CHAPTER 7

A Vision for the Future

Continue to Expand the Science Base

The mental health knowledge base regarding racial and ethnic minorities is limited but growing. Because good science is an essential underpinning of the public health approach to mental health and mental illness, systematic work in the areas of epidemiology, evidence-based treatment, psychopharmacology, ethnic- and culture-specific interventions, diagnosis and assessment, and prevention and promotion needs to be developed and expanded.

Epidemiology

In March 1994, the policies of the National Institutes of Health (NIH) regarding inclusion of racial and ethnic minorities in study populations were significantly strengthened (NIH Guidelines, 1994, p. 14509). This change requires inclusion of ethnic minorities in all NIH-funded research. The results of this policy will be apparent in the coming years as studies funded during this era begin to be published.

Several large epidemiological studies that include significant samples of racial and ethnic minorities have recently been initiated or completed. These surveys, when combined with smaller, ethnic-specific epidemiological surveys, may help resolve some of the uncertain-ties about the extent of mental illness among specific racial and ethnic groups.

The National Institute of Mental Health (NIMH) recently funded a collaborative series of projects that will make great strides in psychiatric epidemiology nationwide. The National Survey of Health and Stress (NSHS) will interview a nationally representative sample of adolescents and adults to estimate the prevalence of mental disorders in the United States. Although the NSHS will interview nearly 20,000 adolescents and adults, its samples of specific racial and ethnic minority groups will be proportionate to their size in the Nation’s population, and, thus, not very large. To complement the NSHS, NIMH has funded the National Survey of American Lives (NSAL) and the National Latino and Asian American Study (NLAAS), which will include large samples of different racial and ethnic minorities. In the NSAL, approximately 9,000 African American adolescents and adults will be interviewed; about a quarter of them will be immigrants to the United States. In the NLAAS, a total of about 8,000 Latino and Asian American adults from a few specific ethnic groups will be interviewed about their mental health and service use patterns. Project investigators have made a substantial portion of the NSHS, NSAL, and NLAAS surveys similar to facilitate cross-study comparisons. Taken together, these studies will permit the most comprehensive assessments to date of symptom patterns, prevalence rates of disorders, access to services, and functioning for different racial and ethnic minority groups.

In addition, a major effort to examine the psychiatric epidemiology and the use of mental health services by American Indians has recently been completed. The American Indian Services Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project (AI–SUPERPFP), sponsored by NIMH and conducted by the National Center for American Indian and Alaska Native Mental Health Research, is a large-scale, multi-stage study of prevalence and utilization rates among over 3,000 individuals in two large American Indian communities, a Southwestern tribe and a Northern Plains tribe. In this study, mental disorders are diagnosed in a manner that is culturally relevant, using methods similar to those employed by the National Comorbidity Survey. The results of this study will be available in 2002 and will add greatly to our understanding of the need for mental health care among American Indians.

The National Household Survey on Drug Abuse (NHSDA) is conducted annually by the Substance Abuse and Mental Health Services Administration (SAMHSA) and interviews approximately 70,000 respondents each year. The NHSDA conducts interviews in both Spanish and English and has generated samples of white Americans, African Americans, and Hispanic Americans large enough to allow separate data analyses by racial or ethnic group. Through this annual survey it will be possible to track changes in the prevalence of substance abuse and dependence, as well as certain mental health problems for several racial and ethnic groups.

It is important that findings from these studies serve as a basis for improving mental health services for all groups.

Evidence-Based Treatment

Research reviewed in the previous chapters provides evidence that ethnic minorities can benefit from mental health treatment. While the Surgeon General’s Report on Mental Health contained strong and consistent documentation of a comprehensive range of effective interventions for treating many mental disorders (DHHS, 1999), most of the studies reporting findings for racial and ethnic minorities had small samples and were not randomized controlled trials. As discussed in Chapter 2, the research used to generate professional treatment guidelines for most health and mental health interventions does not include or report large enough samples of racial and ethnic minorities to allow group-specific determinations of efficacy (see Appendix A). In the future, evidence from randomized controlled trials that include and identify sizable racial and ethnic minority samples may lead to treatment improvements, which will help clinicians to maximize real-world effectiveness of already-proven psychiatric medications and psychotherapies.

At the same time, research is essential to examine the efficacy of ethnic- or culture-specific interventions for minority populations and their effectiveness in clinical practice settings. A good example of a well-designed study addressing these issues is the WE Care Study (Women Entering Care), a major effort to examine treatment for depression in low-income and minority women. Funded by NIMH, this study examines the impact of evidence-based care for depression on a large sample (N = 350) of white, African American, and Latina women who are poor. This randomized controlled trial is not only examining the impact of treatment for depression on this group of women, but it will also determine whether providing treatment to women who are mothers results in improvements in the mental health and functioning of their children.

Psychopharmacology

Some of the variability in people’s responses to medications is accounted for by factors related to race, ethnicity, and lifestyle. Information about race and ethnicity, as well as factors such as age, gender, and family history, may provide a starting point for medical research aimed at developing and testing drug therapies tailored to individual patients. Identifying the various mechanisms responsible for differential pharmacological response will aid in predicting an individual’s likely response to a medication before it is prescribed.

A few studies have examined racial and ethnic differences in the metabolism of clinically important drugs used to treat mental illnesses. As the evidence base grows, improved treatment guidelines will help clinicians be aware that differences in metabolic response, as well as differences in age, gender, family history, lifestyle, and co-occurring illnesses, can alter a drug’s safety and efficacy. For example, clinicians are becoming sensitized to the possibility that a significant proportion of racial and ethnic minority patients will respond to some common medications at lower-than-usual dosages. Care must be taken to avoid overmedicating patients, because over-medication can lead to adverse effects or toxicity. However, because each racial and ethnic population contains the full range of drug metabolic activity across its membership, a clinician should not come to firm conclusions about higher or lower metabolic rates based on an individual’s race or ethnicity alone.

Currently, there is little empirical evidence around improving systems of care for racial and ethnic minorities. To reduce disparities in quality of care, research is needed on strategies to improve the availability and delivery of evidence-based treatments, including state-of-the-art medications and psychotherapies. Consumers, communities, mental health services researchers, and Federal agencies have an opportunity to work together toward the development and dissemination of evidence-based treatment information to improve quality of care for racial and ethnic minorities. In particular, studies are needed that identify effective interventions for minority subpopulations, such as children, older adults, persons with co-occurring mental and physical health conditions, and persons who are living in rural areas.

Ethnic- or Culture-Specific Interventions

Clinicians’ awareness of their own cultural orientation, their knowledge of the client’s background, and their skills with different cultural groups may be essential to improving access, utilization, and quality of mental health services for minority populations. While no rigorous, systematic studies have been conducted to test these hypotheses, evidence suggests that culturally oriented interventions are more effective than usual care at reducing dropout rates for ethnic minority mental health clients. While the efficacy of most ethnic-specific or culturally responsive services is yet to be determined, models already shown to be useful through research could be targeted for further efficacy research and, ultimately, dissemination to mental health providers.

Because stigma and help-seeking behaviors are two culturally determined factors in service use, research is needed on how to change attitudes and improve utilization of mental health services. Some promising areas of study in racial and ethnic minority communities are reducing stigma associated with mental illness, encouraging early intervention, and increasing awareness of effective treatments and the possibility of recovery. These messages should be tailored to the languages and cultures of multiple racial and ethnic communities. Communities that can incorporate evidence-based knowledge about disease and treatments will have a health advantage.

Diagnosis and Assessment

Though the major mental illnesses are found worldwide, manifestations of these and other health conditions may vary with age, gender, race, ethnicity, and culture. Research reported in this Supplement documents that minorities tend to receive less appropriate diagnoses than whites. Further study is needed on how to address issues of clinician bias and diagnostic accuracy, particularly among those providers working with racial and ethnic minority consumers.

As noted in Chapter 1, the DSM–IV marked a new level of acknowledgment of the role of culture in shaping the symptoms and expression of mental disorders. The inclusion of a “Glossary of Culture-Bound Syndromes” and the “Outline for Cultural Formulation” for clinicians was a significant step forward in recognizing the impact of culture, race, and ethnicity on mental health. Further study is needed, however, to examine the relationship between culture-bound syndromes and existing disorders and the connection of culture-bound syndromes with underlying biological, social, and cultural processes. Examining the extent to which culture-bound syndromes are unique idioms of distress for some groups or variants of existing syndromes or disorders is particularly important.

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, now under development, will extend and elaborate concepts introduced in DSM–IV regarding the role and importance of culture and ethnicity in the diagnostic process. While striving to understand the processes that underlie disorders and syndromes, it is also critical to examine how clinicians apply cultural knowledge in their clinical evaluations. Further research is needed on the impact of culture in interview-based diagnosis and assessment techniques, as well as in the use and interpretation of formal psychological tests. Quality mental health assessment and treatment rely on understanding local representations of illness and distress for all populations.

Prevention and Promotion

Preventive interventions have the potential to decrease the incidence, severity, and duration of certain mental disorders or behavioral problems, e.g., depression, con-duct disorder, or substance abuse. In addition, promotive interventions, such as increasing healthy thinking pat-terns or improving coping skills, may be integral to fostering the mental health of the nation. Unfortunately, only a handful of interventions to promote mental health, reduce risk, or enhance resiliency have been empirically validated for racial and ethnic minorities. As part of a public health approach to mental health and mental illness for all Americans, the growing knowledge base for preventive interventions must include racial and ethnic minorities.

Important opportunities exist for researchers to study cultural differences in stress, coping, and resilience as part of the complex of factors that influence mental health. Such work will lay the groundwork for developing new prevention and treatment strategies — building upon community strengths to foster mental health and to ameliorate negative health outcomes.

Study the Roles of Culture, Race, and Ethnicity in Mental Health

How do racial and ethnic groups differ in their manifestations and perceptions of mental illness and their attitudes toward and use of mental health services? What is it about race and ethnicity that helps explain these differences? The mental health community will benefit from a better understanding of how factors such as acculturation, help-seeking behaviors, stigma, ethnic identity, racism, and spirituality provide protection from or risk for mental illness in racial and ethnic minority populations. While no single study can shed light on all these issues simultaneously, scientific research will advance knowledge, increase our ability to prevent or treat mental illness, and promote mental health.

New studies will advance our knowledge about the social and cultural characteristics of racial and ethnic minority groups that correlate with risk and protective factors for mental health. As described earlier, researchers involved in the NSHS, NSAL, NLAAS, and AI–SUPERPFP large-scale epidemiological studies have collaborated on a set of core questions that will facilitate comparisons across populations. For example, across all four studies, it will be possible to assess how socioeconomic status, wealth, education, neighborhood context, social support, religiosity, and spirituality relate to mental illness among African Americans, Latinos, Asian Americans, American Indians, and whites. Similarly, it will be possible to assess how acculturation, ethnic identity, and perceived discrimination affect mental health outcomes for the four underserved racial and ethnic groups. These types of analyses go beyond straightforward epidemiological comparisons; with these ground-breaking studies, the mental health field will gain crucial insight into how social and cultural factors operate across race and ethnicity to affect mental illness in diverse communities.