Mental Health and Disparities In Minority
Disparities in Mental
Health
Disparities in mental health
services for racial/ethnic minorities are continuous, ongoing, and persistent
(Miranda, Lawson, & Escobar, 2002; Institute of Medicine [IOM], 2003; US
Department of Health and Human Services [USDHHS], 2003; Sue , 2003).
Because of
the holistic and preventive care at tributes found in nursing research,
education, and practice, nurses are prepared to address the issues of
disparities in minority mental health. Nurses have ethical responsibilities
that include doing no harm through the provision of safe patient care
(Gastmans, 1998).
Practicing within an ethically challenging environment calls
for nurses to be aware of and to address the issues of health disparities for
racial/ethnic minorities. It is imperative that nurses become culturally
competent in the care that they give to all people including racial/ethnic
minorities.
The Institute of Medicine Committee on understanding and
eliminating racial and ethnic disparities in healthcare (LOM) defines
“disparities in healthcare as racial or ethnic differences in the quality
of healthcare that are not due to access-related factors or clinical needs,
preferences, and appropriateness of intervention” (pp. 3-4).
Racial/ethnic
minorities are less likely to receive needed mental health care and when they
do it is of poorer quality than whites.
Common Racial Groups for Such Practices
The four major minority groups are
both racial-Black, Native Indian/Alaskan Native, and Asian/Pacific Islanders,
and ethnic-Hispanic (any race). Miranda, Nakamura, and Bernal (2003) stated
that although race is based on an outdated impression of biological origin,
race does designate strong social meanings, whereas ethnicity refers to
affinity with a group that is believed to share a common lineage.
According to
the US Census Bureau (2001), from 1900 to 1965, racial/ethnic minorities made
up 10% of the US population. By 2000, they were almost 30% of the US
population, and by the mid-21st century racial/ethnic minorities will be
approximately 40% of the US population.
The US Census Bureau reported that of
the 281.4 million people that live in the United States, 12.3% are Black, 0.9%
are Native Indians/ Alaskan Natives, 3.7% are Asian/Pacific Islanders and 12.5%
are Hispanic.
Today, racial/ethnic minorities are
still affected by long-term legalized racism/discrimination. For Blacks, it was
slavery: Native Americans and Japanese-forced relocations; Hispanics conquest;
and Chinese involuntary non-citizenship.
This led to institutionalized racism,
with a continued distrust by minorities of organized systems, including the
health care system. Stigma prevents many minorities with mental illness from
seeking help.
According to the Surgeon General, stigma plays a stronger role in
not seeking treatment with racial/ethnic minorities than with whites. As stigma
lessens, a change in public attitude should occur and people will be more
likely to seek care.
Prevalence of Mental Health Disorders
Prevalence of mental disorders are
relatively similar across racial/ethnic populations, although there are clear
variances within subgroups (Miranda et al., 2002). Blacks in need of mental
health care receive only half the care of whites, and the rate of uninsured
minorities to whites is 2:1 (USDHHS, 2003).
Almost 30% of Hispanics and 20% of
Blacks do not have a primary source of health care and many racial/ ethnic minorities
live in remote and rural case. People who do not have a primary source of health
care or who live in remote and rural locations are less likely to be insured or
more likely to be under insured. Being insured in creases the likelihood for
accessibility to mental health care.
Mental health disparities for
racial/ethnic minority populations are sustained by barriers to cultural
competence that include racism/discrimination, stigma, communication,
misdiagnosis, treatment, and lack of research (USDHHS, 2003; Miranda et al.,
2002; LO.M. , 2003). The Surgeon General in the landmark supplement, Mental
Health: Culture, Race and Ethnicity (2003) reasoned that racial/ethnic
minorities experience:
(a) less opportunity for entry to and ease of use of
mental health services.
(b) less potential for receipt of mental health
services.
(c) poorer quality of mental health treatment.
(d)
underrepresentation of racial/ethnic minority clinicians, researchers, and
educators in the mental health field.
Data Gap
There are major gaps in empirical
data for mental health services for racial/ethnic minorities. Misdiagnosis,
treatment, and cultural competence have been studied. Most research has been
done with the black population. Misdiagnosis occurs in all groups including
whites but it occurs to a more significant degree in minorities (Miranda et
al., 2002; LO.M., 2003).
Racial/ethnic minorities were less likely to receive
appropriate care for depression or anxiety than were whites. Black patients
with affective disorders are more likely to be diagnosed as schizophrenic than
are white patients and therefore, less like to receive lithium (Miranda et al.;
LO.M.; USDHHS, 2003).
Misdiagnose of Mental Disorders
Misdiagnosis leads to mistreatment
in the form of no treatment, inappropriate treatment, or undertreatment.
Tardive dyskinesia (a major side effect of major antipsychotic medication),
excessive dosing, and as needed medications are complications more likely to
occur in racial/ethnic minority groups than in the white population (Miranda et
al., 2002; LO.M., 2003; USDHHS, 2003).
Unless a proper diagnosis is made,
mindful of the varying presentations of mental health symptoms among
racial/ethnic minorities and patient’s acceptance of the interview process,
which may not be culturally competent, effective treatment is unlikely to occur
(1.OM).
Other studies indicate that minorities are likely to have untoward
effects from treatment because of sensitivity to medication, improper
medication, and intermittent or inappropriate treatment (1.OM, 2003; USDHHS,
2003).
Furthermore, a lack of cultural competence among service providers has
contributed to a lack of use of mental health services that contributes to the
likelihood of minority persons receiving more inappropriate care than whites
(1.0.M.; USDHHS).
Stigmas about Mental Disorders
Stigma of people with mental illness
has existed throughout history (IOM, 2003). Over this period of time, the
treatment of mental illness has always been separated from the treatment of
physical illness.
Stigmatization of mental illness leads to the avoidance of
and the treatment of persons with mental illness. Stigma is so widespread and
such a formidable barrier to seeking mental health services that it is
imperative to determine its dynamics and the impact on persons who need and
deserve mental health services (USDHHS, 2003).
Significant gaps in nursing
literature exist regarding minority mental health. Future research is needed to
increase knowledge and ameliorate racism/discrimination, stigma, communication
problems, misdiagnosis, and treatment in minority mental health (LO.M., 2003;
USDHHS, 2003).
Mental health screening instruments need to demonstrate
satisfactory reliability and validity across diverse ethnic minority
populations to determine their cultural relevance and sensitivity (Baker &
Bell, 1999). Although Baker and Bell addressed instrument appropriateness among
mental health care of blacks, the data are generalizable to other racial/ethnic
minorities.
Treatment and Its outcome
The treatment outcomes for
racial/ethnic minorities are influenced by the cultural incompetence and bias
of providers (LOM, 2003; USDHHS, 2003; Sue, 2003).
Diagnostic criteria for
quantifying mental health symptoms exist, though their use may paradoxically
limit the provider from making an appropriate clinical formulation when varying presentations of mental health symptoms in minority ethnic populations
exist. An appendix to the DSM-IV TR (2000) features guidelines for the cultural
formulation to be putatively incorporated into the clinical interview.
These
have not been included in the text as an integrated part of multiaxial
assessment due to incomplete empirical data to guide practice. Cultural
competence needs to be well-defined, evidence based, and empirically-measured
for its impact on outcomes associated with mental health therapies (Sue, 2003).
Cultural Influence on Mental Disorders
Cultural influences of both provider
and patient potentiate communication difficulties that direct the uninformed
provider to underestimate the prevalence of clinically significant mental
health symptoms among racial/ethnic minorities (Baker & Bell, 1999; IOM, 2003).
After many years of looking at ethnic match of provider and client, where both
are of a common ethnic background, cultural match, where the client regards the
provider as culturally sensitive, flexible, and willing to regard the
individual’s unique needs, is identified as a better predictor of positive
health outcomes, treatment continuity, and function ( Maramba & Hall,
2002).
Also, studies (Miranda, 2003; Baker & Bell, 1999; IOM, 2003; USDHHS,
2003) have recommended that theoretically based inquiry, culturally appropriate
measurements, and culturally-competent mental health treatment options comprise
future scientific studies with racial ethnic minority populations.
Knowledge Development Regarding Mental Disorders
Knowledge development regarding the
needs of racial/ethnic minorities is influenced by several factors, including
historical and ethical influences, provider cultural incompetence, and the
academic and clinical community’s lack of consensus guiding inquiry into
minority mental health care.
Academic and empirical study of minority mental
health and related disparities in mental health care are needed to correct the
provider’s knowledge and decrease prejudice. This is a step towards bringing
the best evidence into day-to-day practice.