"Culture counts." That was the succinct message U.S. Surgeon General David Satcher, M.D., delivered to a standing-room-only crowd of APA members and staff at APA’s fall component meetings in Washington, D.C., on September 8.
That simple phrase is at the heart of "Mental Health: Culture, Race, and Ethnicity," a report the surgeon general issued August 26 that documents the glaring disparity in access, quality, and availability of mental health services faced by Americans who are members of racial and ethnic minority groups.
Satcher went on to describe the complex implications of that statement. "We don’t notice much difference in severity or prevalence of mental illness across ethnic and minority groups," he said. "In fact, there is as much variation within groups as across groups."
The clash of cultures, however, can be extremely damaging to the provision of mental health services because rapport between a psychiatrist and patient is critical for successful treatment.
Culture, according to Satcher, affects how patients communicate and manifest their symptoms, how they cope, the range of their family and community supports, and their willingness to seek treatment.
In addition, clinicians’ own cultures and the service system also influence diagnosis and treatment. Psychiatrists and mental health professionals need to know how to build upon the cultural strengths of people in their care.
The report analyzes data about four racial and ethnic groups: African Americans, American Indians and Alaskan natives, Asian Americans and Pacific Islanders, and Hispanic Americans. The data are organized around five broad service issues: need, availability, access, utilization, and appropriateness and outcomes.
The groups share problems resulting from having unequal access to treatment and services compared with the white majority in the United States. Minority groups have less access to services, often receive a poorer quality of services, and are underrepresented in mental health research. Their cultures, however, also differ in ways that influence the efficacy of mental health services.
A disproportionate number of African Americans, for example, are represented in the most vulnerable segments of the population—people who are homeless, incarcerated, in the child welfare system, victims of trauma—all populations with increased risk for mental disorders. Asian Americans, by contrast, earn the highest average income of the four groups, Satcher told the audience. Asian Americans, however, often show the most severe symptoms when they seek help because shame and stigma may discourage them from acknowledging mental illness until their psychopathology becomes severe.
Access for Hispanic Americans is limited by the lack of Spanish-speaking mental health professionals. Clinics and hospitals of the Indian Health Service are located on reservations, yet the majority of American Indians no longer live on them.
The surgeon general also offered a brief overview of the state of Americans’ mental health. "Mental disorders are real, and they are common. Every year, 1 in 5 people suffers some form of mental disorder. The good news is that 80 percent to 90 percent of them can be treated and returned to productive lives and relationships. The bad news is less than half ever seek treatment, in part because of the stigma surrounding mental illness."
Satcher concluded with a list of ways APA members could help realize the vision of equality outlined in the report. "Go into your communities to develop mental health systems that are culturally competent. We need more professionals who are members of minority groups, but we can’t wait until they are trained. We need to empower people in the communities to work with us."
He also urged the audience to work more closely with primary care clinicians. "They are on the front line and must become more attuned to recognizing the need for mental health services." Financial barriers to equal access must come down, he said, citing the importance of federal legislation for mental health parity. (See box for the report’s full recommendations.)
The messages of the report clearly resonated with APA members. Carl Bell, M.D., president of the Community Mental Health Council in Chicago, introduced Satcher to the audience, calling him a "physician’s physician" and telling of Satcher’s commitment to public health, his sense of strategy, and willingness to take risks.
Bell, who had helped develop the report, expanded on those comments in an interview with Psychiatric News. "This report elevates the conversation about racial disparities in mental health services and brings together in one place a great deal of useful information. The recommendations are sound and can be accomplished."
Altha Stewart, M.D., chair of the APA Council on Psychiatric Services, who responded to the surgeon general’s presentation at the meeting, said, "We all want to commend Dr. Satcher for his tireless work. The highest-ranking health official in the country agrees with us that it’s necessary to acknowledge the role of culture in providing mental health services. To those of us in the room who have been working in the field of cross-cultural psychiatry for more than 20 years, I say, ‘We are vindicated.’ Our work has not been in vain.’ "
APA President Richard Harding, M.D., called Satcher "a personal hero of mine" and said, "Dr. Satcher, we are with you in our commitment and dedication to improving access to quality psychiatric care. . . .in fighting stigma that affects our patients and the professionals who care for them. . . , in eliminating disparities in psychiatric care for members of minority groups, and in using scientific rigor to arrive at credible recommendations."
Harding concluded the meeting by awarding Satcher a presidential commendation in "recognition of his superb leadership in battling against the stigma and prejudice affecting persons who suffer from mental illness" and announcing that he would appoint a work group on the implementation of the report.
The cochairs of that group, named the Steering Committee for Eliminating Disparities in Access to Psychiatric Care, are Altha Stewart, M.D., and R. Dale Walker, M.D. Other members are Harding, Carl Bell, M.D., Edward Foulkes, M.D., Ph.D., Francis Lu, M.D., Patricia Isbell Ordorica, M.D., and Pedro Ruiz, M.D. The staff liaison is James Thompson, M.D., deputy medical director and director of the APA Division of Education, Minority, and National Programs.
The 200-page report is a supplement to the "Surgeon General’s Report on Mental Health," issued in 1999. The new report is available on the Web at www.surgeongeneral.gov/library/mentalhealth/cre/default.asp. ▪