Striking racial and ethnic disparities exist in access, quality, and availability of mental health services for Americans, according to a Surgeon General's report released in August. Mental Health: Culture, Race, and Ethnicity, a supplement to the Surgeon General's 1999 report on mental health, repeats the important messages of the earlier report—that mental health is fundamental to overall health, that mental illnesses are real health conditions, and that a variety of effective treatments are available for most mental disorders.
However, the latest report documents a disproportionately high burden of disability from mental illness among the four most-recognized U.S. minority populations: African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanic Americans. The higher burden, according to the report, stems from minorities' receiving less care and poorer quality care than white Americans rather than from their illnesses being inherently more severe or prevalent. In addition, minorities are overrepresented in the nation's most vulnerable populations, such as the homeless population, which experience higher rates of mental disorders and greater barriers to care. The report also notes that the burden for minorities is growing as these groups become larger and continue to face a social and economic environment of inequality, including greater exposure to racism and discrimination, violence, and poverty—all of which take a toll on mental health.
Shortly after the report was released, Surgeon General David Satcher, M.D., spoke at the plenary session of the fall component meetings of the American Psychiatric Association in Washington, D.C. The main message of the report, he said, is, "Culture counts. We must recognize the great impact of culture on mental health. It affects how people experience and perceive disorders and how they seek help." He noted that mental health professionals are also subject to cultural influences and that cultural differences between providers and patients often create additional barriers to treatment. Dr. Satcher challenged the audience of psychiatrists to help design systems of care that recognize the importance of culture and to develop services that are more responsive to the needs of racial and ethnic minorities.
APA President Richard K. Harding, M.D., responded to the challenge by announcing the formation of a seven-member presidential steering committee to study the report and recommend actions to reduce and eliminate the disparities it documents. He presented Dr. Satcher with a presidential commendation for his efforts to focus national attention on mental illness and to reduce stigma.
The main findings in the 200-page report are presented in separate chapters on each of the four racial or ethnic groups. The report emphasizes that many distinct subgroups exist within each group, and the chapters describe the historical context and mental health issues of some subgroups. However, because data are limited, the primary focus is on findings for the broader racial and ethnic categories. Some of the disparities highlighted in the report are summarized below.
• Nearly 60 percent of older African Americans do not receive necessary mental health services.
• About 25 percent of African Americans are uninsured, compared with 16 percent of the U.S. population.
• African Americans are more likely to use emergency services, and they are overrepresented in emergency settings and psychiatric hospitals, because they delay seeking help until their symptoms are severe.
• African Americans account for only 2 percent of psychiatrists, 2 percent of psychologists, and 4 percent of social workers in the United States.
• American Indians represent less than 2 percent of the population, yet they constitute 8 percent of the homeless population.
• Alcohol abuse rates among Northern Plains Indians and American Indian Vietnam veterans are as high as 70 percent, compared with rates ranging from 11 to 32 percent among whites and African Americans.
• The rate of violence among American Indians is twice that of the general population, and more violence plays a role in the higher rate of posttraumatic stress disorder in this group—22 percent compared with 8 percent in the general population.
• Only 50 percent of American Indians and Alaska Natives have employer-based health insurance, compared with 72 percent of whites.
• Nearly half of Asian Americans and Pacific Islanders lack access to adequate mental health services, largely because of language barriers.
• Asian Americans and Pacific Islanders who seek mental health care often present with more severe illnesses than other racial or ethnic groups, which suggests that stigma and shame are critical deterrents to service use. Mental illnesses may be undiagnosed or treated late in their course because they are often expressed as physical symptoms.
• Thirty-seven percent of Hispanic Americans are uninsured, compared with 16 percent of all Americans.
• Hispanic youths experience disproportionately high rates of anxiety, depression, drug use, and delinquency.
• There are only 29 Hispanic mental health professionals for every 100,000 Hispanics in the United States, compared with more than 173 non-Hispanic white providers per 100,000 non-Hispanic whites.
The report concludes by proposing broad courses of action to improve the quality of mental health care available to racial and ethnic minority populations. The first recommendation is to continue to expand the science base by including members of minority groups in research studies, by confirming the efficacy of evidence-based treatments for these groups, and by studying cultural differences in the experience of mental illness. Other recommendations include improving access to treatment, reducing barriers to and improving the quality of mental health services, supporting the development of culturally relevant skills among all mental health professionals, and promoting leadership from within the community.
In a statement accompanying the report, Dr. Satcher underscored the primary health recommendation made in the report: "I want to be absolutely certain that my message is heard by America's millions of Hispanic Americans, African Americans, Asian Americans, Pacific Islander Americans, American Indians, and Alaska Natives. The message is this: If you or a loved one is experiencing what you think might be symptoms of a mental disorder, seek treatment and seek it now. Insist on the kinds of services that can and should be available to you, whatever your language, your income, your geographic location, your race, or your ethnicity. You will discover that your community has a wealth of resources."
Mental Health: Culture, Race, and Ethnicity is available on the Surgeon General's Web site at www.surgeongeneral.gov. A copy of the report's executive summary and fact sheets can be obtained by calling 800-789-2647.
Recent analyses have shown that psychiatric and addictive disorders cost the U.S. economy a total of $205 billion a year. Less than half of that amount—$92 billion—is for direct treatment. Lost productivity accounts for $105 billion, and crime and welfare for $8 billion. According to a report by the National Mental Health Association (NMHA), a 5.5 increase in investment in treatment for people with these disorders—or a $5 billion spending increase—could reduce total costs by at least $10 billion. Other estimates in the report—those at the higher end of the economic return—put the savings figure at $56.5 billion.
Although these and other figures contained in NMHA's 2001 Labor Day Report are important for all major social institutions in the United States, the report calls for "assertive responsibility and action" from American businesses. It urges employers to ensure that their investment in the mental health of workers is on par with their investment in physical health and to end workplace practices that discriminate against people who have psychiatric and substance use disorders. The report states that "the cost-benefit on these kinds of investments would clearly bolster a company's bottom line."
To support this claim the report cites the finding from the 1997 National Comorbidity Survey that the U.S. civilian workforce lost one billion days of productivity because of mental illness. The report also mentions a 2000 study by the International Labor Organization, which found that clinical depression affects one in ten working-age adults each year, resulting in a loss of about 200 million working days. In addition, NMHA found in a previous study that the unemployment rate among American adults with depression is 23 percent, compared with 6 percent for the general population. Among men between the ages of 21 and 49 who are depressed, the unemployment rate is 30 percent—four times the national average for that age group.
The NMHA report acknowledges that American businesses cannot carry out this task alone. The report also calls on federal and state elected officials to pass legislation ending discrimination in insurance practices against people with mental illnesses.
The report is available on the NMHA Web site at www.nmha.org.
Menninger move called off: Negotiations to form a partnership between the Menninger Clinic, Baylor College of Medicine, and the Methodist Health Care System have ended unsuccessfully because of irresolvable differences. The merger plan, which was driven by Menninger's serious financial problems, would have resulted in the clinic's move to Houston from Topeka, Kansas, its home since 1925. Half of Menninger's employees have been laid off in the past year, its residency training program has been shut down, and its bed capacity has been reduced from 143 to 95. Because of ongoing financial difficulties, Menninger continues to seek a partnership with a major medical school and hopes to move to a metropolitan area with a larger population of potential patients.
Schizophrenia Wellness Center: A collection of the latest medical information on schizophrenia is available on the Medscape Web site at www. medscape.com/mp/rc/schizophrenia. The site offers journal articles, summaries from major medical conferences, programs for CME credit, and links to patient resources.