health field has not yet developed standard measures of “need for treatment” in the general population, much less for a given racial or ethnic group (DHHS, 1999). Where relevant, this Supplement also uses the diagnosis of a culture-bound syndrome as indicating a need for treatment.

This Supplement pays special attention to vulnerable, high-need populations, such as people who are homeless or incarcerated, or children in foster care. These are among the populations of most concern because they have the greatest need for services, defined by a higher risk for or prevalence of mental disorder than a relevant comparison population (Aday, 1994). Other populations, such as persons with co­occurring disorders or those living in migrant or rural communities, are also likely to be underserved or to have difficulty accessing needed treatment.

The chapters for each minority group vary some-what in terms of which high-need populations they cover. High-need populations were included in specific chapters on the basis of having overrepresentation by that particular minority group. For example, the chapter on Hispanic Americans covers refugees, whereas the chapter on American Indians and Alaska Natives covers children in foster care and people who abuse alcohol and drugs. The placements of these emphases should not be used to stereotype the group. High-need populations of all types exist in every group.

Availability

Availability of services refers to the number of providers in a given area and to whether these providers are able to offer mental health services that meet the needs of the population(s) they serve. The development of such services requires recognizing and responding to cultural concerns of racial and ethnic groups, including histories, traditions, beliefs, and value systems (U.S. Center for Mental Health Services [CMHS], 2000).

Accessibility

Access is defined as probability of use, given need for services. Because of the difficulty of operationalizing this definition, this Supplement relies on a commonly accepted measure of access, insurance status, i.e., whether or not people have private or public insurance to cover some or all of the cost of services (Brown et al., 2000). People with health insurance have greater access to services than those who do not (Newhouse, 1993). The nature of the coverage is also important — details such as coverage limits, deductibles, and the like — but few studies of minorities provide this level of specificity. Other cultural and organizational factors impede access, such as attitudes against treatment, mistrust, stigma, and fragmentation of services.

Utilization

Utilization of services is generally reported in this Supplement by rates of use of mental health services in any of the settings and sectors where they are provided. The chapters also provide some insight into more specific aspects of use such as intensity and duration of treatment, timing of care from first onset of symptoms, dropout rates, type of provider (e.g., specialist or primary care), sector, setting, and treatment modality. Many of these characteristics are described in the section on Service Settings (Chapter 2). Utilization is conceptualized as a combined function of all the previous topics — need, availability, and access.

Utilization is also reported for alternative or complementary sources of care including acupuncture, meditation, spiritual healing, herbal remedies, and/or traditional Chinese or American Indian medicine. The need to report these sources of care was prompted by the first national study of more than 16,000 people that found that about 10 percent of people reporting a mental condition used practitioner based alternative or complementary treatments. This rate of use was greater than that for people reporting a chronic medical condition (Druss & Rosenheck, 1999, 2000). The study also suggested that consumers¹¹ tend to use these therapies for milder mental health problems and continue to use mainstream medical services for more severe mental illnesses. Studies of the overall population in primary care clinics and in clinics specializing in complementary health care note that anxiety and depression are two of the disorders for which individuals use complementary care (Elder et al., 1997; Davidson, et al., 1998; Eisenberg et al., 1998).

Appropriateness and Outcomes

Appropriateness is defined herein as receiving an accurate diagnosis or guideline-based treatment. An accurate diagnosis is one in which a careful evaluation of a patient’s symptoms show that they correspond to diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. An appropriate treatment con-forms to the treatment guidelines for that disorder published by professional mental health associations or evidence-based reports on healthcare outcomes (drawn from comprehensive syntheses and analyses of relevant scientific literature) supported by government agencies.

Outcomes of treatment ordinarily refer either to the efficacy or effectiveness of treatment. Efficacy is whether treatment works in highly controlled research settings, whereas effectiveness is whether treatment works in clinical practice settings. Common outcomes that are measured are improved mortality and morbidity — such as less suicide or a reduction in symptoms or levels of distress — and improvement in mental health. Outcomes also cover improvements in disability, work performance, and other functional measures. Outcomes are studied in relation to any type of treatment, including those that are culturally responsive.

¹¹ Although a number of terms identify people who use or have used mental health services (e.g., mental health consumer, survivor, ex-patient, client), the terms “consumer” and “patient” will be used interchangably throughout this Supplement.