New Freedom Commission
President's New Freedom
Achieving the Promise: Transforming Mental Health Care in America
Goal 3: Disparities in Mental Health Services Are Eliminated
3.1 Improve access to quality care that is culturally competent.
3.2 Improve access to quality care in rural and geographically remote areas.
Understanding the Goal
Minority Populations Are Underserved in the Current Mental Health System
Racial and ethnic minority Americans comprise a substantial and vibrant segment of the U.S. population, enriching our society with many unique strengths, cultural traditions, and important contributions. As a segment of the overall population, these groups are growing rapidly; current projections show that by 2025, they will account for more than 40% of all Americans.102
Unfortunately, the mental health system has not kept pace with the diverse needs of racial and ethnic minorities, often underserving or inappropriately serving them. Specifically, the system has neglected to incorporate respect or understanding of the histories, traditions, beliefs, languages, and value systems of culturally diverse groups. Misunderstanding and misinterpreting behaviors have led to tragic consequences, including inappropriately placing minorities in the criminal and juvenile justice systems.
While bold efforts to improve services for culturally diverse populations currently are underway, significant barriers still remain in access, quality, and outcomes of care for minorities. As a result, American Indians, Alaska Natives, African Americans, Asian Americans, Pacific Islanders, and Hispanic Americans bear a disproportionately high burden of disability from mental disorders. This higher burden does not arise from a greater prevalence or severity of illnesses in these populations. Rather it stems from receiving less care and poorer quality of care.16
The mental health system has not kept pace with the diverse needs of racial and ethnic minorities, often underserving or inappropriately serving them.
Receiving appropriate mental health care depends on accurate diagnosis. Racial and ethnic minorities' higher rates of misdiagnosis may contribute to their greater burden of disability. For instance, African Americans are more likely to be overdiagnosed for schizophrenia and under-diagnosed for depression.16 To compound this problem, physicians are less likely to prescribe newer generation antidepressant or antipsychotic medications to African American consumers who need them.103
The report, Mental Health: Culture, Race and Ethnicity, A Supplement to Mental Health: A Report of the Surgeon General, highlighted striking disparities in mental health services for racial and ethnic minority populations. For example, these populations:
Are less likely to have access to available mental health services,
Are less likely to receive needed mental health care,
Often receive poorer quality care, and
Are significantly under-represented in mental health research.16
Minorities Face Barriers to Receiving Appropriate Mental Health Care
Although many barriers deter minority populations from accessing and receiving proper treatment, some barriers are shared by all populations. For instance, all populations with mental disorders are affected by fragmented services, unavailable services, and high costs, as well as societal stigma.
However, additional barriers prevent racial and ethnic minorities from seeking services, including:
Mistrust and fear of treatment;
Different cultural ideas about illnesses and health;
Differences in help-seeking behaviors, language, and communication patterns;
Varying rates of being uninsured; and
Discrimination by individuals and institutions.16
Racial and ethnic minorities are seriously under-represented in the core mental health professions.
Cultural Issues Also Affect Service Providers
Cultural issues affect not only those who seek help but also those who provide services. Each group of providers embodies a culture of shared beliefs, norms, values, and patterns of communication. They may perceive mental health, social support, diagnosis, assessment, and intervention for disorders in ways that are both different from one another and different from the culture of the person seeking help.
While professionals of all racial and ethnic backgrounds can and do deliver culturally competent care, much of the existing workforce is inadequately trained in this area. Racial and ethnic minorities are seriously under-represented in the core mental health professions, many providers are inadequately prepared to serve culturally diverse populations, and investigators are not trained in research on minority populations.104; 105
Without concerted efforts to remedy this problem, the shortage of providers and researchers will intensify the disproportionate burden of mental disorders on racial and ethnic minorities. With the rapid growth in minority populations, disparities will deepen if they are not systemically and urgently addressed.
Rural America Needs Improved Access to Mental Health Services
The vast majority of all Americans living in underserved, rural, and remote areas also experience disparities in mental health services. Rural America makes up 90% of our Nation's landmass and is home to approximately 25% of the U.S. population.102 Despite these proportions, rural issues are often misunderstood, minimized, and not considered in forming national mental health policy. Too often, policies and practices developed for metropolitan areas are erroneously assumed to apply to rural areas.
Access to mental health care, attitudes toward mental illnesses, and cultural issues that influence whether people seek and receive care differ profoundly between rural and urban areas.
While the prevalence and incidence of serious mental illnesses among adults and serious emotional disturbances for children are similar in rural and urban areas,106 the experience of individuals in those areas differs in important ways. In rural and other geographically remote areas, many people with mental illnesses have inadequate access to care, limited availability of skilled care providers, lower family incomes, and greater social stigma for seeking mental health treatment than their urban counterparts.5; 107 As a result, rural residents with mental health needs:
Enter care later in the course of their disease than their urban peers,
Enter care with more serious, persistent, and disabling symptoms, and
Require more expensive and intensive treatment response.108
For rural racial and ethnic minorities, these problems are compounded by their minority status and the dearth of culturally competent or bilingual providers in these medically underserved areas.
Compounding the problems of availability and access is the fact that rural Americans have lower family incomes and are less likely to have private health insurance benefits for mental health care than their urban counterparts.109 Lack of coverage often occurs because small groups and individual purchasers dominate the rural health insurance marketplace, so insurance policies are more likely to have large deductibles and limited or no mental health coverage.109
Rural residents also have longer periods without insurance coverage than their urban peers and are less likely to seek services when they cannot pay for them.110 For many rural Americans, the cost of mental health services - particularly prescription drugs - may be too high.
Rural areas also suffer from chronic shortages of mental health professionals. Virtually all of the rural counties in this country have a shortage of practicing psychiatrists, psychologists, and social workers.111 Of the 1,669 Federally designated mental health professional shortage areas, more than 85% are rural.112 These professional shortage problems are even worse for children and older adults.111
In addition, many primary care providers who work in rural areas are unprepared to diagnose or treat mental illnesses. Where general health providers in rural areas often use physician extenders, mental health extenders are not yet widely used. Where they are available, their services are frequently not reimbursed by insurance.
Another problem is that suicide rates are significantly higher among older men and Native American youth who live in rural areas. The rate of suicide appears to increase as the population becomes more rural.21; 108; 113 While several factors may contribute to this phenomenon, researchers have yet to conduct in-depth analyses and studies across different geographic settings.
However, one certainty is that access to mental health care, attitudes toward mental illnesses, and cultural issues that influence whether people seek and receive care differ profoundly between rural and urban areas.
Achieving the Goal
3.1 Improve access to quality care that is culturally competent
Culturally Competent Services Are Essential to Improve the Mental Health System
Culturally competent services are "the delivery of services that are responsive to the cultural concerns of racial and ethnic minority groups, including their language, histories, traditions, beliefs, and values."16 Cultural competence in mental health is a general approach to delivering services that recognizes, incorporates, practices, and values cultural diversity. Its basic objectives are to ensure quality services for culturally diverse populations, including culturally appropriate prevention, outreach, service location, engagement, assessment, and intervention.16
Despite widespread use of the concept of cultural competence, research on putting the concept into practice and measuring its effectiveness is lacking. While critical indicators and standards for culturally competent care have been available for several years, the field has yet to systematically apply, measure, and link these standards to treatment outcomes. In addition, implementing these standards in the public sector has been slow.
Culturally competent services - the delivery of services that are responsive to the cultural concerns of racial and ethnic minority groups, including their language, histories, traditions, beliefs, and values.
Nevertheless, many in the mental health field consider cultural competence to be essential to ensure quality of care, responsiveness of services, and renewed hope for recovery among ethnic and racial minorities. Empirical research is needed to assess the effectiveness of culturally competent practices. (See Goal 5.)
Meanwhile, mental health systems can respond to the needs of ethnic and racial minority populations by implementing existing standards, thus building trust, increasing cultural awareness, and responding to cultural and linguistic differences. In fact, programs that reflect the demographics, diversity, and values of a community-as shown by the Dallas school-based mental health model-are more likely to engage and keep racial and ethnic minorities in mental health services. (See Figure 3.1.)
The Commission recommends that States address and monitor racial and ethnic disparities in access, availability, quality, and outcomes of mental health services as part of their Comprehensive State Mental Health Plans. (See Goal 2.) This State-level strategic effort should include:
Setting standards for culturally competent care;
Collecting data to identify points of disparity;
Evaluating services for effectiveness and consumer satisfaction;
Developing collaborative relationships with culturally driven, community-based providers; and
Establishing benchmarks and performance measures.
In addition, State plans should promote increased opportunities to include individuals from diverse cultural backgrounds in the mental health workforce. These opportunities should reflect the changing demographics and needs of communities for culturally and linguistically competent providers.
Figure 3.1. Model Program: A Culturally Competent School-Based Mental Health Program
Dallas School-based Youth and Family Centers
To establish the first comprehensive, culturally competent, school-based program in mental health care in the 12th largest school system in the Nation. The program overcomes stigma and inadequate access to care for underserved minority populations.
Annually serves the physical and mental health care needs of 3,000 low-income children and their families. The mental health component features partnerships with parents and families, treatment (typically 6 sessions), and follow-up with teachers. The well-qualified staff, who reflect the racial and ethnic composition of the population they serve (more than 70% Latino and African American), train school nurses, counselors, and principals to identify problems and create solutions tailored to meet each child's needs.
Improvements in attendance, discipline referrals, and teacher evaluation of child performance. 114 Preliminary findings reveal improvement in children's standardized test scores in relation to national and local norms.
To sustain financial and organizational support of collaborative partners despite resistance to change or jurisdictional barriers. Program's $3.5 million funding comes from the school district and an additional $1.5 million from Parkland Hospital.
Recognize the importance of mental health for the school success of all children, regardless of race or ethnicity. Rethink how school systems can more efficiently partner with and use State and Federal funds to deliver culturally competent school-based mental health services.
Dallas and Fort Worth, Texas
Finally, emerging evidence shows that collaborative efforts to bridge community health and mental health services are effective in the outreach, identification, engagement, and treatment for racial and ethnic minorities with mental illnesses.16 Accordingly, national leadership is needed to improve the training of general medical practitioners and specialty mental health practitioners in caring for consumers at the intersection of these two parts of our overall health care system.
Therefore, the Commission recommends making strong efforts to recruit, retain, and enhance an ethnically, culturally, and linguistically competent mental health workforce throughout the country.
The Commission encourages government agencies, colleges, universities, professional associations, and minority advocacy groups to work together to address the workforce crisis in mental health services for racial and ethnic minority populations, especially for youth and their families. These efforts could include:
Recruiting and retaining racial and ethnic minority and bilingual professionals;
Developing and including curricula that address the impact of culture, race, and ethnicity on mental health and mental illnesses, on help-seeking behaviors, and on service use;
Training and research programs targeting services to multicultural populations;
Funding these training programs; and
Engaging minority consumers and families in workforce development, training, and advocacy.
The Commission recommends forming public-private partnerships for pre-service and in-service training. All Federally funded health and mental health training programs should explicitly include cultural competence in their curricula and training experiences. (See Goal 5 for a broader recommendation on the mental health workforce.)
The Commission recommends making strong efforts to recruit, retain, and enhance an ethnically, culturally, and linguistically competent mental health workforce throughout the country.
Given the significant role of faith-based organizations and leaders in the lives of many people, including ethnic and racial minorities, the Commission recommends enlisting their support and partnership in mental health care. This effort would involve working with the faith communities and leaders to help:
Increase understanding of mental and physical health in their communities,
Reduce stigma associated with mental disorders and problems,
Encourage individuals and families to seek help,
Collaborate with mental health providers, and
When necessary, link people with appropriate services.
These faith-based leaders also may be critical in helping the mental health system and providers better understand the community.
3.2 Improve access to quality care in rural and geographically remote areas.
Rural Needs Must Be Met
To address the specific needs of the rural and geographically remote communities, the Commission encourages the U.S. Department of Health and Human Services (HHS) to convene a cross-agency workgroup to examine rural workforce issues to:
Study current Federal workforce enhancement programs,
Encourage a collaborative focus on rural mental health needs, and
Oversee development of a rural mental health workforce strategy that includes using and supporting mid-level and alternative providers of mental health services.
The Commission recommends that the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources and Services Administration (HRSA) collaborate to support the training, deployment, and continuing education of rural mental health professionals. Such efforts should focus on strengthening the capacity and competency of the workforce to sustain an evidence-based service delivery system. (Also see Goals 5 and 6.)
In addition, the Commission recommends developing a Rural Mental Health Plan with specific, measurable targets and benchmarks. An important goal for this plan would be to fully integrate mental health into the existing infrastructure for rural public health. SAMHSA and HRSA should fully participate in developing this plan and should carefully consider the recommendations of the HHS Rural Task Force and the Initiative on Rural America. This national plan should closely align with States' Comprehensive Mental Health Plans. (See Recommendation 2.4.)
The Commission recommends that rural Americans receive increased access to mental health emergency response, early identification and screening, diagnosis, treatment and recovery services.
The Commission recognizes that affordable mental health care is a critical issue for rural communities and residents. Federal and State agencies should explore policy options that enable rural individuals and small businesses to enter pools to purchase insurance so that they gain access to more affordable, high quality, health insurance. In addition, Federal agencies should ensure that new funding announcements do not place unrealistic non-Federal matching fund requirements on rural entities.
The emergence of telehealth offers access to care. Telehealth is using electronic information and telecommunications technologies to provide long-distance clinical health care, patient and professional health-related education, public health, and health administration. (See Goal 6.)
The Commission recommends that SAMHSA, HRSA, and the National Institutes of Health fund demonstration grants in rural areas to provide and evaluate the effectiveness of mental health services delivered by distant providers through new technologies. Enhanced coordination between funded telehealth systems and public mental health systems must be promoted.
The Commission supports this technology as one of the most promising means of improving access to specialty mental health care in underserved rural areas.