Efforts to improve mental health disparities underway

KAUAI, HAWAII – It’s been nearly 12 years since former U.S. Surgeon General David Satcher released a report spotlighting the impact of mental illnesses on racial and ethic minority groups in the United States.

Today, that report "still rings true in terms of its findings of the striking ethnic, racial, and linguistic disparities in mental health care, with members of diverse groups being less likely to receive services and to have a poorer quality of care once they enter the door for psychiatric care," Dr. Annelle B. Primm said at the annual meeting of the American College of Psychiatrists.

"To compound matters, they are underrepresented in mental health research, making it more difficult for us to be certain that we’re providing these populations the best care. Taken together, these disparities impose a great disability burden."

In 2011, minority births exceeded white births, she said, and 50% of 3- and 4-year-olds were white and 50% were nonwhite. "Our country is becoming more and more diverse to the point where we may need to start referring to these populations as an emerging majority," said Dr. Primm, director of minority and national affairs at the American Psychiatric Association (APA). "What this means is that in our mental health care settings, there are going to be even greater cross-cultural interactions. This is something that we in the psychiatry community need to be prepared for."

Patient-level factors, system-level factors, and individual practitioner factors contribute to the existing disparities, said Dr. Primm, who is also the APA’s deputy medical director. Data from the Agency for Healthcare Research and Quality’s (AHRQ’s) National Healthcare Disparities Report, which was published in 2011, show that blacks and Hispanics who had major depressive episodes within the last 12 months were less likely to receive treatment during that time, compared with whites.

"There are also some differences with respect to education level, with people with any college education being more likely to receive treatment, compared with those who are either high school graduates or had less than a high school education," Dr. Primm said.

The AHRQ also notes disparities in substance abuse treatment. For example, among people aged 12 and older who need treatment for illicit drug use or an alcohol problem, blacks are more likely to receive treatment, compared with their white or American Indian counterparts. Yet, blacks are less likely to complete treatment, compared with the other cohorts.

The rate of uninsured also is a barrier to mental health care. Data from the 2010 U.S. Census estimate that about 20% of the nonelderly population are uninsured. Of those uninsured, 46% are white, 31% are Hispanic, 16% are black, and 5% are Asian American. "We can expect an influx of these populations with health care reform and Medicaid expansion," Dr. Primm said.

Another access challenge is the shortage of behavioral health providers in some geographic areas, major cutbacks in public mental health services, and a lack of mental health workforce diversity. "If we look at the diversity of the psychiatry workforce, in almost all groups, there is a mismatch between the population percentage and the percentage of the psychiatric workforce," she said.

Despite current challenges that mental health care clinicians face in providing services to underserved patient populations, Dr. Primm emphasized that significant efforts are underway to bring meaningful change. Whatever shape pending health care reform ultimately takes, she predicted, it will contribute to improving access to mental health services by special populations. For example, mental health parity "will be helpful in terms of access to mental health services for diverse groups," she said. "Expanding health coverage through the employer mandate, health exchanges, Medicaid expansion, and allowance of coverage for people with preexisting conditions will also be [important]."

She said she envisions improved access through other pathways as well, such as community health centers, the Indian Health Care Improvement Act, and the Health Resources and Services Administration’s National Health Service Corps, "which pays for medical school and other health professional training for those who are prepared to ‘give back’ after they finish their training," Dr. Primm said.

Other trends underway aimed at eliminating disparities in the provision of mental health services include the involvement of peer support specialists – which has been proposed by recovery-oriented models of care. This trend "also stems from the saying ‘nothing about us without us,’ where people with mental illness who have been successful in managing their illness become a part of the team to help patients who are struggling, to identify with their recovery success," Dr. Primm explained. "We also need to see that community health workers and mental health navigators can serve as cultural brokers, particularly if they reflect the culture of the patient population served.

"This is new for many of us who have not had the opportunity to work with people in these sorts of positions."

Health care reform’s emphasis on prevention and primary care also is likely to drive change for the better, she said, noting that people with serious mental illness die, on average, 25 years earlier than the general population. "The integrated care between primary care and mental health is particularly important with ethnically and racially diverse groups," she said. "There are very high rates of chronic disease and premature death, so this is another way in which these patients can benefit from having a ‘one-stop shop,’ to benefit from collaborative care."

In 2006, the APA and the National Alliance on Mental Illness embarked on a project to develop a 3-hour continuing medical education curriculum called "In Living Color: Depression Treatment in Primary Care." The curriculum was developed to equip primary care practitioners with the knowledge and skills to work more effectively with diverse populations.

"The approach in teaching this is innovative in that it involves physicians working with a person of color with a history of depression as well as with a family mental health advocate from a diverse background," Dr. Primm said. "So the primary care practitioners [gain] a full appreciation – not only of the science but also of the lived experience of what it’s like to be a person of color with a mental illness and to struggle with it." To date, the curriculum has been rolled out in California, Florida, Louisiana, Missouri, and Tennessee.

The recent proliferation of cultural competence training, and practitioner and organizational assessments, also are likely to result in improved access to quality mental health care. The Affordable Care Act "does pay attention to the issue of cultural competency training," she said. "Some states have taken the lead on this, including New Jersey, which requires cultural competency training for medical licensure and renewal. In addition, California requires that all CME programs include a cultural competence focus."

On the national front, the Department of Health and Human Services Office of Minority Health has launched a National Partnership for Action to End Health Disparities. According to its website, the mission of NPA is to "increase the effectiveness of programs that target the elimination of health disparities through the coordination of partners, leaders, and stakeholders committed to action." Efforts by the Patient Care Outcomes Research Institute to conduct comparative effectiveness research also will be key. "Perhaps this will be an opportunity to learn more about what sort of treatments work best in which populations and by which providers, et cetera," Dr. Primm said. "In terms of quality improvement, it’s important to have national indicators tracked by race and ethnicity."

Other quality standards focused on eliminating disparities include the National Standards on Culturally and Linguistically Appropriate Services, the National Quality Forum’s Healthcare Disparities and Cultural Competency Consensus Standards, and the National Committee for Quality Assurance’s Standards and Guidelines for Distinction in Multicultural Health Care. "These will all be more prominent going forward," Dr. Primm said.

Dr. Primm said she had no relevant financial disclosures.

d.brunk@elsevier.com

KAUAI, HAWAII – It’s been nearly 12 years since former U.S. Surgeon General David Satcher released a report spotlighting the impact of mental illnesses on racial and ethic minority groups in the United States.

Today, that report "still rings true in terms of its findings of the striking ethnic, racial, and linguistic disparities in mental health care, with members of diverse groups being less likely to receive services and to have a poorer quality of care once they enter the door for psychiatric care," Dr. Annelle B. Primm said at the annual meeting of the American College of Psychiatrists.

"To compound matters, they are underrepresented in mental health research, making it more difficult for us to be certain that we’re providing these populations the best care. Taken together, these disparities impose a great disability burden."

In 2011, minority births exceeded white births, she said, and 50% of 3- and 4-year-olds were white and 50% were nonwhite. "Our country is becoming more and more diverse to the point where we may need to start referring to these populations as an emerging majority," said Dr. Primm, director of minority and national affairs at the American Psychiatric Association (APA). "What this means is that in our mental health care settings, there are going to be even greater cross-cultural interactions. This is something that we in the psychiatry community need to be prepared for."

Patient-level factors, system-level factors, and individual practitioner factors contribute to the existing disparities, said Dr. Primm, who is also the APA’s deputy medical director. Data from the Agency for Healthcare Research and Quality’s (AHRQ’s) National Healthcare Disparities Report, which was published in 2011, show that blacks and Hispanics who had major depressive episodes within the last 12 months were less likely to receive treatment during that time, compared with whites.

"There are also some differences with respect to education level, with people with any college education being more likely to receive treatment, compared with those who are either high school graduates or had less than a high school education," Dr. Primm said.

The AHRQ also notes disparities in substance abuse treatment. For example, among people aged 12 and older who need treatment for illicit drug use or an alcohol problem, blacks are more likely to receive treatment, compared with their white or American Indian counterparts. Yet, blacks are less likely to complete treatment, compared with the other cohorts.

The rate of uninsured also is a barrier to mental health care. Data from the 2010 U.S. Census estimate that about 20% of the nonelderly population are uninsured. Of those uninsured, 46% are white, 31% are Hispanic, 16% are black, and 5% are Asian American. "We can expect an influx of these populations with health care reform and Medicaid expansion," Dr. Primm said.

Another access challenge is the shortage of behavioral health providers in some geographic areas, major cutbacks in public mental health services, and a lack of mental health workforce diversity. "If we look at the diversity of the psychiatry workforce, in almost all groups, there is a mismatch between the population percentage and the percentage of the psychiatric workforce," she said.

Despite current challenges that mental health care clinicians face in providing services to underserved patient populations, Dr. Primm emphasized that significant efforts are underway to bring meaningful change. Whatever shape pending health care reform ultimately takes, she predicted, it will contribute to improving access to mental health services by special populations. For example, mental health parity "will be helpful in terms of access to mental health services for diverse groups," she said. "Expanding health coverage through the employer mandate, health exchanges, Medicaid expansion, and allowance of coverage for people with preexisting conditions will also be [important]."

She said she envisions improved access through other pathways as well, such as community health centers, the Indian Health Care Improvement Act, and the Health Resources and Services Administration’s National Health Service Corps, "which pays for medical school and other health professional training for those who are prepared to ‘give back’ after they finish their training," Dr. Primm said.

Other trends underway aimed at eliminating disparities in the provision of mental health services include the involvement of peer support specialists – which has been proposed by recovery-oriented models of care. This trend "also stems from the saying ‘nothing about us without us,’ where people with mental illness who have been successful in managing their illness become a part of the team to help patients who are struggling, to identify with their recovery success," Dr. Primm explained. "We also need to see that community health workers and mental health navigators can serve as cultural brokers, particularly if they reflect the culture of the patient population served.

"This is new for many of us who have not had the opportunity to work with people in these sorts of positions."

Health care reform’s emphasis on prevention and primary care also is likely to drive change for the better, she said, noting that people with serious mental illness die, on average, 25 years earlier than the general population. "The integrated care between primary care and mental health is particularly important with ethnically and racially diverse groups," she said. "There are very high rates of chronic disease and premature death, so this is another way in which these patients can benefit from having a ‘one-stop shop,’ to benefit from collaborative care."

In 2006, the APA and the National Alliance on Mental Illness embarked on a project to develop a 3-hour continuing medical education curriculum called "In Living Color: Depression Treatment in Primary Care." The curriculum was developed to equip primary care practitioners with the knowledge and skills to work more effectively with diverse populations.

"The approach in teaching this is innovative in that it involves physicians working with a person of color with a history of depression as well as with a family mental health advocate from a diverse background," Dr. Primm said. "So the primary care practitioners [gain] a full appreciation – not only of the science but also of the lived experience of what it’s like to be a person of color with a mental illness and to struggle with it." To date, the curriculum has been rolled out in California, Florida, Louisiana, Missouri, and Tennessee.

The recent proliferation of cultural competence training, and practitioner and organizational assessments, also are likely to result in improved access to quality mental health care. The Affordable Care Act "does pay attention to the issue of cultural competency training," she said. "Some states have taken the lead on this, including New Jersey, which requires cultural competency training for medical licensure and renewal. In addition, California requires that all CME programs include a cultural competence focus."

On the national front, the Department of Health and Human Services Office of Minority Health has launched a National Partnership for Action to End Health Disparities. According to its website, the mission of NPA is to "increase the effectiveness of programs that target the elimination of health disparities through the coordination of partners, leaders, and stakeholders committed to action." Efforts by the Patient Care Outcomes Research Institute to conduct comparative effectiveness research also will be key. "Perhaps this will be an opportunity to learn more about what sort of treatments work best in which populations and by which providers, et cetera," Dr. Primm said. "In terms of quality improvement, it’s important to have national indicators tracked by race and ethnicity."

Other quality standards focused on eliminating disparities include the National Standards on Culturally and Linguistically Appropriate Services, the National Quality Forum’s Healthcare Disparities and Cultural Competency Consensus Standards, and the National Committee for Quality Assurance’s Standards and Guidelines for Distinction in Multicultural Health Care. "These will all be more prominent going forward," Dr. Primm said.

Dr. Primm said she had no relevant financial disclosures.

d.brunk@elsevier.com

KAUAI, HAWAII – It’s been nearly 12 years since former U.S. Surgeon General David Satcher released a report spotlighting the impact of mental illnesses on racial and ethic minority groups in the United States.

Today, that report "still rings true in terms of its findings of the striking ethnic, racial, and linguistic disparities in mental health care, with members of diverse groups being less likely to receive services and to have a poorer quality of care once they enter the door for psychiatric care," Dr. Annelle B. Primm said at the annual meeting of the American College of Psychiatrists.

"To compound matters, they are underrepresented in mental health research, making it more difficult for us to be certain that we’re providing these populations the best care. Taken together, these disparities impose a great disability burden."

In 2011, minority births exceeded white births, she said, and 50% of 3- and 4-year-olds were white and 50% were nonwhite. "Our country is becoming more and more diverse to the point where we may need to start referring to these populations as an emerging majority," said Dr. Primm, director of minority and national affairs at the American Psychiatric Association (APA). "What this means is that in our mental health care settings, there are going to be even greater cross-cultural interactions. This is something that we in the psychiatry community need to be prepared for."

Patient-level factors, system-level factors, and individual practitioner factors contribute to the existing disparities, said Dr. Primm, who is also the APA’s deputy medical director. Data from the Agency for Healthcare Research and Quality’s (AHRQ’s) National Healthcare Disparities Report, which was published in 2011, show that blacks and Hispanics who had major depressive episodes within the last 12 months were less likely to receive treatment during that time, compared with whites.

"There are also some differences with respect to education level, with people with any college education being more likely to receive treatment, compared with those who are either high school graduates or had less than a high school education," Dr. Primm said.

The AHRQ also notes disparities in substance abuse treatment. For example, among people aged 12 and older who need treatment for illicit drug use or an alcohol problem, blacks are more likely to receive treatment, compared with their white or American Indian counterparts. Yet, blacks are less likely to complete treatment, compared with the other cohorts.

The rate of uninsured also is a barrier to mental health care. Data from the 2010 U.S. Census estimate that about 20% of the nonelderly population are uninsured. Of those uninsured, 46% are white, 31% are Hispanic, 16% are black, and 5% are Asian American. "We can expect an influx of these populations with health care reform and Medicaid expansion," Dr. Primm said.

Another access challenge is the shortage of behavioral health providers in some geographic areas, major cutbacks in public mental health services, and a lack of mental health workforce diversity. "If we look at the diversity of the psychiatry workforce, in almost all groups, there is a mismatch between the population percentage and the percentage of the psychiatric workforce," she said.

Despite current challenges that mental health care clinicians face in providing services to underserved patient populations, Dr. Primm emphasized that significant efforts are underway to bring meaningful change. Whatever shape pending health care reform ultimately takes, she predicted, it will contribute to improving access to mental health services by special populations. For example, mental health parity "will be helpful in terms of access to mental health services for diverse groups," she said. "Expanding health coverage through the employer mandate, health exchanges, Medicaid expansion, and allowance of coverage for people with preexisting conditions will also be [important]."

She said she envisions improved access through other pathways as well, such as community health centers, the Indian Health Care Improvement Act, and the Health Resources and Services Administration’s National Health Service Corps, "which pays for medical school and other health professional training for those who are prepared to ‘give back’ after they finish their training," Dr. Primm said.

Other trends underway aimed at eliminating disparities in the provision of mental health services include the involvement of peer support specialists – which has been proposed by recovery-oriented models of care. This trend "also stems from the saying ‘nothing about us without us,’ where people with mental illness who have been successful in managing their illness become a part of the team to help patients who are struggling, to identify with their recovery success," Dr. Primm explained. "We also need to see that community health workers and mental health navigators can serve as cultural brokers, particularly if they reflect the culture of the patient population served.

"This is new for many of us who have not had the opportunity to work with people in these sorts of positions."

Health care reform’s emphasis on prevention and primary care also is likely to drive change for the better, she said, noting that people with serious mental illness die, on average, 25 years earlier than the general population. "The integrated care between primary care and mental health is particularly important with ethnically and racially diverse groups," she said. "There are very high rates of chronic disease and premature death, so this is another way in which these patients can benefit from having a ‘one-stop shop,’ to benefit from collaborative care."

In 2006, the APA and the National Alliance on Mental Illness embarked on a project to develop a 3-hour continuing medical education curriculum called "In Living Color: Depression Treatment in Primary Care." The curriculum was developed to equip primary care practitioners with the knowledge and skills to work more effectively with diverse populations.

"The approach in teaching this is innovative in that it involves physicians working with a person of color with a history of depression as well as with a family mental health advocate from a diverse background," Dr. Primm said. "So the primary care practitioners [gain] a full appreciation – not only of the science but also of the lived experience of what it’s like to be a person of color with a mental illness and to struggle with it." To date, the curriculum has been rolled out in California, Florida, Louisiana, Missouri, and Tennessee.

The recent proliferation of cultural competence training, and practitioner and organizational assessments, also are likely to result in improved access to quality mental health care. The Affordable Care Act "does pay attention to the issue of cultural competency training," she said. "Some states have taken the lead on this, including New Jersey, which requires cultural competency training for medical licensure and renewal. In addition, California requires that all CME programs include a cultural competence focus."

On the national front, the Department of Health and Human Services Office of Minority Health has launched a National Partnership for Action to End Health Disparities. According to its website, the mission of NPA is to "increase the effectiveness of programs that target the elimination of health disparities through the coordination of partners, leaders, and stakeholders committed to action." Efforts by the Patient Care Outcomes Research Institute to conduct comparative effectiveness research also will be key. "Perhaps this will be an opportunity to learn more about what sort of treatments work best in which populations and by which providers, et cetera," Dr. Primm said. "In terms of quality improvement, it’s important to have national indicators tracked by race and ethnicity."

Other quality standards focused on eliminating disparities include the National Standards on Culturally and Linguistically Appropriate Services, the National Quality Forum’s Healthcare Disparities and Cultural Competency Consensus Standards, and the National Committee for Quality Assurance’s Standards and Guidelines for Distinction in Multicultural Health Care. "These will all be more prominent going forward," Dr. Primm said.

Dr. Primm said she had no relevant financial disclosures.

d.brunk@elsevier.com