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Cultural Competency

Not only do ethnic populations often face communication and other external barriers to obtaining mental health treatment, but their own cultural perceptions of mental health problems may prevent them from seeking it in the first place. Because many cultures attach even more stigma to mental illness than does mainstream America, minority populations remain underserved or inappropriately served. A 2001 report by the Office of the Surgeon General found that fewer than one in 20 Latinos with mental health problems sought treatment from mental health specialists.

Because of their association with health and not mental health per se, primary care clinics escape, to some degree, the stigma that surrounds specialty mental health services in the minds of many. But to be effective, practitioners must remain sensitive to the many cultural nuances that impact upon how their clients perceive, communicate about and act upon mental health problems. Because the concept of mental health vary among cultural groups, it is important that practitioners look to these groups for guidance.

Mental Health Problems May Manifest Themselves As Physical Ailments Among Different Cultural Groups

Primary care providers should be aware that some mental disorders are experienced as or are communicated as physical disorders among various ethnicities. For example, according to experts cited in a September 4, 2007 Washington Post article entitled “Many Immigrants Face Cultural Barriers, Other Obstacles to Psychiatric Treatment”, Asian immigrants have a common tendency to describe psychiatric problems in physical terms, “which can obscure diagnosis and complicate treatment.” The article also discusses an anger syndrome among Koreans known as “hwa-byung,” – “a psychiatric disorder listed in the psychiatric Diagnostic and Statistical Manual as a ‘culture bound’ malady. Symptoms include insomnia, fatigue, indigestion, panic and a heavy feeling in the chest. Many sufferers insist their ailments are purely physical and reject the notion that their pain may have an emotional cause.” The article goes on to say that “Muslim patients often express emotional distress similarly, as fatigue, dizziness, heart pain or a headache.” According to an expert quoted, psychiatrist Amir Afkhami, “There is no word for depression in Persian or Arabic,” I know several patients who’ve been worked up the wazoo for headaches by neurologists when they were really suffering from depression.”

A very useful instrument in assessing levels of cultural competence in health care agencies was developed in 2002 by the Lewin Group for the U.S. Department of Health and Human Services, HRSA. Entitled “Indicators of Cultural Competence in Health Care Delivery Organizations: An Organizational Cultural Competence Assessment Profile”, it is a comprehensive examination of how health care organizational and service delivery elements reflect levels of cultural sensitivity and how these levels can best be measured.

Information About Hispanics And Mental Disorders

National Institute Of Mental Health

  • Hispanics tend to experience depression as bodily aches and pains (like stomachaches, backaches or headaches) that persist despite medical treatment. Depression is often described by Hispanics as feeling nervous or tired. Other symptoms of depression include changes in sleeping or eating patterns, restlessness or irritability, and difficulty concentrating or remembering.
  • Among Hispanic Americans with a mental disorder, fewer than 1 in 11 contact mental health specialists, while fewer than 1 in 5 contact general health care providers. Among Hispanic immigrants with mental disorders, fewer than 1 in 20 use services from mental health specialists, while fewer than 1 in 10 use services from general health care providers.
  • One national study found that only 24% of Hispanics with depression and anxiety received appropriate care, compared to 34% of whites. Another study found that Latinos who visited a general medical doctor were less than half as likely as whites to receive either a diagnosis of depression or antidepressant medicine.
  • One study found that only 4% of its Mexican American sample consulted a curandero, herbalista, or other folk medicine practitioner within the past year, while percentages from other studies have ranged from 7 to 44%. The use of folk remedies is more common than consultation with a folk healer, and these remedies are generally used to complement mainstream care.
  • While the percentage of Spanish-speaking mental health professionals is not known, only about 1% of licensed psychologists who are also members of the American Psychological Association identify themselves as Hispanic. Moreover, there are only 29 Hispanic mental health professionals for every 100,000 Hispanics in the United States, compared to 173 non-Hispanic white providers per 100,000.
  • Nationally, 37 percent of Hispanics are uninsured, compared to 16% for all Americans.
  • Hispanics with bipolar disorder are more likely to be labeled with schizophrenia, and Hispanics with depression (and probably anxiety) tend to somatize distress, reporting an excess of somatic and hypochondriacal features (Escobar, 1987; Mukherjee et al., 1983). (from Psychiatric Times)
  • Several studies point toward a better response, higher drop-out rate and higher side-effect reporting in Hispanics given antidepressants. A higher placebo response in Hispanics is also mentioned (Marin, 2003; Marin and Escobar, 2001). (from Psychiatric Times)

Surgeon General’s Report On Mental Health

Generally speaking, the rate of mental disorders among Hispanic Americans living in the community is similar to that of non-Hispanic white Americans. However:

  • Adult Mexican immigrants have lower rates of mental disorders than Mexican Americans born in the United States, and adult Puerto Ricans living on the island tend to have lower rates of depressions than Puerto Ricans living on the mainland.
  • Studies have found that Latino youth experience proportionately more anxiety-related and delinquency problem behaviors, depression, and drug use than do non-Hispanic white youth.
  • Regarding older Hispanic Americans, one study found over 26% of its sample were depressed, but depression was related to physical health; only 5.5% of those without physical health problems said they were depressed.
  • Culture-bound syndromes seen in Hispanic Americans include susto (fright), nervios (nerves), mal de ojo (evil eye), and ataque de nervios. Symptoms of an ataque may include screaming uncontrollably, crying, trembling, verbal or physical aggression, dissociative experiences, seizure-like or fainting episodes, and suicidal gestures.
  • In 1997, Latinos had a suicide rate of about 6% compared to 13% for non-Hispanic whites. However, in a national survey of high school students, Hispanic adolescents reported more suicidal ideation and attempts proportionally than non-Hispanic whites and blacks.
  • Mexican immigrants who lived fewer than 13 years in the US had surprisingly lower prevalence rates for depression and other disorders than Mexican Americans born in the US.
  • Particularly in the Hispanic community, the stigma and taboo surrounding mental illnesses can prevent many people from seeking the professional treatment they need. The U.S. Surgeon General reports that Latinos are far less likely than other Americans to seek professional help for mental health problems. Cultural values such as “personalismo” (self-sufficiency) and “familismo” (family centeredness) can contribute to this reluctance to seek outside assistance. Cultural variables, too, present numerous barriers to obtaining appropriate mental health treatment. Not only are many Latinos adverse to seeking treatment, those who do seek treatment are also very likely to drop out again, possibly due to feelings of shame, a sense of resignation towards suffering, discomfort with therapy, or cultural values of self reliance.
  • Those people who do attempt to consult with a professional must face a daunting array of socioeconomic, cultural and language barriers as they try to negotiate the mental healthcare system in this country. To begin with, U.S. Latinos experience the highest uninsurance rates of all minority groups, and fully 49% of Hispanic families have no regular doctor (compared to 25% of non-Hispanic whites). As a result, half of all Latinos do not see specialists but, rather, use a public clinic or a hospital as their usual source of care, with a high reliance on emergency room visits.
  • The fact that over 14 million U.S. Latinos do not speak fluent English also makes visiting a doctor most challenging. A recent poll by the Commonwealth Fund found that 45% of Spanish-speaking Hispanics report communication problems when interacting with their doctors. One-quarter of these individuals also report that they have left a doctor’s visit without even asking questions that they had about their care. Fully half report difficulties in understanding prescription information.

Dr. Renalto Alaron Of Emory University

  • 30 percent of the immigrant population are depressed. Culturally determining factors for underuse of mental health services include: overprotectiveness of family members against strange and feared social institutions, masking mental disorders by drinking and other behaviors, pride or embarrassment or shame, preference for folk healers, and language barriers.

National Mental Health Alliance

  • A study conducted by NAMI found Awareness about bipolar disorder among whites is 24 percent, among  Hispanics, it’s 23 percent, and among blacks it’s 10 percent.

U.S.  Department Of Health And Human Services:

  • The rate of depression in Hispanic American/Latina women remains about twice that of men. And major depression (also known as clinical depression, in which symptoms last for at least 2 weeks but usually for several months or longer) and dysthymia (a type of depression that lasts for at least two years) may be diagnosed slightly more frequently in Hispanic American/Latino women than in White women. (US Dept. of Health and Human Services)

Archives Of General Psychiatry, 2003

  • Latinos were disproportionately diagnosed as havingmajor depression, despite the fact that    significantly higherlevels of psychotic symptoms were self-reported by Latinos

Other Resources

Because there are a plethora of websites, training, conferences and written material about cultural competence, we will not delve into the subject here, but will simply list a few of the many resources available. Tawara. D. Goode from Georgetown University developed a cultural competence self-assessment for physicians to identify “areas in which they might improve the quality of their services to diverse populations.”

The American Psychiatric Association’s “Let’s Talk Facts About Mental Health in the Hispanic/Latino Community”, published in English and in Spanish, emphasizes the vulnerability of Hispanics, especially seniors and youth, to the stresses of acculturation.

The University of Colorado at Denver maintains “The American Indian and Alaska Native Mental Health Research: The Journal of the National Center”.

The University of Pennsylvania developed Cultural Competence Standards for Managed Care Mental Health Services for Asians and Pacific Islander Americans at the behest of SAMSHA.  Peter Manoleas, from University of California at Berkeley, has recently (February, 2007) authored a paper discussing integrated care service delivery for Latinos: “Integrated Primary Care and Behavioral Health Services For Latinos; A Blueprint And Research Agenda”, not yet in print.

The Hogg Foundation, in concert with the U.S. Department of Health and Human Services Office of Minority Health, published “Enhancing the Delivery of Health Care: Eliminating Health Disparities through a Culturally and Linguistically Centered Integrated Care Approach” in June, 2012.  The report gives recommendations, best practices examples and strategies for achieving cultural competency within an integrated care framework.  They also created a literature review report entitled “Eliminating Disparities Through the Integration of Behavioral Health and Primary Care Services for Racial and Ethnic Minority Populations, Including Individuals with Limited English Proficiency” in September, 2012.

In their April, 2012 Newsletter, the Center for Integrated Health Solutions discusses integrated care for minority populations.