Cultural barriers to mental health care delivery in Alaska

Geographically diverse providers from all mental health disciplines attended a recent conference in Anchorage and discussed cultural barriers to the delivery of mental health care in Alaska. Based on their knowledge, experience, and perceptions, this article describes barriers contributed by the mental health care delivery system as well as those contributed by the American Indian and Alaska Native cultures. American Indians and Alaska Natives are experiencing deculturation, outmigration, alienation, distrust, and despair. The difficulties at the interface between Alaskan mental health care providers and consumers indigenous to Alaska have implications for administrative and clinical endeavors in culturally diverse settings elsewhere. Progress in this area will require special administrative skills.     

Tewa children who have epilepsy: a health care dilemma

This paper explores the part ethnicity may play in utilization of available western health care methods by Tewa families who have a child with epilepsy. Suggestions are made for appropriate responses by non-Indian health care providers to Tewa patients with epilepsy and their families. Findings indicate that, on the surface, Tewa families behave much like other Americans generally in utilization of western health care services. However, the Tewa are extremely reluctant to discuss with non-Indian health care providers traditional healing practices that may be used simultaneously. Such reluctance is well-documented in literature on the Tewa Pueblos and is substantiated in the present research. Suggestions are made for health care providers who wish to be "culturally aware" about the appropriateness of routinely asking a patient about his or her perception of the traditional etiology of the disease. The roles of the family and the western health care system are challenged. The response of Tewa extended families to children who have epilepsy is complex and not necessarily supportive. Often considered the primary health care provider for Native Americans, the Indian Health Service is based on an acute care model and lacks the ability to serve chronically disabled American Indian children. Finally, the paper argues that epilepsy is varied enough to complicate the development of a single model of chronic illness that is appropriate for those who suffer from the disability.     

Contact with mental health and primary care providers before suicide: a review of the evidence

OBJECTIVE: This study examined rates of contact with primary care and mental health care professionals by individuals before they died by suicide. METHOD: The authors reviewed 40 studies for which there was information available on rates of health care contact and examined age and gender differences among the subjects. RESULTS: Contact with primary care providers in the time leading up to suicide is common. While three of four suicide victims had contact with primary care providers within the year of suicide, approximately one-third of the suicide victims had contact with mental health services. About one in five suicide victims had contact with mental health services within a month before their suicide. On average, 45% of suicide victims had contact with primary care providers within 1 month of suicide. Older adults had higher rates of contact with primary care providers within 1 month of suicide than younger adults. CONCLUSIONS: While it is not known to what degree contact with mental health care and primary care providers can prevent suicide, the majority of individuals who die by suicide do make contact with primary care providers, particularly older adults. Given that this pattern is consistent with overall health-service-seeking, alternate approaches to suicide-prevention efforts may be needed for those less likely to be seen in primary care or mental health specialty care, specifically young men.     

Mental health services for American Indians and Alaska Natives: need, use, and barriers to effective care.

This special review summarizes and illustrates the state of our knowledge regarding the mental health needs of American Indians and Alaska Natives. These needs are considerable and pervasive. The discussion begins by reflecting on the limits of psychiatric nomenclature and conceptual frameworks for revealing Native constructions of mental health and mental illness. The experience and manifestation of psychopathology can be both different and the same across cultures, hinging upon the extent to which such basic assumptions as the relationship of mind to body--and spirit in the case of Native people--or the primacy of the individual or social collective are shared. Having set the stage, this paper moves to recent empirical evidence regarding the mental health needs of American Indians and Alaska Natives: we review that evidence and consider it within the broader context of available services. The report closes with a brief overview of the most pressing issues and forces for change afoot in Indian country in the US. Most have to do with the structure and financing of care as tribes and other Native community-based organizations seek to balance self-determination and resource management to arrive at effective, fiscally responsible, culturally informed prevention, treatment, and aftercare options for their members. These changes may herald similar trends among First Nations people to the immediate north.     

Brief reports: Unequal treatment: mental health care for sexual and gender minority groups in a rural state

OBJECTIVE: This qualitative study examined the social dynamics of communities and clinic settings that impede the delivery of culturally relevant services to lesbian, gay, bisexual, and transgender (LGBT) people living in rural areas. METHODS: Ethnographic interviews were conducted with 20 providers in rural areas to document their perceptions of LGBT mental health care. RESULTS: A majority of rural providers claimed that there is no difference between working with LGBT clients and non-LGBT clients. This neutral therapeutic posture may be insufficient when working with rural LGBT clients. Despite providers' claims of acceptance, lack of education about LGBT mental health issues, and homophobia influenced services for rural LGBT people. LGBT clients had been denied services, discouraged from broaching sexuality and gender issues by providers, and secluded within residential treatment settings. CONCLUSIONS: The challenges of ensuring access to quality care for this population are magnified by provider discourses of "therapeutic neutrality."     

Challenges to the recognition and assessment of Alzheimer's disease in American Indians of the southwestern United States

Little is known about Alzheimer's disease (AD) and related neurodegenerative diseases in American Indian (AI) populations. To provide appropriate health care to elder AIs, whose population is expected to increase dramatically during the next 50 years, it is imperative to attain a better understanding of the interaction of culture and disease in this underserved population. Raising awareness in the AI population regarding the nature of dementia as it compares to normal aging and the development of culturally appropriate instruments to detect and stage AD are essential for future health care efforts. Barriers restricting clinical service to this population include historical factors relating to access to health care, cultural beliefs regarding aging, demographic diversity of the population, competing epidemiologic risk factors, and lack of proper assessment tools for clinicians.     

Barriers to Providing Effective Mental Health Services to American Indians

Like most indigenous populations throughout the world who have undergone innumerable cultural changes, the mental health care needs of American Indians are great. Some surveys conducted by the Indian Health Service show high rates of suicide, mortality, depression and substance abuse. Little is known about effective mental health care among American Indians due, in part, to the lack of culturally appropriate models of mental health in American Indians. This article presents a cultural framework in order to understand the mental health care needs of American Indians and discusses barriers to providing effective mental health services to American Indians.     

Mental health experiences and needs among primary care providers treating OEF/OIF veterans: preliminary findings from the Geisinger Veterans Initiative

This study describes the results of the Reaching Rural Veterans Initiative (RRVI) funded by the Commonwealth of Pennsylvania and the Federal Government. The purpose of this project was to address the needs of veterans and their family members in rural communities who were seen by non-VA primary care providers. As part of this project, an assessment of healthcare providers' knowledge and awareness of mental health-related issues and experiences with veterans' healthcare services was conducted. Following this assessment, an education program was developed and implemented at primary care sites within the Geisinger Health System and also made available to other area providers. The survey indicated that Geisinger's primary care providers are currently involved with providing mental health care to area service members and their families. It was estimated that these providers saw about 1,200 Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) patients and 3,600 of their family members in clinics over a 6 month period. A significant number of these persons had mental health problems. About two-thirds (65.4%) of providers reported having a mental health professional onsite and nearly 23% reported that over one-third of their patients have mental health problems. Significant mental health gaps discovered indicated that providers lacked knowledge of PTSD and other combat-related stress disorders, as well as knowledge of VA resources. In addition only 20% of the providers rated their mental health treatment skills as high and only about 8% reported that they had adequate knowledge of current mental health treatment strategies. Based on this needs assessment and the results of the provider intervention, further service improvements are planned.     

Lives in Isolation: Stories and Struggles of Low-income African American Women with Panic Disorder

Research evidence points to the existence of racial-ethnic disparities in both access to and quality of mental health services for African Americans with panic disorder. Current panic disorder evaluation and treatment paradigms are not responsive to the needs of many African Americans. The primary individual, social, and health-care system factors that limit African Americans' access to care and response to treatment are not well understood. Low-income African American women with panic disorder participated in a series of focus-group sessions designed to elicit (1) their perspectives regarding access and treatment barriers and (2) their recommendations for designing a culturally consistent panic treatment program. Fear of confiding to others about panic symptoms, fear of social stigma, and lack of information about panic disorder were major individual barriers. Within their social networks, stigmatizing attitudes toward mental illness and the mentally ill, discouragement about the use of psychiatric medication, and perceptions that symptoms were the result of personal or spiritual weakness had all interfered with the participants' treatment seeking efforts and contributed to a common experience of severe social isolation. None of the focus-group members had developed fully effective therapeutic relationships with either medical or mental health providers. They described an unmet need for more interactive and culturally authentic relationships with treatment providers. Although the focus-group sessions were not intended to be therapeutic, the women reported that participation in the meetings had been an emotionally powerful and beneficial experience. They expressed a strong preference for the utilization of female-only, panic disorder peer-support groups as an initial step in the treatment/recovery process. Peer-support groups for low-income African American women with panic disorder could address many of the identified access and treatment barriers.     

Mental health care of Filipino Americans

Filipino Americans are the second-fastest-growing Asian immigrant group in the United States, following the Chinese. Yet there exists a dearth of information on mental health issues concerning Filipino Americans, who represent a diverse mixture of culture, beliefs, and practices and vary widely from other minorities as well as from the larger population. This group has experienced emotional and behavioral challenges in acclimatizing to Western culture. Their historical underpinnings, native core values, and traditions exert a crucial influence on their mental well-being. Filipino Americans underutilize existing mental health care services that are culturally, socially, and linguistically incompatible with their needs. Along with stigma, the adherence of traditional practices and healing methods remains a formidable barrier to the appropriate provision of care. The authors review factors influencing perceptions of mental health and illness, including religion, family, support systems, coping styles, and indigenous culture-bound traits. Recommendations for treatment consist of a structured, culturally sensitive, comprehensive approach that addresses the individual as well as the cultural milieu.     

Ethnic/Racial diversity and posttraumatic distress in the acute care medical setting

Recent commentary has advocated for epidemiological investigation as a foundational science for understanding disparities in the delivery of mental health care and for the development of early trauma-focused interventions. Few acute care investigations have examined the diversity of ethnic/racial heritages or compared variations in early posttraumatic distress in representative samples of injured trauma survivors. Hospitalized injury survivors at two United States level I trauma centers were randomly approached in order to document linguistic and ethnic/racial diversity. Approximately 12% of patients approached were non-English speaking with 16 languages represented. English speaking, inpatients were screened for posttraumatic stress disorder, peritraumatic dissociative, and depressive symptoms. For 269 English speaking study participants, ethnic/racial group status was clearly categorized into one group for 72%, two groups for 25%, and three groups for 3% of participants. Regression analyses that adjusted for relevant clinical and demographic characteristics revealed that relative to whites, patients from American Indian, African American, Hispanic, and Asian heritages demonstrated significant elevations in one or more posttraumatic symptom clusters. A remarkable diversity of heritages was identified, and posttraumatic distress was elevated in ethnic/racial minority patients. Policy-relevant clinical investigations that combine evidence-based treatments, bilingual/bicultural care-management strategies, and support for trauma center organizational capacity building may be required in order to enhance the quality of mental health care for diverse injured trauma survivors.     

A doubtful guest: managed care and mental health

This article examines the ways in which mental health services have been affected by managed care and describes how to address some of the ethical conflicts that have always existed, but have been transformed immeasurably. It outlines the ethical dilemmas between the competing values of mental health providers and managed care, as well as the practical ethical considerations related to confidentiality, billing, and coding. It suggests that there can be no real improvement for mental health providers in the ethical minefield of managed care until they stop focusing on how distressed they are about it and start dealing with the larger, systemic issues in psychiatry and American health care. The article concludes by noting that the only way to effect meaningful change in the health care system is to combine knowledge with advocacy and to proactively define the standards needed to make the necessary choices.     

Demand for,access to and use of community mental health care: lessons from a demonstration project in India and Pakistan

BACKGROUND: A widely promoted model of mental health care and prevention appropriate to many low-income countries is one that is integrated into the local primary health care system. AIMS: To examine the influence of health-seeking behaviours (demand-side factors) and the access to/availability of services (supply-side factors) on local service utilisation patterns for people with common mental disorders. METHOD: Two rural catchment populations outside Bangalore (India) and Rawalpindi (Pakistan), one with the standard primary health care system, the other with additional mental health care training and support, were screened for common mental disorders. Diagnosed cases were interviewed about their use of and perceptions of local health care services (repeated three months later). RESULTS: Individuals' use of integrated mental health and other care was modest. Principal (self-rated) supply-side factors were the cost of care, distance from treatment centre, a perception that care would not be effective, and concerns regarding stigma. Perceptions improved over three months, accompanied by an increased preference for public over private providers, but this was not restricted to the integrated care localities. CONCLUSION: The use (and therefore effectiveness) of mental health services integrated into primary care is influenced by the health-seeking behaviours and perceptions of the local population. Efforts to integrate mental health into primary care need to be accompanied by educational activities in order to increase awareness, reduce stigma and draw attention to the availability of effective treatment.     

Culture and the organization of psychiatric care.

Health care systems of the 21st century confront the confluence of two important forces that conform their policies regarding culture. On the one hand, population demographics announce increasing diversity; on the other, a rising knowledge base regarding the impact of culture on mental health awaits to be incorporated into actual clinical practices nationwide. As regulators and payors incorporate this knowledge into their practices, standards and guidelines, the dream of mental health cultural parity will come somewhat closer to fulfillment. In this article, we have aimed to review how the integration of developing knowledge and evolving standards may contribute to such fulfillment.     

Some distinctive features of the impact of managed care on psychiatry

Past research suggests that the spread of managed care is affecting the treatment of mental and physical illnesses differently. This article develops six hypotheses that could explain the differential effects of managed behavioral health care, based on characteristics of mental disorders, professional norms of treatment, and the broader societal consequences of untreated mental illness. Using data from the 1998 Socioeconomic Monitoring System fielded by the American Medical Association, we tested these hypotheses by comparing the experiences of psychiatrists under managed care with those of primary care providers and medical specialists. We found the following: (1) psychiatrists face substantially more aggressive external review than do primary care providers and are less successful in overturning denials; (2) psychiatrists feel significantly more at risk for disaffiliation from health plans; (3) psychiatrists report facing review protocols that are more confusing than those for primary care physicians, but psychiatrists' staff spend less time on external review; (4) psychiatrists are more likely than other physicians to report that their patients have difficulty making informed choices about managed care; and (5) psychiatrists evidence greater time commitment to advocacy on behalf of their patients with respect to managed care.     

A qualitative study of barriers to mental health services utilisation among migrants from mainland China in south-east Sydney

BACKGROUND: Chinese-language speakers comprise the largest non-English speaking population in Australia but they have among the lowest rates of mental health services utilisation. MATERIAL: A bilingual (Mandarin/English) researcher conducted in-depth interviews with China-born mental health patients and members of the general community, and mental health service providers. DISCUSSION: Participants identified several factors that limit access to mental healthcare as well as the quality of care received: mental health literacy, communication difficulties, stigma, confidentiality concerns, service constraints and discrimination. Cross-cultural communication was not just a matter of hearing individual words but also appreciating idioms and cultural and social references. CONCLUSION: Findings have implications for the prevention and treatment of mental disorders among migrants from China, and caution against assuming heterogeneity within ethnic groups. Mental health services must become more culturally competent in their attempts to engage the target group and to deliver both acute and continuing care.     

Metabolic adverse events in patients with mental illness treated with antipsychotics: a primary care perspective

Background: Individuals with mental illness are at a higher risk of medical mortality than the general population, primarily due to an increased risk of cardiovascular disease. There are a number of modifiable metabolic risk factors associated with some atypical antipsychotics that warrant careful monitoring and treatment in both psychiatric and primary care practice if the risk of cardiovascular disease is to be effectively reduced.Data Sources: Previous guidelines have focused on awareness of metabolic risk factors in psychiatry, yet few articles have appeared in the primary care-focused journals. We present pragmatic guidelines that focus on monitoring metabolic abnormalities in primary care based on established guidelines, including joint recommendations of the American Diabetes Association, the American Psychiatric Association, the American Association of Clinical Endocrinologists, and the North American Association for the Study of Obesity, and the Mount Sinai conference.Data Synthesis: All patients receiving atypical antipsychotic agents associated with metabolic adverse events should be routinely monitored for weight gain and abnormalities in blood glucose and lipid levels. Effective communication and collaboration between mental health and primary care services and better access to primary care screening and treatment for individuals with mental health problems are needed.Conclusion: There is a clear need for awareness among primary care physicians, particularly as metabolic effects of atypical antipsychotics such as blood pressure and glucose and lipid levels are possibly best monitored in a primary care setting.     

Culturally Competent Systems of Care for Children’s Mental Health: Advances and Challenges

There has been a remarkable growth in cultural diversity in the United States over the past 20 years. The population of minority groups has increased at a much faster rate than the European-background population in America, and faster even among children and youth. At the same time, minority youth face increasing disparities in their mental health and in access to mental health services. These are related to the multiple challenges they already face in socioeconomic status, but are aggravated by the lack of culturally competent services that can address their specific mental health needs within the context of their culture, family, and community. This paper reviews the current knowledge about the mental health of culturally diverse youth in the United States, and provides guidance on approaches to address the disparities they face.     

Coming to terms with ADHD: how urban African-American families come to seek care for their children

OBJECTIVE: This study investigated how parents' interpretations of their child's disruptive or inattentive behaviors led them to seek medical care that resulted in a diagnosis of attention-deficit hyperactivity disorder (ADHD). METHODS: Qualitative, semistructured telephone interviews were conducted with parents of children who had been newly diagnosed as having ADHD (96% of the children were African American). The 26 participants were recruited from primary care, developmental and behavioral, and specialty mental health pediatric clinics affiliated with a large, urban teaching hospital. The analysis followed a grounded theory approach. RESULTS: By the time that parents sought treatment for their child's ADHD, they had been through an extensive process to pinpoint their child's problems. Parents' conceptualizations emerged as they described their child's behavior, explained the situation, described how ADHD affected their children, and explained how they sought answers. Their reactions to the behavior and visions they had for their child's future reflected their motivation to manage the situation. Parents' conceptualization and management of the behaviors described the process of coming to terms with their child's ADHD and the need for care. Four distinct patterns describing this process emerged from the analysis: immediate resolution, pragmatic management, attributional ambivalence, and coerced conformance. CONCLUSIONS: It is likely that clinicians' awareness of the different approaches by which families come to the decision to seek care for their child's ADHD will allow clinicians to provide more responsive care and better tailor interventions to improve therapeutic outcomes for children receiving mental health treatments.