Mental Health and Disparities In Minority
Disparities in Mental Health
Disparities in mental health services for racial/ethnic minorities are continuous, ongoing, and persistent (Miranda, Lawson, & Escobar, 2002; Institute of Medicine [IOM], 2003; US Department of Health and Human Services [USDHHS], 2003; Sue , 2003).
Because of the holistic and preventive care at tributes found in nursing research, education, and practice, nurses are prepared to address the issues of disparities in minority mental health. Nurses have ethical responsibilities that include doing no harm through the provision of safe patient care (Gastmans, 1998).
Practicing within an ethically challenging environment calls for nurses to be aware of and to address the issues of health disparities for racial/ethnic minorities. It is imperative that nurses become culturally competent in the care that they give to all people including racial/ethnic minorities.
The Institute of Medicine Committee on understanding and eliminating racial and ethnic disparities in healthcare (LOM) defines "disparities in healthcare as racial or ethnic differences in the quality of healthcare that are not due to access-related factors or clinical needs, preferences, and appropriateness of intervention" (pp. 3-4).
Racial/ethnic minorities are less likely to receive needed mental health care and when they do it is of poorer quality than whites.
Common Racial Groups for Such Practices
The four major minority groups are both racial-Black, Native Indian/Alaskan Native, and Asian/Pacific Islanders, and ethnic-Hispanic (any race). Miranda, Nakamura, and Bernal (2003) stated that although race is based on an outdated impression of biological origin, race does designate strong social meanings, whereas ethnicity refers to affinity with a group that is believed to share a common lineage.
According to the US Census Bureau (2001), from 1900 to 1965, racial/ethnic minorities made up 10% of the US population. By 2000, they were almost 30% of the US population, and by the mid-21st century racial/ethnic minorities will be approximately 40% of the US population.
The US Census Bureau reported that of
the 281.4 million people that live in the United States, 12.3% are Black, 0.9%
are Native Indians/ Alaskan Natives, 3.7% are Asian/Pacific Islanders and 12.5%
are Hispanic.
Today, racial/ethnic minorities are still affected by long-term legalized racism/discrimination. For Blacks, it was slavery: Native Americans and Japanese-forced relocations; Hispanics conquest; and Chinese involuntary non-citizenship.
This led to institutionalized racism, with a continued distrust by minorities of organized systems, including the health care system. Stigma prevents many minorities with mental illness from seeking help.
According to the Surgeon General, stigma plays a stronger role in
not seeking treatment with racial/ethnic minorities than with whites. As stigma
lessens, a change in public attitude should occur and people will be more
likely to seek care.
Prevalence of Mental Health Disorders
Prevalence of mental disorders are relatively similar across racial/ethnic populations, although there are clear variances within subgroups (Miranda et al., 2002). Blacks in need of mental health care receive only half the care of whites, and the rate of uninsured minorities to whites is 2:1 (USDHHS, 2003).
Almost 30% of Hispanics and 20% of Blacks do not have a primary source of health care and many racial/ ethnic minorities live in remote and rural case. People who do not have a primary source of health care or who live in remote and rural locations are less likely to be insured or more likely to be under insured. Being insured in creases the likelihood for accessibility to mental health care.
Mental health disparities for racial/ethnic minority populations are sustained by barriers to cultural competence that include racism/discrimination, stigma, communication, misdiagnosis, treatment, and lack of research (USDHHS, 2003; Miranda et al., 2002; LO.M. , 2003). The Surgeon General in the landmark supplement, Mental Health: Culture, Race and Ethnicity (2003) reasoned that racial/ethnic minorities experience:
(a) less opportunity for entry to and ease of use of mental health services.
(b) less potential for receipt of mental health services.
(c) poorer quality of mental health treatment.
(d)
underrepresentation of racial/ethnic minority clinicians, researchers, and
educators in the mental health field.
Data Gap
There are major gaps in empirical data for mental health services for racial/ethnic minorities. Misdiagnosis, treatment, and cultural competence have been studied. Most research has been done with the black population. Misdiagnosis occurs in all groups including whites but it occurs to a more significant degree in minorities (Miranda et al., 2002; LO.M., 2003).
Racial/ethnic minorities were less likely to receive
appropriate care for depression or anxiety than were whites. Black patients
with affective disorders are more likely to be diagnosed as schizophrenic than
are white patients and therefore, less like to receive lithium (Miranda et al.;
LO.M.; USDHHS, 2003).
Misdiagnose of Mental Disorders
Misdiagnosis leads to mistreatment in the form of no treatment, inappropriate treatment, or undertreatment. Tardive dyskinesia (a major side effect of major antipsychotic medication), excessive dosing, and as needed medications are complications more likely to occur in racial/ethnic minority groups than in the white population (Miranda et al., 2002; LO.M., 2003; USDHHS, 2003).
Unless a proper diagnosis is made, mindful of the varying presentations of mental health symptoms among racial/ethnic minorities and patient's acceptance of the interview process, which may not be culturally competent, effective treatment is unlikely to occur (1.OM).
Other studies indicate that minorities are likely to have untoward effects from treatment because of sensitivity to medication, improper medication, and intermittent or inappropriate treatment (1.OM, 2003; USDHHS, 2003).
Furthermore, a lack of cultural competence among service providers has
contributed to a lack of use of mental health services that contributes to the
likelihood of minority persons receiving more inappropriate care than whites
(1.0.M.; USDHHS).
Stigmas about Mental Disorders
Stigma of people with mental illness has existed throughout history (IOM, 2003). Over this period of time, the treatment of mental illness has always been separated from the treatment of physical illness.
Stigmatization of mental illness leads to the avoidance of and the treatment of persons with mental illness. Stigma is so widespread and such a formidable barrier to seeking mental health services that it is imperative to determine its dynamics and the impact on persons who need and deserve mental health services (USDHHS, 2003).
Significant gaps in nursing literature exist regarding minority mental health. Future research is needed to increase knowledge and ameliorate racism/discrimination, stigma, communication problems, misdiagnosis, and treatment in minority mental health (LO.M., 2003; USDHHS, 2003).
Mental health screening instruments need to demonstrate satisfactory reliability and validity across diverse ethnic minority populations to determine their cultural relevance and sensitivity (Baker & Bell, 1999). Although Baker and Bell addressed instrument appropriateness among mental health care of blacks, the data are generalizable to other racial/ethnic minorities.
Treatment and Its outcome
The treatment outcomes for racial/ethnic minorities are influenced by the cultural incompetence and bias of providers (LOM, 2003; USDHHS, 2003; Sue, 2003).
Diagnostic criteria for quantifying mental health symptoms exist, though their use may paradoxically limit the provider from making an appropriate clinical formulation when varying presentations of mental health symptoms in minority ethnic populations exist. An appendix to the DSM-IV TR (2000) features guidelines for the cultural formulation to be putatively incorporated into the clinical interview.
These
have not been included in the text as an integrated part of multiaxial
assessment due to incomplete empirical data to guide practice. Cultural
competence needs to be well-defined, evidence based, and empirically-measured
for its impact on outcomes associated with mental health therapies (Sue, 2003).
Cultural Influence on Mental Disorders
Cultural influences of both provider and patient potentiate communication difficulties that direct the uninformed provider to underestimate the prevalence of clinically significant mental health symptoms among racial/ethnic minorities (Baker & Bell, 1999; IOM, 2003).
After many years of looking at ethnic match of provider and client, where both are of a common ethnic background, cultural match, where the client regards the provider as culturally sensitive, flexible, and willing to regard the individual's unique needs, is identified as a better predictor of positive health outcomes, treatment continuity, and function ( Maramba & Hall, 2002).
Also, studies (Miranda, 2003; Baker & Bell, 1999; IOM, 2003; USDHHS,
2003) have recommended that theoretically based inquiry, culturally appropriate
measurements, and culturally-competent mental health treatment options comprise
future scientific studies with racial ethnic minority populations.
Knowledge Development Regarding Mental Disorders
Knowledge development regarding the needs of racial/ethnic minorities is influenced by several factors, including historical and ethical influences, provider cultural incompetence, and the academic and clinical community's lack of consensus guiding inquiry into minority mental health care.
Academic and empirical study of minority mental
health and related disparities in mental health care are needed to correct the
provider's knowledge and decrease prejudice. This is a step towards bringing
the best evidence into day-to-day practice.
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