Mental health problems in children and young people from minority ethnic groups: the need for targeted research

In this editorial we argue for the need for better research evidence on the prevalence of child mental health problems in minority ethnic groups, service utilisation among these groups and whether some service barriers are specific for certain groups. Without such evidence it is not possible to influence policy and practice so that evidence-based and appropriate services can be designed and offered to these populations. The terms ethnicity, race and migration are often imprecisely defined, and mental health needs and outcomes vary between immigrants from different generations. There is also a complex interplay between minority status and social class, with terms such as ethnicity being a proxy for multifaceted sociocultural and economic variables. However, we need to start collecting better data on children from minority ethnic groups so that these relationships can be understood, services tailored on the available evidence and ultimately better care delivered to this group of children.     

Ethnic Minority Elders in the UK

This article looks at the current literature on minority ethnic elders and mental health problems in the UK. It raises fundamental problems in definition, since the literature contains great variations in definitions of ethnicity and old age. It relates issues concerning ethnicity with gender, geography and family structure. In the second part of the article, the authors review the influential theory of triple jeopardy and discuss the interplay of views about cultural factors and medical responses to health and illness in this context. Communication is used as an example of a commonly held problem but it is argued that language problems are often over-simplified and over-generalized. The authors consider broad questions of access to psychiatric services for minority ethnic elders, then focus on diagnostic difficulties with dementia and depression to illustrate particular problems. The article concludes that there is a general lack of research from the UK about ethnic elders and mental health, in particular about coping strategies and strengths among individuals, families and communities. The authors argue that attention to definitions may also be fruitful for policy-makers and researchers.     

Examining Racial/Ethnic Minority Treatment Experiences with Specialty Behavioral Health Service Providers

This study investigated whether satisfaction and helpfulness of treatment by mental health service provider is related to race/ethnicity and psychosocial factors. Data from the National Co morbidity Survey-Replication study, which administered mental health service use questions for the past 12-months (1332), was analyzed. Data were stratified by service provider and analyzed with multiple logistic regressions. Racial/ethnic minorities were generally more likely to be satisfied with services provided by specialty mental health providers compared to white respondents. Racial/ethnic minorities generally perceived the services provided by specialty mental health providers as more helpful than did other racial/ethnic groups. Those who reported high cultural identity were more likely to find their treatment experience less satisfying and less helpful. Greater attention to specialty referrals for racial/ethnic minority groups may fruitfully contribute to improve help-seeking for these groups. The role culture plays in shaping the mental health treatment experience needs to be further investigated.     

Patterns and Predictors of Mental Healthcare Utilization in Schools and Other Service Sectors Among Adolescents at Risk for Depression

This study examined racial/ethnic and socioeconomic differences in service utilization across sectors (specialty mental health, school, primary care) for youth at risk for depression. Our sample included 362 adolescents who were enrolled in a larger project examining the effects of an indicated school-based depression prevention program. Service use across sectors mirrored national trends and previous research findings in which the education sector was most frequently utilized for mental health services. Race/ethnicity was significantly associated with parent-reported specialty mental health service utilization, even when controlling for other predictors of use. The study also suggests that racial disparities in service access generally appear to be reduced through the availability of education sector mental health services. Socioeconomic status was not associated with service use in any sector when controlling for other predictors. Parent–child agreement was moderate for report of specialty mental health service use and low for report of use of services within the education and primary care sectors.     

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.     

Unmet need for mental health care among U.S. children: variation by ethnicity and insurance status

OBJECTIVE: Policy discussions regarding the mental health needs of children and adolescents emphasize a lack of use of mental health services among youth, but few national estimates are available. The authors use three national data sets and examine ethnic disparities in unmet need (defined as having a need for mental health evaluation but not using any services in a 1-year period) to provide such estimates. METHOD: The authors conducted secondary data analyses in three nationally representative household surveys fielded in 1996-1998: the National Health Interview Survey, the National Survey of American Families, and the Community Tracking Survey. They determined rates of mental health service use by children and adolescents 3-17 years of age and differences by ethnicity and insurance status. Among the children defined as in need of mental health services, defined by an estimator of mental health problems (selected items from the Child Behavior Checklist), they examined the association of unmet need with ethnicity and insurance status. RESULTS: In a 12-month period, 2%-3% of children 3-5 years old and 6%-9% of children and adolescents 6-17 years old used mental health services. Of children and adolescents 6-17 years old who were defined as needing mental health services, nearly 80% did not receive mental health care. Controlling for other factors, the authors determined that the rate of unmet need was greater among Latino than white children and among uninsured than publicly insured children. CONCLUSIONS: These findings reveal that most children who need a mental health evaluation do not receive services and that Latinos and the uninsured have especially high rates of unmet need relative to other children. Rates of use of mental health services are extremely low among preschool children. Research clarifying the reasons for high rates of unmet need in specific groups can help inform policy and clinical programs.     

A method for estimating underutilization of mental health services by ethnic groups

Most studies of utilization of mental health services by ethnic groups have used parity as a measure of whether members of ethnic groups are receiving a fair share of services. The level of services is assumed to be adequate if the percentage of ethnic group members in the treatment population is the same as the group's percentage in the general population. However, service planning based on achieving parity fails to consider whether some groups have higher levels of need than others. The authors describe a method for more accurately projecting service needs of minority groups based on population data and on sample surveys of needs. The results help define more equitable service goals for all population groups.     

Exploring the Relationship Between Race/Ethnicity,Age of First School-Based Services Utilization,and Age of First Specialty Mental Health Care for At-Risk Youth

This study investigated race/ethnic variations in age of entry into school-based services and specialty mental health outpatient services among 1552 high-risk youths served in a publicly funded system of care. Non-Hispanic White youths were more likely to receive school-based services as compared to ethnic minority groups, and to begin use at an earlier age. In addition, the earlier a child was identified for school-based services, the earlier the child first utilized specialty outpatient mental health services. Multiple regression models showed that inclusion of race/ethnicity as a predictor significantly increased the overall variance explained in the model predicting age of first school-based services, and both race/ethnicity and first use of school-based services increased the overall variance explained in the model predicting age of first specialty mental health outpatient service use. The results suggest that involvement in school-based services may play an important role in facilitating specialty outpatient mental health service use for youths.     

Ethnic factors in mental health service utilisation among people with intellectual disability in high-income countries: systematic review

Background An emerging literature suggests that ethnic and cultural factors influence service utilisation among people with intellectual disability (ID), but this has not previously been reviewed. Aims To investigate possible ethnic variation in uptake of mental health services in children, adolescents and adults with ID in high‐income countries. Method A systematic review using main databases of studies that consider ethnic influences on mental health utilisation of people with ID. Methodological quality of studies was assessed. Results Nine studies that reached selection criteria were identified. Six studies that compared two or more ethnic groups found a variation in levels of mental health service utilisation. The most consistent finding was that South Asian children, adolescents and adults with ID in the UK had lower use of mental health services than White British comparison groups. Conclusion Ethnic influences on mental health service utilisation were identified. Understanding their significance and potential negative consequences requires further investigation.     

Engaging an Asian Immigrant Older Adult in Depression Care: Collaborative Care,Patient-Provider Communication and Ethnic Identity

Minority older adults face multiple barriers when trying to access mental health services and often present with more severe symptoms of mental health conditions. We describe the multilevel factors that contributed to the engagement of an Asian immigrant older adult with depression. Systems-level innovations such as collaborative care in primary care can increase access to care for all, including minority older adults; however, one size fits all interventions may not meet the needs of communities of older adults with different life experiences, language needs, norms and values regarding help-seeking for mental health. Health outcomes remain unequal , suggesting the need to tailor interventions for minority older adults. For the patient, specific factors related to language and ethnic concordance between patient and healthcare provider, communication behaviors, ethnic identity, and social norms may be important to take into account. The recognition of the heterogeneity of patients and the limitations of cultural competence approaches defined as broad, general knowledge about ethnic cultures may be needed. A need to learn continuously from clinical experience and adopt a patient-oriented model of communication and decision-making may successfully engage Asian immigrant older adults in depression care services.     

Factors associated with adolescent mental health service need and utilization

OBJECTIVE: To determine the association of parent, family, and adolescent variables with adolescent mental health service need and utilization. METHOD: Correlates of adolescent mental health service utilization, self-perceived need and unmet need were investigated in a general population sample of 1,120 Dutch adolescents aged 11 to 18 years (78% response rate). RESULTS: 3.1% of the sample had been referred for mental health services within the preceding year, and 3.8% reported unmet need. 7.7% of adolescents at risk for psychopathology, and 17.8% of those indicating a need for help, had been referred. Family stress and adolescent's self-reported problems were most strongly associated with service need and utilization. Internalizing problems, female gender, and low education level were associated with self-perceived unmet need. Adolescent ethnicity and competence in activities and school were associated with service use, but did not influence service need, while the opposite effect was found for adolescent age and parental psychopathology. CONCLUSION: In designing intervention programs aimed at increasing adolescent mental health service use, distinctions should be made between efforts focused at adolescents not recognizing their problems, and those with unmet need.     

Barriers to mental health care for Hispanic Americans: a literature review and discussion

The Hispanic American population, the second largest and fastest growing minority population in the United States, faces barriers to access to both medical health and mental health care. This paper examines both financial and cultural barriers to utilization of mental health care services; it is a broad review of the literature and is not intended to be comprehensively detailed. The research review suggests that the financial barrier is a major determinant of mental health service access for Hispanic American populations. Also, nonfinancial barriers such as acculturation are examined. A two-part plan is suggested to reduce both financial and nonfinancial barriers. Very little literature on utilization of substance abuse services was found; suggestions for further research are thus proposed.     

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.     

EPA guidance on building trust in mental health services

PurposeTo advance mental health care use by developing recommendations to increase trust from the general public and patients, those who have been in contact with services, those who have never been in contact and those who care for their families in the mental health care system.MethodsWe performed a systematic literature search and the retrieved documents were evaluated by two independent reviewers. Evidence tables were generated and recommendations were developed in an expert and stakeholder consensus process.ResultsWe developed five recommendations which may increase trust in mental health care services and advance mental health care service utilization.DiscussionTrust is a mutual, complex, multidimensional and dynamic interrelationship of a multitude of factors. Its components may vary between individuals and over time. They may include, among others, age, place of residence, ethnicity, culture, experiences as a service user, and type of disorder. For mental health care services, issues of knowledge about mental health services, confidentiality, continuity of treatment, dignity, safety and avoidance of stigma and coercion are central elements to increase trust.ConclusionEvidence-based recommendations to increase mutual trust of service users and psychiatrists have been developed and may help to increase mental health care service utilization.     

Usefulness of the construct of social network to explain mental health service utilization by the maori population in new zealand

This article briefly reviews the literature on the relationship between social network and mental health, and presents a theoretical framework outlining the role social networks may play in explaining the differential mental health service utilization rates between Maori and European people of New Zealand. By buffering individuals from the ill effects of stressful events, social networks may have a protective effect on people's mental health. In addition, social networks influence the way people with mental illnesses use mental health services. An inverse relationship between the size of an individual's social network and the rate of utilization of in-patient services has been reported. Despite having a larger and presumably more supportive social networks, Maori are over-represented in mental health service utilization statistics. Using the Maori example, we demonstrate that ethnic differences exist in the structure of social networks and the provision of social support to their members. Such differences may be based on the degree of emphasis placed on kinship or on individualism by cultures and on the receptivity or prejudice of the host community. We examine the sources of stress on Maori social networks that may adversely affect the network's ability to support its members experiencing mental illnesses. Caution must be exercised in using service utilization rates as measures of the mental health needs of different ethnic groups because of problems with help seeking and the detection of mental health issues in different ethnic groups.     

Socioeconomic status, ethnicity, psychological distress, and readiness to utilize a mental health facility

The effects of minority status versus ethnic culture on Mexican-Americans' underutilization of mental health services were reassessed through development and testing of an analytic path model that proposes a sequence of factors, including Mexican-American ethnicity, socioeconomic status, degree of social and institutional support, and depression, which culminate in a person's decision to utilize mental health facilities. The model also predicts that life stress will affect utilization through its influence on depression. Data from 783 subjects generally supported the model's predictions. A multifactorial approach to the causes of mental health problems and utilization behavior in the Mexican-American population is suggested.     

Children's mental health services and ethnic diversity: Gujarati families' perspectives of service provision for mental health problems

The aim of this study was to explore Gujarati parents' and adolescents' perceptions of child and adolescent mental health services and how these should be improved to best meet their needs. Semi-structured qualitative interviews were carried out with 15 parents and 15 young people, recruited from a community centre. Overall, the quality of the service appeared more important than its responsiveness to culture or ethnicity for both young people and their parents. These findings indicate the need for further evidence and debate on whether Black and ethnic minority families should be treated as though they are a homogenous group.     

Predictors of mental health services use among lesbian and heterosexual women

Studies examining mental health services have identified a series of indicators with demonstrated effects on services access, barriers, and utilization, including gender, race/ethnicity, and socioeconomic status, as well as indicators such as type of insurance, client attitudes toward mental health, and diagnosis. This study identifies predictors of mental health services utilization in a diverse community sample of lesbians and heterosexual women (N=120). Outcomes for study participants are compared to those found in the services utilization literature, and similarities and differences among lesbians and heterosexual women are examined. Suggestions are offered for identifying new factors in mental health service utilization among groups with diverse sexual orientations.     

Consumer and Family Views on Evidence-Based Practices and Adult Mental Health Services

Evidence-based practice (EBP) is an important construct in mental health services. Though much has been written about them, there is little in the literature that fully explores consumers’ and family members’ views regarding EBPs. Using a focus group methodology, this study asked the question “What are consumers’ and family member’s views of EBPs within the larger context of their mental health service needs and their experiences with the mental health service system?” Results indicate that consumers and families have limited knowledge of EBPs, are generally supportive of EBPs, but have questions and concerns that are grounded in systemic and contextual considerations.