Unmet Needs for Mental Health Services for Latino Older Adults: Perspectives from Consumers, Family Members, Advocates, and Service Providers

This study qualitatively assessed the need for mental health services among Latino older adults in San Diego, California. The primary mental health issue was depression. Primary organizational barriers to accessing services were language and cultural barriers secondary to a lack of translators, dearth of information on available services, and scarcity of providers representative of the Latino community. Other challenges included a lack of transportation and housing, and the need for socialization and social support. Latino older adults experienced their unmet needs in ways associated with their cultural background and minority status. Age- and culturally-appropriate services are needed to overcome these barriers.     

Limited English proficiency as a barrier to mental health service use: A study of Latino and Asian immigrants with psychiatric disorders

Language barriers pose problems in mental health care for foreign-born individuals in the United States. Immigrants with psychiatric disorders may be at particular risk but are currently understudied. The purpose of this study was to examine the effect of limited English proficiency (LEP) on mental health service use among immigrant adults with psychiatric disorders. Drawn from the National Latino and Asian American Study (NLAAS), Latino and Asian immigrant adults aged 18-86 with any instrument-determined mood, anxiety, and substance use disorder (n = 372) were included in the present analysis. Results from hierarchical logistic regression analyses showed that having health insurance, poor self-rated mental health, and more psychiatric disorders were independently associated with higher probability of mental health service use in the Latino group. After controlling for all background characteristics and mental health need factors, LEP significantly decreased odds of mental health service use among Latino immigrants. None of the factors including LEP predicted mental health service use among Asian immigrants, who were also the least likely to access such services. LEP was a barrier to mental health service use among Latino immigrants with psychiatric disorders. This study suggests that future approaches to interventions might be well advised to include not only enhancing the availability of bilingual service providers and interpretation services but also increasing awareness of such options for at least Latino immigrants. In addition, further investigation is needed to identify factors that can enhance access to mental health care services among Asians.     

Gender and Racial/Ethnic Differences in Use of Outpatient Mental Health and Substance Use Services by Depressed Adults

This study examines depressed adults’ use of mental health services, focusing on Latinos and African Americans. Self-report data for adults meeting CIDI criteria for major depression or dysthymia from the 1997–98 HealthCare for Communities Survey were analyzed. Gender stratified logistic regression models examined the relationship between race/ethnicity and outpatient mental health service use, controlling for sociodemographic, health status, insurance, and geographic characteristics. Latinas and African American women and men exhibited low use of outpatient mental health services. Similar results were observed in an insured subsample. Service use by minorities was more affected by financial and social barriers (e.g., stigma). No gender differences were observed in self-reported barriers to care. Concerted and continued efforts to promote access to mental health services are critical for minority men and women affected by depression; adults may have unmet mental health needs. Other vulnerable populations include older adults especially, men, and men in poor health.     

Differences in School-Based Referrals for Mental Health Care: Understanding Racial/Ethnic Disparities Between Asian American and Latino Youth

School-based mental health services (SBMHS) are thought to reduce access barriers and disparities in care. This study explores whether there is parity or disparity in SBMHS referral and receipt between two ethnic minority groups and identifies explanations for observed differences. Asian American and Latino students from one urban school district completed a mental health survey at the beginning of the 2010–2011 academic year assessing behavior problems and impairment. Information regarding SBMHS referral and receipt were obtained at end of the school year. Latino youth were more than 4 times more likely to be referred to SBMHS than Asian Americans. Differences in referral likelihood were partially mediated by externalizing problems, school bonding, impairment, and academic performance. However, a statistically significant direct effect of race/ethnicity remained to predict referral even after accounting for these factors. Following referral, no racial/ethnic differences were found in acceptance and receipt of treatment. These findings suggest that usual referral processes through SBMHS gatekeepers may still result in disparities in care despite equivalent access, with Asian Americans more likely to have needs unmet. However, once referred, Latino and Asian students appear to face few barriers in receiving care in schools.     

Treatment of culturally diverse children and adolescents with depression

This article is written for the practitioners treating depression in ethnic minority youth. It will review the context in which services are delivered to these youth: Researchers have recognized persistent ethnic differences in terms of utilization of services and unmet need. Furthermore, when ethnic minority youth do receive pediatric mental health care, the services that they receive may differ from those given to White patients. The reasons for these discrepancies have been examined in numerous studies, and have included contextual variables (economics, availability, and accessibility of services), patient variables (differences in prevalence or manifestation of the disorder, cultural beliefs and attitudes, preferential use of alternative or informal services, health literacy, and adherence), and provider variables (referral bias and patient-provider communication). Information about the differences between White and minority youth in the pharmacodynamics and pharmacokinetics of the antidepressant response is still limited. There are significant challenges for developing evidence-based guidelines that inform practice with these youth, hinging on both the underrepresentation of ethnic minority groups in clinical trials, and the great variability in biological and cultural characteristics of individuals in ethnic minority categories. Awareness on the part of the practitioner of the cultural variables that influence help-seeking and ongoing utilization of mental health services may aid in the engagement, effective treatment, and retention of ethnic minority children and adolescents with depression. However, given the great heterogeneity that exists within any cultural grouping, clinicians will need to integrate information about cultural patterns with that obtained from the individual patient and family to inform optimal practices for each patient. This article is written to enhance awareness on the part of the practitioner as to the variables that influence psychiatric care for depression in culturally diverse youth. The mental health needs of minority youth are not well served: They are treated less frequently, and when they are treated, the services they receive are less frequently adequate. The reasons that have been proposed for the disparities in their care, particularly with regard to diagnosis and treatment for depression, will be reviewed. They include contextual factors (such as economics, insurance, and other variables affecting the availability of services) patient and family factors (such as prevalence, symptom presentation, and values and beliefs that influence whether patients are referred to and avail themselves of services), and provider factors (such as referral bias and patient-provider communication, which affect whether patients engage and stay in treatment). The implications for the practitioner treating ethnic minority youth with depression will be discussed. Culture, as used in this article, refers to the common values, beliefs, and social behaviors of individuals with a shared heritage. Some aspects of culture that are likely to influence service utilization include health beliefs, particularly regarding models of mental illness, and level of stigma toward mental health treatment, which are frequently shared by individuals in a cultural group. However, some caveats for the explanatory potential of "culture" should be kept in mind. Conventions for naming groups vary between investigators and over time (e.g., the restriction of the category "White" into "White NonHispanic," is quite recent). Although heterogeneity is assumed within a named cultural or racial group, the terms Hispanic, Asian, and African-American incorporate subgroups can be very different in linguistic, historical, and geographical ancestry (e.g., Stewart 2008 ), and each group incorporates individuals who may not share any components of their historical heritage. Even among those with historical ties, values, beliefs, and social behaviors can vary according to the extent to which they identify with the mainstream culture. Social class frequently creates a "culture" of its own, with individuals in the same social class across traditional cultural groupings sharing disparities in care, and many beliefs and values. Individuals are likely to belong to numerous "cultures," and may not share specific typical behaviors or beliefs with any of them.     

Racial/Ethnic Differences in the Association Between Symptoms of Depression and Self-rated Mental Health Among Older Adults

The study examined racial/ethnic differences in the association between symptoms of depression and self-rated mental health among older adults. Data came from the first wave of the National Social Life, Health, and Aging Project, a population-based study of non-institutionalized older adults aged 57 to 85. The sample consisted of non-Hispanic Whites (n = 2,110), Blacks (n = 509), and Hispanics (n = 304). The association between symptoms of depression and self-rated mental health was weaker among minority groups than that among non-Hispanic Whites. Tests of interaction effects showed that the predictability of depressive symptoms to self-rated mental health was substantially weakened among Blacks of advanced ages and Hispanics with multiple chronic conditions. The study explored potential sources of racial/ethnic differences in subjective reports of mental health and called attention to older minorities with advanced ages and cormorbid conditions in mental health services and interventions.     

Attitudes toward mental health services: Age-group differences in Korean American adults

The present study examined the attitudes toward mental health services held by younger (aged 20–45, n = 209) and older (aged 60 and older, n = 462) groups of Korean Americans. Following Andersen's (1968; A behavioral model of families’ use of health service, Center for Health Administration Studies) behavioral health model, predisposing (age, gender, marital status and education), need (anxiety and depressive symptoms) and enabling (acculturation, health insurance coverage and personal experience and beliefs) variables were considered. In the mean-level assessment, younger and older adults were found to hold a similar level of positive attitudes toward mental health services. In the multivariate analysis, culture-influenced beliefs were shown to have a substantial contribution to the model of attitudes toward mental health services in both age groups. The belief that depression is a medical condition was found to be a common predictor of positive attitudes across the groups. In the older adult sample, more negative attitudes were observed among those who believed that depression is a sign of personal weakness and that having a mentally ill family member brings shame to the whole family. Our findings show that older adults are not only more subject to cultural misconceptions and stigma related to mental disorders, but also their attitudes toward service use are negatively influenced by the cultural stigma. The findings provide important implications for interventions targeted to improve access to mental health care among minority populations. Based on the similarities and differences found between young and old, both general and age-specific strategies need to be developed in order to increase effectiveness of these programs.     

Improving access to geriatric mental health services: a randomized trial comparing treatment engagement with integrated versus enhanced referral care for depression, anxiety, and at-risk alcohol use

OBJECTIVE: The authors sought to determine whether integrated mental health services or enhanced referral to specialty mental health clinics results in greater engagement in mental health/substance abuse services by older primary care patients. METHOD: This multisite randomized trial included 10 sites consisting of primary care and specialty mental health/substance abuse clinics. Primary care patients 65 years old or older (N=24,930) were screened. The final study group consisted of 2,022 patients (mean age=73.5 years; 26% female; 48% ethnic minority) with depression (N=1,390), anxiety (N=70), at-risk alcohol use (N=414), or dual diagnosis (N=148) who were randomly assigned to integrated care (mental health and substance abuse providers co-located in primary care; N=999) or enhanced referral to specialty mental health/substance abuse clinics (i.e., facilitated scheduling, transportation, payment; N=1,023). RESULTS: Seventy-one percent of patients engaged in treatment in the integrated model compared with 49% in the enhanced referral model. Integrated care was associated with more mental health and substance abuse visits per patient (mean=3.04) relative to enhanced referral (mean=1.91). Overall, greater engagement was predicted by integrated care and higher mental distress. For depression, greater engagement was predicted by integrated care and more severe depression. For at-risk alcohol users, greater engagement was predicted by integrated care and more severe problem drinking. For all conditions, greater engagement was associated with closer proximity of mental health/substance abuse services to primary care. CONCLUSIONS: Older primary care patients are more likely to accept collaborative mental health treatment within primary care than in mental health/substance abuse clinics. These results suggest that integrated service arrangements improve access to mental health and substance abuse services for older adults who underuse these services.     

Psychological symptoms among persons 50 years of age and older living with HIV disease

Although persons 50 years of age and older account for 10% of all US AIDS cases, the mental health needs of this growing group remain largely overlooked. The current study delineated patterns and predictors of psychological symptoms amongst late middle-aged and older adults living with HIV/AIDS in two large US cities. In late 1998, 83 HIV-infected individuals 50-plus years of age (M = 55.2, Range = 50-69) completed self-report surveys eliciting data on psychological symptomatology, HIV-related life-stressor burden, social support, barriers to health care and social services, and sociodemographic characteristics. Based on the Beck Depression Inventory, 25% of participants reported 'moderate' or 'severe' levels of depression. HIV-infected older adults also evidenced an elevated number of symptoms characteristic of somatization. A hierarchical multiple regression analysis revealed that HIV-infected older adults who endorsed more psychological symptoms also reported more HIV-related life-stressor burden, less support from friends, and reduced access to health care and social services due to AIDS-related stigma. As the impact of HIV on older communities continues to increase, geropractitioners must be prepared to provide care to greater numbers of HIV-infected older adults, a substantial minority of whom will present with complex comorbid physical and mental health conditions.     

Managed Care and Ethnic Minority Populations

Managed care in mental health has changed practice patterns and utilization with largely unknown consequences for ethnic minority populations. Managed care promotes oversight and continuity, but may inadvertently create barriers to access beyond those already apparent under fee-for-service. Capitation rewards efficiency and flexibility but may promote incentives that discourage minority inclusion. As mental health system reform proceeds, the need for culturally informed programs, practices, and practitioners has not diminished. The challenge is to bring cultural expertise to bear within new organizational arrangements and financing schemes.     

Unmet needs for services for older adults with mental illness: comparison of views of different stakeholder groups.

OBJECTIVE: The authors assessed the need for mental health services among older adults in San Diego County, California, by determining what needs were not being addressed by existing services, what services were necessary to address these needs, and how much consensus there was among different stakeholders with respect to the problems and solutions related to service delivery. METHODS: Semistructured interviews were conducted with 23 health care and social service providers and administrators, 16 services consumers and other older adults (55 years of age and older), and 19 caregivers/family members and patient/client advocates. This was followed by four focus groups comprised of 18 providers and administrators, six focus groups comprised of 50 consumers and other older adults, and five focus groups comprised of 39 caregivers (family members and advocates). RESULTS: The unmet needs fell into three categories: mental health services, physical health services, and social services. Two interrelated themes were identified by participants: 1) the need for age-appropriate and culturally appropriate services to overcome barriers to mental health services access, use, and quality; and 2) the interrelations between unmet needs that address prevention as well as treatment of mental illness, including socialization and social support, transportation, housing, and physical health care. Differences in stakeholder assessment of unmet needs were associated with respective roles in delivery and use of mental health services. CONCLUSION: Age-appropriate and culturally appropriate solutions that address both prevention and treatment may represent the best strategies for addressing the challenges of mental illness and are most likely to be endorsed by all three groups of stakeholders.     

Racial/Ethnic Differences in Parental Endorsement of Barriers to Mental Health Services for Youth

The present study investigated parental endorsement of barriers to care in a racially/ethnically diverse, at-risk sample of youth with mental health needs by testing the following hypotheses: (1) African American, Asian/Pacific Islander American, and Latino youth would have higher levels of unmet need compared to Non-Hispanic Whites (NHWs); (2) Parents of ethnic minority youth would report a greater number of barriers to mental health services for their children than would parents of NHWs; (3) The pattern of greater barrier endorsement by parents of ethnic minorities compared to parents of NHWs would persist across different barrier types; (4) Barrier endorsement would be related to unmet need for mental health services. As hypothesized, ethnic minority youth had higher levels of unmet need as compared to NHWs. However, despite this finding, parents of ethnic minority youth reported fewer barriers than did parents of NHWs, and this pattern generally persisted across barrier types. Furthermore, barrier endorsement was unrelated to unmet need. Post hoc analyses suggest the influence of cultural factors upon barrier endorsement, indicating the importance of taking such influences into account in future research on barriers to care.     

Caring for mental illness in the United States: a focus on older adults.

OBJECTIVE: The authors compared rates of common mental disorders and the use of primary care and specialty mental health services among younger and older adults. METHODS: They used data from 9,585 respondents to the HealthCare for Communities (HCC) Household Telephone Survey. Mental disorders during the past year, including depression, dysthymia, and generalized anxiety disorder, were identified with a short questionnaire. The survey also collected information about sociodemographic and insurance status, perceived need for mental health care, and use of health services. RESULTS: Older adults (age 65 and older) were significantly less likely than younger adults (18-29) or middle-aged adults (30-64) to meet diagnostic criteria for a mental disorder (8% versus 15% in each of the younger age-groups). Older adults who met diagnostic criteria for mental disorders were less likely to perceive a need for mental health care, to receive specialty mental health care or counseling, or to receive referrals from primary care to mental health specialty care than young or middle-aged adults. CONCLUSION: Few older adults with mental disorders use mental health services, particularly specialty mental health services. The lack of perceived need for mental health care may contribute to low rates of mental health service use among older adults.     

Public's view of mental health services for the elderly: responses to Dear Abby

The need for adequate mental health services for older adults is an increasingly urgent issue as the life expectancy of Americans continues to extend; yet there are unresolved questions regarding the public's perception of service needs. The Group for the Advancement of Psychiatry collaborated with advice columnist Jeannie Phillips of "Dear Abby" to invite public feedback on mental health services for the elderly. Feedback was invited on access to services as well as perceived need for improvement in the quality or quantity of those services. The effort resulted in 800 responses that identified three primary issues: problems in accessing care, inadequate detection of mental health conditions by general practitioners, and a need for more psychotherapy services. It is hoped that this Open Forum will stimulate discussion throughout the country for the benefit of older persons with mental health needs as the country grapples with changes to come after the passage of health care reform.     

Racial and ethnic disparities in pediatric mental health

Disparities remain in mental health status and care for racial and ethnic minority youth, despite national attention to disparity reduction. This article offers a comprehensive picture of the status of pediatric disparities, by addressing the major areas affecting minority youth mental health, including: prevention of problems, need for services, access to care, mental health treatment types, and treatment outcomes. The authors address relevant factors in the family, community and socioeconomic context, and describe various local and national programs that aim to tackle the obstacles and fill the gaps in high-quality care for racial/ethnic minority youth. The article concludes by offering recommendations for improvement that acknowledge the importance of understanding preferences and attitudes toward treatment, ensuring that screening and diagnosis is appropriate to minority youth, and ensuring that evidence-based programs are available at multiple levels to best service children and succeed in addressing their needs.     

Changes in Health Insurance Coverage and Barriers to Health Care Access Among Individuals with Serious Psychological Distress Following the Affordable Care Act

The Affordable Care Act (ACA) aims to expand health insurance coverage and minimize financial barriers to receiving health care services for individuals. However, little is known about how the ACA has impacted individuals with mental health conditions. This study finds that the implementation of the ACA is associated with an increase in rate of health insurance coverage among nonelderly adults with serious psychological distress (SPD) and a reduction in delaying and forgoing necessary care. The ACA also reduced the odds of an individual with SPD not being able to afford mental health care. Mental health care access among racial and ethnic minority populations and people with low income has improved during 2014–2016, but gaps remain.     

How well do older adults recognise mental illness? A literature review

Older adults tend to underutilise mental health services. Mental health literacy plays a critical role in identifying and overcoming barriers to accessing mental health care. The ability to recognise mental illness is an essential component of mental health literacy, with important implications to whether the person will seek professional help. We conducted a review of the literature on older adults’ abilities to recognise mental illness. Of the 421 papers that were retrieved in the comprehensive search in PubMed, 32 studies met inclusion criteria. Studies were heterogeneous in terms of target population and methodology, yet findings show that older adults are less likely to correctly recognise mental disorders. Cueing older participants with mental labels improved their recognition abilities. Recognition was particularly poor among immigrant and ethnic/racial older adults, likely due to linguistic and cultural barriers. Our findings demonstrate that older adults show low levels of mental illness recognition and tend to view some illnesses as normal parts of aging. Findings emphasise the need for developing educational programs tailored by the specific phenomenology, conceptualisations and cultural meanings of mental illness among older adults, with attention to informal sources of information and social networks.     

Does stigma keep poor young immigrant and U.S.-born Black and Latina women from seeking mental health care?

OBJECTIVE: This study examined the extent to which stigma-related concerns about mental health care account for the underuse of mental health services among low-income immigrant and U.S.-born black and Latina women. METHODS: Participants included 15,383 low-income women screened for depression in county entitlement services who were asked about barriers to care, stigma-related concerns, and whether they wanted or were getting mental health care. RESULTS: Among those who were depressed, compared with U.S.-born white women, each of the black groups were more likely to report stigma concerns (African immigrants, odds ratio [OR]=3.28, p=.004; Caribbean immigrants, OR=6.17, p=.005; U.S.-born blacks, OR=6.17, p=.06). Compared with U.S.-born white women, immigrant African women (OR=.18, p<.001), immigrant Caribbean women (OR=.11, p=.001), U.S.-born black women (OR=.31, p<.001), and U.S.-born Latinas (OR=.32, p=.03) were less likely to want treatment. Conversely, compared with U.S.-born white women, immigrant Latinas (OR=2.17, p=.02) were more likely to want treatment. There was a significant stigma-by-immigrant interaction predicting interest in treatment (p<.001). Stigma reduced the desire for mental health treatment for immigrant women with depression (OR=.35, p<.001) to a greater extent than it did for U.S.-born white women with depression (OR=.52, p=.24). CONCLUSIONS: Stigma-related concerns are most common among immigrant women and may partly account for underutilization of mental health care services by disadvantaged women from ethnic minority groups.     

‘They’re all depressed,aren’t they?’ A qualitative study of social care workers and depression in older adults

Statutory and voluntary social services provide care and support for vast numbers of vulnerable older adults, yet little is known about how social care practitioners respond to depression in this high risk population. This study elicited the perceptions and conceptualizations of this condition among social care staff, and views on how the response of social care and other agencies might be improved. Qualitative interviews were conducted with 20 social care practitioners working in generic services for older adults in south London. Depression was perceived to be remarkably common among clients, a phenomenon largely attributed to the adverse circumstances of old age, particularly social isolation. A key message from participants was that social causes indicate a need for social interventions. While primary care was criticised for not taking depression seriously in older people, mental health services were generally praised. Expansion of social, recreational and psychological interventions was advocated.