For Better Mental Health Care for Latinos, Look at Neighborhoods

Overcoming stubbornly persistent racial and ethnic disparities in mental health care requires new approaches that address the complexity of the problem, said Margaret Alegria, Ph.D., a professor of psychology in the Department of Psychiatry at Harvard Medical School and director of the Center for Multicultural Mental Health Research in Somerville, Mass.

Thomas McGuire

“This is a serious public-health issue that is not thought of as a serious public-health issue,” said Alegria at a forum sponsored by APA’s Division of Diversity and Health Equity at APA’s 2014 annual meeting in New York in May. “Existing policies are just not sufficient.”

“The onset of mental illness may be lower among minorities, but persistence is greater,” said Alegria. “Minorities receive only half the services compared with non-Hispanic white people, and they receive less care even within the same [health care] systems.”

Alegria’s recommendations for change went beyond familiar calls for better access and more funding.

“There is no single solution,” she acknowledged. “I think we need to focus less on race and ethnicity to address mental health disparities and more on the socioecology of neighborhoods and on the intersection of socioeconomic status, child and adult adversity, and disadvantaged role constellation.”

There is still a dearth of knowledge about the role of socioeconomic status in health inequities, she said. “Even within social classes, you see disparities for minorities.”

Family structures and roles also affect the prevalence of mental illness. “The nuclear family is long gone,” she said. “Single parenthood is far too common.”

Also, more must be learned about how neighborhood characteristics increase the opportunities and risks for developing mental disorders and for obtaining care once they do develop.

Finally, epidemiological data about individual- and county-level health care resources and barriers are lacking, she noted.

“Supply of providers—especially ones who can speak the language of their patients—is a very important driver of access,” she emphasized. “But supply is not the only thing; it’s more complicated than that.”

For instance, minorities are treated more often than whites in public outpatient settings, and they are more often uninsured, at least before the Affordable Care Act (ACA) went into effect. Massachusetts’ health care reform expanded the population with insurance, she noted but disparities still persist, so the ACA alone is not the solution.

“The challenge is to see that the quality of care is as good in the public as the private sector,” she said.

“We must also go to community agencies or schools, where the people are, rather than wait for them to come to us,” she added. For example, “Telephone psychotherapy can help overcome stigma and reach patients who cannot or will not go to a clinic. We have to change their negative view of mental health.”

Anti-immigrant laws in some states impose additional social and institutional barriers to receiving care, she said. “It is a grave injustice to exclude noncitizens from medical care coverage.”

In addition, using current racial and ethnic categories may mask important subcategories, and neighborhood factors may be more important as well, she said. “We need to use neighborhoods as laboratories and conduct randomized, controlled trials of social policy, not just of clinical interventions,” she said.

She believes that reducing ethnic segregation and social and economic inequality might create safer neighborhoods and lessen risks for mental illness.

“We also have to change the role of the patient and increase shared decision making so that their agenda is as important as that of the provider,” she said. “One-to-one mental health care is an unrealistic solution. We need a public-health approach that focuses on social dynamics, on communities rather than individuals.” ■