Mental Health and Health Disparities

Transcription

1 November 10, 2013 Mental Health and Health Disparities Shani A. Dowd, Director, Culture InSight Ass t Clinical Professor of Psychiatry, Boston University School of Medicine

2 Learning Objectives At the end of this presentation, participants will be able to: Identify at least three factors in the social determinants of health Describe at least four ways in which social determinants influence mental health Identify at least three ways in which culture influences mental health presentations Identify at least three disparities in mental health 2

3 Social Determinants of Health Developed by the World Health Organization (WHO) Identifies social factors beyond the health care system that influence Factors can be integrated into understanding patient s socio-emotional well-being 3

4 The Social Gradient Poor economic circumstances affect life throughout the life-cycle. Low relative social ranking increases chances of disease: Among middle class office workers, lower ranking staff suffer much more disease than higher ranking staff. The longer people live in stressful circumstances, the greater the physiological wear and tear they suffer, and the greater the odds of decreased quality of life. 4

5 The Social Gradient Disadvantage may have many forms: Poor education Insecure employment Hazardous or dead end job Poor housing Inadequate retirement or pension Physical/mental disability Victimization by violence 5

6 The Social Gradient These disadvantages tend to accumulate in the same people: Poor education, tends to lead to inadequate housing, jobs, income, etc. 6

7 The Social Gradient Social Gradient influences management of life transitions: Emotional mastery in early childhood Transition from primary to secondary education Starting work Leaving home Starting a family Changing jobs Preparation for or ability to retire 7

8 The Social Gradient Each life stage transition can push people into a more or less disadvantaged position. Those who are disadvantaged in the past, are at greatest risk in each subsequent transition. Policies that reduce levels of educational failure and under- and unemployment, also support good health. 8

9 Stress Social factors contribute to long term stress levels Long-term stress has a greater impact on health than high stress. But the combination of HIGH and LONG-TERM stress set individuals up for greater chances of chronic, poor health. 9

10 Stress Factors that increase stress: Continuing anxiety Insecurity Low self-esteem Lack of control over work and/or home life Social Isolation Low income 10

11 Social Exclusion Poverty creates conditions that impair people s Access to adequate housing Access decent education Transportation options Ability to be included in social life of the community 11

12 Social Exclusion Increases risks of: Divorce and separation Disability Illness Addiction Creates vicious cycle 12

13 Work/ Unemployment Health suffers when people have little opportunity to utilize their skills, and/or have low decision making authority. Increases risk of: Low back pain Cardiovascular disease Repetitive stress injuries (e.g. Carpal tunnel syndrome) Absenteeism Presenteeism 13

14 Built Environment Influences the physical surroundings and options for healthy behaviors: Lack of parks Safe play/exercise spaces Lack of green space Presence of environmental toxins (air, ground, water) Presence of highways, truck and bus routes Sidewalks, street crossings Sidewalk cut outs for wheeled chairs, strollers Sheltered bus stops Street lights 14

15 Transportation Healthy Transport means less driving and more walking, and cycling, backed up by safe reliable public transportation Promotes regular exercise, reduces: Heart disease Obesity Stress Auto accidents Reliance on non-renewable fuels 15

16 Food Having it is good! Having healthy food is much better! Lack of healthy food creates malnutrition and food insufficiency. Excess intake is often related to a variety of illness conditions US is prone to overconsumption of energy dense, high sodium, high fat, high sugar foods. 16

17 Culture The learned and shared knowledge, beliefs, and rules that people use to interpret experience and to generate social behavior. The guiding forces behind what people think, say, expect, and do. While there are observable general characteristics associated with cultural groups, there is significant heterogeneity among individuals within groups. Culture is dynamic. 17

18 Complexities of Identity Depending on the health condition or behavior, one aspect of one s identity may be more salient than others. Aspects of identity interact: a Trinidadian woman experiences femininity differently than a Puerto Rican woman. Both filter womanhood against what it means to them to be of their ethnic group. 18

19 DIVERSITY LENS Working Thinking Style Organizational Style Parental Status Education/Degree Culture Marital Status Appearance Sexual Title Own/Rent Socio-Economic Orientation Status Occupation Work Age Race Family Size Experience Military Medical Specialty Experience Hobbies Gender Ethnicity Geographical Personality Location Physical Friends Values Background Abilities/ Accent Birth Order Qualities Suburban/Urban Neighborhood Citizenship Vocabulary Religious Beliefs Full/Part Time Harvard Pilgrim Health Care, Inc. Adopted from: Marilyn Loden & Judy B. Rosener,

20 Culture Influences: Definitions of illness Decisions to use or not use medications Help-seeking behaviors US dominant culture has ambivalent relationship to concepts of mental illness, e.g. Mad vs Bad The organizational cultures of our health care organizations influence access to mental health care, e.g., how late or missed appointments are handled, language used for communication Alegria M, Atkins M, et al. (2010) One size does not fit all: Taking diversity, culture and context seriously. Adm Policy Ment Health, 37:

21 ..a Culture of No Culture. that is, a community defined by the shared cultural conviction that its shared convictions were not in the least cultural, but, rather, timeless truths. Taylor, J. (2003) Confronting Culture in medicine s Culture of No Culture, Acad Med, 78(6):

22 Resilience Factors Contributors to resilience: Sense of purpose in life Mastery Frequent attendance at religious services Lower negative religious coping (i.e. internalizing shame based and punitive concepts from religion) Optimism Higher emotional expression Active Coping Social support Alim TM, Feder A, Graves, RE et al. (2008) Trauma resilience and recovery in a high risk African American population. Am J Psychiatry, 165:

23 Communication of Mental Health Issues Minority patients are less likely to fully communicate emotional states May convey distress in subtle manner, through hints and cues. Those who are not fully fluent in English may not have the vocabulary to convey emotional states. Even those who are fluent, may be unable to access that fluency if they are upset or in a great deal of emotional distress. De Maesschalck S, Deveugele M & Willems, S (2011) Language, culture and emotions: Exploring ethnic minority patients emotional expressions in primary healthcare consultations. Pat Educ and Counseling, 84:

24 Disparities in Use of Psychotherapy No difference in accessing mental health services between American Caucasians, African Americans and Latinos. African Americans and Latinos more likely to be uninsured However, higher drop out rates among Latinos and African Americans English language proficiency greatest predictor of use of MH services. Chen J & Rizzo, J (2010) Racial and Ethnic disparities in use of psychotherapy: Evidence from US National Survey data. Psychiatric Services, 61(4):

25 Role of Racial Discrimination A study of Asian Americans compared low family cohesion, poverty, acculturative strain, self-reports of discrimination and incidence of mental disorders. Self report of discrimination was the MOST ROBUST predictor of mental disorders, including anxiety Gee GG, Spencer M Chen JC et al. (2007) The association between selfreported racial discrimination and 12-month DSM-IV mental disorders among Asian Americans Soc Sci Med, 64(10):

26 We don t need or want you here. If immigrants weren t here we americans would do the jobs you are doing. We need our troops home from Iraq, etc... send immigrants back where they came from, patrol our airports and borders with machine guns! None of the immigrants appreciate being here. They get free everything (food stamps WIC medical care etc). Let a white ENGLISH speaking american try to get help. Almost impossible! By the way our language is ENGLISH!!!! LEARN it READ it SPEAK it!!!show some respect to us AMERICANS. Since you fled your pathetic country to come to ours!!go BACK!!! Fed up american Apr 09,

27 Report Difficulty Communicating with MD The Commonwealth Fund Health Care Quality Survey,

28 Differences in Symptom Presentation: Depression may present with few or no affective symptoms. Somatic symptoms may predominate. Anxiety often misdiagnosed as depression among ethnic patients. Overdiagnosis of schizophrenia, under-diagnosis of bipolar illness in ethnic populations. Patients may lack vocabulary to express and describe emotional states. Easier to learn names of parts of the body, than to differentiate vocubularies of emotion. 28

29 Culturally influenced Anxiety SX Presentations in Asian Populations. Country of Origin Most Common Anxiety Presentations China Japan Korea Dizziness, attribution to weak heart or weak kidney. Weak Kidney is associated with dizziness, blurry vision, tinnitus and back pain. Weak nerves : excessive worry, headache, fatigue Dizziness upon standing, fatigue, headache. Fear of people (distinguished from social phobia) that focuses on fear of offending people Fear of choking, palpitations, fear of cardiac arrestindia Cambodia weakness : body percieved a weakened by worry.characterized by woory, tinnitus, shortness of breath, feeling depleted. Disturbed wind flow, Wind overload Hinton DE, Park L, Hsia C. et al. (2009) Anxiety disorder presentations in Asian populations: A review. CNS Neuroscienc & Therapeutics, 15:

30 Mental Illness among Ethnic Minority Elders Non-US born Asians had 2x lifetime prevalence of anxiety disorders, especially GAD Latinos born abroad had higher rates of dysthymia and GAD than US born Latinos. African Americans had lower rates of depression, dysthymia and anxiety, but higher rates of substance use, especially alcohol. Latino and Asian elders less likely to attain fluency in English, more likely to be socially isolated, and may experience disappointment in the elusive American Dream Jimenez DE, Alegria M, Chen C et al. (2010) Prevalence of psychiatric illnesses among ethnic minority elderly. J Am Geriatric Soc 58(2):

31 Power and Control Many campaigns and programs are seen by others as efforts to control behavior and personal choices. We are, after all, trying to influence people in order to change behavior. 31

32 Who do we trust to give us information? Many ethnic cultures are oral cultures: This does not mean that they are not literate, but that information, especially important information is transmitted orally. 32

33 Explanatory Models Responsibility for illness falls mainly on the patient Common in the industrial West Often encouraged by health campaigns Ill health blamed on not taking care of self or risky behavior Illness can be ascribed to incorrect behavior, e.g. sitting in a draft after a hot bath Helman, C. (1994) Culture, Health and Illness 33

34 Expalnatory Models Moral Failure Fate Retribution Heredity Religion 34

35 Common Explanatory Models: US Debilitation Degeneration Invasion Imbalance Stress Mechanical causes Environmental causes Hereditary proneness 35