The Bridge Program 10 Years Later Teddy Chen, PhD, MSSW Director Mental Health Bridge Program Charles B. Wang Community Health Center 1
Mental Health Needs of the Asian American Community 2
API Females Age 65 and Over Suicide Rates Detailed Race, Hispanic Origin: United States, Selected Years 1990-2001 9 8 65+ Female 7 6 5 4 3 2 1 0 1990* 1993* 1994* 1995-97* 2001 Black Female Hispanic Female Asian or Pacific Islander Female White, non-hispanic Female * Except for 1994 and 1996, fewer than 20 deaths reported in these years for Hispanic females, American Indian females, or Alaska Native females. SOURCES: Centers for Disease Control and Prevention, National Center for Health Statistics, Grove RD And Hetzel AM. Vital Statistics rates in the United States, 1940-60. Washington: Public Health Service, 1968; Vital statistics of the United States, vol.88,mortality, part A, for data years 1950-97. Washington:Public Health Service;data computedby the Division of Health and Utilization Analysis from data compiled by the Division of Vital Statistics and from national population estimates for race groups from table 1 and unpublished Hispanic population 3 estimates prepared by the Housing and Household Economic Statistics Division, U.S. Bureau of the Census.
API Rates for Suicide Female Age 15-24 Detailed Race, Hispanic Origin: United States, Selected Years 1990-2001 6 5 Black Female Asian or Pacific Islander Female Hispanic Female White, non-hispanic Female 4 3 2 1 0 1990* 1993 1994* 1995-97 2001 * Fewer than 20 deaths reported in these years for American Indian or Alaska Native females. SOURCES: Centers for Disease Control and Prevention, National Center for Health Statistics, Grove RD And Hetzel AM. Vital Statistics rates in the United States, 1940-60. Washington: Public Health Service, 1968; Vital statistics of th United States, vol II, mortality, part A, for data years 1950-97. Washington: Public Health Service; data computed by the Division of Health and Utilization Analysis from data compiled by the Division of Vital Statistics and from national population estimates for race groups from table 4 1 and unpublished Hispanic population estimates prepared by the Housing and Household Economic Statistics Division, U.S. Bureau of the Census.
Prevalence of Depression Among Chinese Americans 18% 16.9% 16% 14% CAPES NCS 12% 10.0% 10% 8% 6.9% 5.2% 6.4% 7.0% 6% 4% 3.4% 0.9% 2.5% 2% 0% Lifetime 12-month Lifetime 12-month Neurasthenia Major Depressive Episode Dysthymia Takeuchi, D.T., et al.(1998) American Journal of Psychiatry, 155, 1407-1414. 5
Suicide and Death Ideation in Depressed Primary Care Elderly (Bartels et al. Am J Geriatric Psychiatry, 14(4) 2002, p 417-427) 427) 40.00% 35.00% Death Ideation Suicidal Ideation 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% Black (N=530) Asian or Pacific Islander (N=111) Hispanic or Latino (N=299) White (N=1228) 6
High Rates of Major Depression in Primary Health Care A two-phase of epidemiological survey of the prevalence of major depressive disorder among Asian Americans in the primary care setting in Boston (N= 503) The Chinese version of the Beck Depression Inventory was used Positive cases were validated by clinical interview The prevalence rate of MDD among Asian-American American in the primary care setting was estimated to be 19.6% ± 0.06 Yeung A, Chan R, Mischoulon D, et al: Prevalence of major depressive sive disorder among Chinese-Americans in primary care. General Hospital Psychiatry 26:24-30, 2004 7
Prevalence Rate of Mental Disorders (Depressive disorders, Anxiety disorders, Substance use disorders) s) 18.00% 16.00% 14.00% 12.00% 10.00% 8.00% 6.00% 4.00% 2.00% 0.00% 17.30% 9.20% Lifetime Rate 12 Months Rate * Takeuchi, D.T., Zane, N., Hong, S., Chae, D. H., Gong, F., Gee, G. C., Walton, E., Sue, S., Alegrfa, M., (2007). Immigration-Related Factors and Mental Disorders Among Asian Americans. American Journal of Public Health, 97, 1, 84-90. 8
The New York Times Report Cornell is making a special effort to reach out to Asian and Asian-American American students. Of 16 students there who have committed suicide since 1996, 9 were of Asian descent. The New York Times, December 3, 2004 9
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Persistent Underutilization 12
Stigma and Shame The reluctance to use services is attributable to factors such as the shame and stigma accompanying use of mental health services, cultural conceptions of mental health and treatment that may be inconsistent with Western forms of treatment, and the cultural or linguistic inappropriateness of services (Sue & Sue, 1999). (U.S. Department of Health and Human Services. (2001). Mental Health: Culture, Race, and Ethnicity-A A Supplement to Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Public Health Services, Office of the Surgeon General) 13
Underutilization of Mental Health Services Asian Americans Constituted 8.7% of Los Angeles County Population, But Only 3.1% of Mental Health Service Clients in Los Angeles County (Sue, et al. 1983-1988) 1988) Asian Americans Constituted 9.1% of San Diego County Population, but Only 3.6% of Mental Health Service Clients in San Diego County (Chen, et al. 1991-1994) 1994) 14
Underutilization of Mental Health Services by AAPI AAPI populations re 3 times less likely than White populations to use available mental health services (Marsuoka, Breaux, & Ryujin, 1997). Only 17% of Chinese Americans who experienced problems with emotions, anxiety, drugs, alcohol, or mental health in the past 6 months sought care; less than 6% of them saw mental health professionals, 4% saw medical doctors, and 8% saw a minister or priest. (Young, 1998). 15
NYS Public Mental Health System Mental Health Utilization Ethnic composition of population served Other/American Indian 5% Asian 1% Hispanic 20% White 50% Black 24% Total persons served = 630,000 Source: Carpinello,, S. (2004). Providing Quality Services in Culturally Diverse Settings. S Mental Health News, Fall 2004, 9. 16
NYS Public Mental Health System Service Use Service Use Rates per 1000 55.81 53.95 26.39 7.74 Black Other/Multiracial White Asian Source: Carpinello,, S. (2004). Providing Quality Services in Culturally Diverse Settings. S Mental Health News, Fall 2004, 9. 17
Rate of Mental Health Care Use in Medicare Managed Care White African American Asian Hispanic Overall Denominator size 4,319,145 486,696 68,865 141,322 5,016,02 8 Any mental health care (rate per 1000 members*) 24.6 16.6 + 11.7 + 24.1 23.6 * Rates are age and sex adjusted + P<0.05 vs. white Source: Virnig, B, et al. (2004). Does Medicare Managed Care Provide Equal Treatment for Mental Illness Across Races? Archives of General Psychiatry, 61, 201-205. 18
Utilizing MH Services 18.0% 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% 8.6% 17.90% Any Services Chinese General Population *Abe-Kim, J., Takeuchi, D.T., Hong, S., Zane, N., Sue, S., Spencer, M.S., Appel, H., Nicdao, E., & Alegria, M. (2007). Use of Mental Health Related Services Among Immigrant and US-Born Asian Americans. American Journal of Public Health, 97, 1, 91-98. 19
Utilizing MH Services 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% 34.1% 41.1% Chinese General Population *Abe-Kim, J., Takeuchi, D.T., Hong, S., Zane, N., Sue, S., Spencer, M.S., Appel, H., Nicdao, E., & Alegria, M. (2007). Use of Mental Health Related Services Among Immigrant and US-Born Asian Americans. American Journal of Public Health, 97, 1, 91-98. 20
Utilizing MH Services 14.00% 12.00% 12.65% 10.00% 8.00% 6.00% 4.00% 2.00% 6.19% 6.79% 7.35% 2.17% 3.50% Any Specialty MH General Medical 0.00% US Born Foreign Born N= 454 N= 1639 *Abe-Kim, J., Takeuchi, D.T., Hong, S., Zane, N., Sue, S., Spencer, M.S., Appel, H., Nicdao, E., & Alegria, M. (2007). Use of Mental Health Related Services Among Immigrant and US-Born Asian Americans. American Journal of Public Health, 97, 1, 91-98. 21
Utilize MH Services by Generations 20.00% 18.00% 16.00% 14.00% 12.00% 10.00% 8.00% 6.00% 4.00% 2.00% 0.00% 7.35% 2.17% 3.50% 1st Generation 8.11% 3.51% 3.29% 2nd Generation N= 1639 N= 272 19.28% 11.88% 10.10% 3rd Generation or Later N= 182 Any Specialty MH Medical *Abe-Kim, J., Takeuchi, D.T., Hong, S., Zane, N., Sue, S., Spencer, M.S., Appel, H., Nicdao, E., & Alegria, M. (2007). Use of Mental Health Related Services Among Immigrant and US-Born Asian Americans. American Journal of Public Health, 97, 1, 91-98. 22
Greater Delay of Treatment: Increased Severity Many studies demonstrate that Asian Americans who use mental health services are more severely ill than white Americans who use the same services. This pattern is true in many community mental health centers (Brown et al., 1973; Sue, 1977), county mental health systems (Durvasula & Sue, 1996 for adults; Bui & Takeuchi, 1992, for adolescents), and student psychiatric clinics (Sue & Sue, 1974). (U.S. Department of Health and Human Services. (2001). Mental Health: Culture, Race, and Ethnicity-A A Supplement to Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Public Health Services, Office of the Surgeon General) 23
Access to Mental Health Services 24
Barriers To Care Lack of Access Language Economic Education Lack of Identification Cultural and Linguistic Mismatch Focus on Somatic Symptoms Family Shame and Guilt Fear of Reprisal Lack of Treatment Patient and Family Resistance Lack of Providers Models of Care Not Competent Fragmented Services 25
Over-Crowed Community Mental Health Clinic Distribution of Psychiatric Diagnoses at a Community Mental Health Clinic Other 10% Mood Disorders 25% Psychotic Disorders 60% Anxiety Disorders 5% 26
Symptom Presentation: Somatization Asians are thought to deny the experience and expression of emotions. These factors make it more acceptable for psychological distress to be expressed through the body rather than the mind. Attention to the emotional and interpersonal symptoms or concerns are positively correlated with increased acculturation (Chen at al, 2003) (U.S. Department of Health and Human Services. (2001). Mental Health: Culture, Race, and Ethnicity-A A Supplement to Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Public Health Services, Office of the Surgeon General) 27
The Bridge Program 10 Years Ago Mental Disorders May Be Difficult to Recognize in busy primary care practice Lack of Training and Expertise with Mental Health Issues Encountering Patient and Family Stigma Somatic Problems that often Mask Psychiatric Difficulties BUT OPPORTUNITY FOR EARLY ENGAGEMENT and INTERVENTION!! 28
Charles B. Wang Community Health Center A federally qualified community health center Established in 1970s Only community health center services Asian Americans (Chinese American) in NYC Providing Internal Medicine, Pediatrics, Women s s Health, Mental Health, and Dental services. Has 307 F/T and 162 P/T employees 29
A Bridge Between......Primary Care and Mental Health Training and supporting primary care physicians to provide mental health care Early detection and treatment of mental health problems Providing mental health care in a primary care setting Helping patients enter the specialty mental health system, if necessary 30
The Bridge Program: 10 Years Later 31
Increased Access to Mental Health Better services Easier access Decreased trauma and stigma 32
Number of Encounters 6000 CHC FPCC 5475 5000 4739 4000 3611 3725 3782 3000 2755 2388 2000 1000 622 258 869 648 1053 1208 695 742 777 739 946 1514 1469 0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 33
Number of Patients 1000 900 800 700 600 500 400 300 200 100 0 Patients 729 801 665 559 395 416 317 167 895 1998 1999 2000 2001 2002 2003 2004 2005 2006 34
Gender N=2315 Female, 1397, 60% Male, 918, 40% 35
Age N=2315 45-54, 352, 15% 55-64, 310, 13% 65-74, 202, 9% 75 and older, 177, 8% 35-44, 309, 13% Age 1-17, 418, 19% 25-34, 261, 11% 18-24, 279, 12% 36
Adj Dis w/anxiety, 29, 1% Diagnosis Distribution Adj Dis w/disturbance of Conduct, 51, 2% Adj Dis w/mixed Anxiety & Depressed Mood, 90, 4% Adj Dis w/depressed Mood, 100, 4% ADHD, 115, 5% Adj Dis w/ Mixed Disturbance of Emotions & Conduct, 31, 1% Anxiety, 276, 12% Adj Dis NOS, 47, 2% Others, 665, 29% Depression, 775, 34% Psychotic, 129, 6% 37
Early Detections Adult Depression Screening and Treatment Pediatric Services: ADHD Detection and Treatment Adolescent Screening and Treatment 38
Challenges Difficulties referring patients to specialty mental health clinics Continued increasing needs Persistent shortage of bilingual mental health professionals Stigma and biased attitude Lack of research studies 39
Are We Doing Enough? It is like traveling back to China Yes, it is more than fifty percent I... You don t t need them. They can not help you. 40