Diversity, Culture, and Mental Health

Diverse Populations and Mental Health

July is the American Psychiatric Association’s Diversity Mental Health Month, a time to appreciate the diversity among us and to focus on the unique mental health issues of diverse populations and efforts to reduce mental health disparities.  It’s clear we live in an increasingly diverse society, but how does that diversity relate to mental health and receiving quality mental health services?

Cultural background, including race/ethnicity and other aspects, can greatly influence how we think and feel about mental health and illness, how we experience symptoms, how we communicate about mental illness, and how and where we seek help.  Some people may be reluctant to talk about mental health concerns out of fear or shame, some people may seek help from faith leaders, while others may turn to a family doctor or a mental health professional.  (See the infographic from APA:  Mental Health and Diverse Populations.)

Extensive research tells us that ethnic and racial disparities in mental health care exist. A new report from Substance Abuse and Mental Health Services Administration (SAMHSA) notes that among adults with mental illness, whites, American Indian/Alaska Natives, and adults reporting two or more races reported higher mental health service use than black, Asian, and Hispanic adults. (See chart.)
Being aware of differences in the use of mental health services among different ethnic/racial population groups is critical for mental health professionals. That is part of what Diversity Mental Health Month is about – increasing understanding among psychiatrists about the influences of cultural diversity in their practices.

The SAMHSA report also looked at why people don’t use mental health services.  Adults across all racial/ethnic groups cited the same reason most frequently for not using mental health services:  the cost of services cost or lack of insurance.  Other reasons included:  low perceived need; stigma; and structural barriers. Concern about whether mental health services would help was the least cited reason by all racial/ethnic groups.

The top barrier to care, cost, may at least be partly addressed as more people gain access to mental health care with the Affordable Care Act and the Mental Health Parity Act. Many organizations, including the APA, are working to improve cultural sensitivity and to reduce the stigma of mental health, particularly among racial and ethnic minority populations.

By Ranna Parekh, M.D., M.P.H., Director
APA Division of Diversity and Health Equity

This post is part of an ongoing series spotlighting diversity from APA’s Division of Diversity and Health Equity.

Marijuana: Legal Doesn’t Mean Safe

Twenty-three states and the District of Columbia have laws legalizing some form of marijuana use, and recreational use of marijuana is legal in four states and D.C.

Does this growing trend to legalize marijuana mean we don’t need to worry about it?  About one in 10 people who try marijuana will become addicted to it which means that they most likely will use it in increasing quantities, develop tolerance (less effect from it as time goes on), will have withdrawal symptoms if they try to stop, and will find that the marijuana use is causing them to neglect other important areas of their life like work, relationships and leisure activities. 

Even occasional use of marijuana can have negative effects.  hen someone has marijuana in his/her system, short term memory is impaired, reflexes are impaired and judgment is impaired.  These impairments can last 24 hours or longer after the use of the marijuana so it is certainly not safe to drive after using marijuana. Most people will not be able to perform other demanding tasks (work-related activities, childcare) at the level they are accustomed to after using marijuana. 

All the evidence that we now have indicates that marijuana is possibly permanently damaging to the developing adolescent brain. All children should be strongly discouraged from using it at all until they are at least 21 years of age. If marijuana is smoked there are also potential physical health risks, such as damage to the lungs or cardiovascular system.

For more information, see American Psychiatric Association’s  Resource Document on Marijuana as Medicine.

By Andrew Saxon, MD

Professor and Director, Addiction Psychiatry Residency Program

University of Washington

Director, Center of Excellence in Substance Abuse Treatment and Education

VA Puget Sound Health Care System

Seattle, WA

Transgender: A Diverse Group of Individuals

With the recent spotlight on people who identify as transgender, it’s important to keep in mind that transgender people are as diverse as the general population and express themselves in a number of ways.

On a very basic level, a transgender person is born as male or female, but identifies as either the opposite gender, both genders, or no gender at all.  Some who are labeled as transgender may also decide not to even use that term. There is plenty of evidence that transgender people have existed as long as there has been a concept of male and female. Only recently have they received enough support from society to express themselves in a more open way.  This new recognition and support has opened the door for transgender people to pursue life in a body that feels on the outside the way they have always felt inside.

People who identify as transgender usually start to notice their differences early in life. However people can identify and come to understand themselves to be transgender at any point during their life.  Along the lines of discovering one’s sexual orientation, there are no clear “rules,” and identifying as a transgender individual is a very personal and unique process.  This means that those who identify as transgender may decide to dress as the opposite gender, take hormones to change their bodies, and even have surgical procedures to change their appearance to fit how they feel on the inside. There are also many transgender people who decide that these options are not right for them and express themselves in other ways.

Because society has traditionally been unaccepting to those who identify as transgender, they are at higher risk of depression, anxiety, substance abuse and even suicide. Symptoms can generally improve once the person is in a more supportive and accepting environment. Being supportive can be as simple as using the person’s preferred name and pronoun. Traditionally, even this level of support has not been reached in the health care industry because lack of education and training. It’s important that health care providers become more educated about this diverse group of individuals so that all transgender people can receive appropriate health care for their minds and bodies.

For more information on the historical and psychological evolution of transgender Individuals, please see Association for Gay and Lesbian Psychiatrists (AGLP).
More information and medical guidelines can be found at World Professional Association for Transgender Health (WPATH), www.wpath.org/

By Eric Yarbrough, M.D.
President, Association of Gay and Lesbian Psychiatrists
Director of Psychiatric Services, Callen-Lorde Community Health Center
New York City

This post is part of an ongoing series spotlighting diversity from APA’s Division of Diversity and Health Equity.

Human Trafficking: Modern Day Slavery

Human trafficking is one of the fastest-growing global crimes according to the United Nations. No country is immune to this modern-day slavery. According to one estimate, some 15,000 people are trafficked each year in the U.S. for either forced labor or sexual exploitation. Though governments across the world have declared slavery illegal, more than 20 million people worldwide are victims of forced labor. Human trafficking is the second largest source of illegal income, second only to drug trafficking. This inhumane business cuts across gender, age and ethnicity.

A number of factors—poverty, child abuse, adverse social conditions, gender inequality—make people susceptible to trafficking. Children and youth are among the most vulnerable. Long and short-term physical and mental torture endured by victims leads to many health consequences. Physical health consequences can include traumatic brain injuries and other physical injuries, gastrointestinal problems, infectious diseases, poor nutrition, and reproductive health problems. Psychological consequences can include shame, grief, fear, distrust, self-blame and self-hatred, drug and alcohol addiction, suicide, suicidal thoughts, and post-traumatic stress disorder (PTSD).

Though this business operates in our communities, we don’t see these victims in day-to-day life as they are often kept behind locked doors. However, there are things we can do to fight human trafficking—educate ourselves, spread the word, become involved with groups fighting human trafficking and, take a closer look in our communities. With little knowledge about the human trafficking indicators and few follow-up questions, one can identify incidences of victimization and report them to the relevant authorities. Below is a list of indicators and questions from the U.S. Department of State which may help spot a victim.

Human Trafficking Indicators

   • Living with employer
   • Poor living conditions
   • Multiple people in cramped space
   • Inability to speak to individual alone
   • Answers appear to be scripted and rehearsed
   • Employer is holding identity documents
   • Signs of physical abuse
   • Submissive or fearful
   • Unpaid or paid very little
   • Under 18 and in prostitution

Questions to Ask

Assuming you have the opportunity to speak with a potential victim privately and without jeopardizing the victim’s safety because the trafficker is watching, here are some sample questions to ask to follow up on concerns:
• Can you leave your job if you want to?
• Can you come and go as you please?
• Have you been hurt or threatened if you tried to leave?
• Has your family been threatened?
• Do you live with your employer?
• Where do you sleep and eat?
• Are you in debt to your employer?
• Do you have your passport/identification? Who has it?

For more information, visit Stop the Traffik, a global movement of activists working to stop human trafficking.


By
Sejal Petal, Sr. Program Coordinator, and
Ranna Parekh, M.D., M.P.H., Director
APA Division of Diversity and Health Equity

This post is part of an ongoing series spotlighting diversity from APA’s Division of Diversity and Health Equity.

Stigma: Changing the Conversation and Changing Lives

Renee Binder, MD
APA President

I was reminded recently of the death of an acquaintance who was at the top of her career when she died suddenly after complications from surgery, according to her obituary. I later learned that she had died from suicide, possibly in response to her struggle with chronic pain and resulting depression. 

Stigma serves as a barrier to seeking treatment often because of fears of discrimination. A few years ago, a patient requested that I not keep any records and wanted to pay me in cash. He was concerned that if his psychiatric records were ever discovered, his career could be negatively impacted. Were this man’s concerns legitimate? In a more public incident Sen. Tom Eagleton was forced to withdraw as a candidate for vice president in 1972 after it became public that he had suffered from depression and undergone ECT (electroconvulsive therapy). 

According to the Merriam-Webster Dictionary, the definition of stigma is a set of negative and unfair beliefs that a society or group of people has about something; it is a mark of shame or discredit. 

How can we begin to address mental health stigma? Here are several ideas: We need courageous spokespersons who are willing to come forward and talk about mental health issues that they or their families are experiencing. Former Rep. Patrick Kennedy is one such champion. He has openly discussed his struggles with mental illness and substance abuse and how treatment has helped him lead a productive and rewarding life.
We can learn from the LGBT community and their struggles with stigma and negative stereotypes. They have taught us that “coming out” by public figures and celebrities can decrease stigma.


Another way of combating stigma is for my fellow mental health professions, psychiatrists and others, to take responsibility for examining the language that is used by the media and in our society. Words such as “lunatic,” “crazy person,” or “maniac” convey images of people who are out of control and dangerous rather than people who are experiencing a mental illness and deserve our compassion and support in getting effective treatments. 

Mental health professionals and others can take an active role in drawing attention to language and advocating for more appropriate, compassionate and less stigmatizing language. Mental health care is an essential part of health care. Almost everyone will suffer from a mental health problem at some point in his or her lifetime.. But for people to be willing to access the mental health care they need, we have to continue the fight against stigma.

If we are successful in addressing stigma, and we must be, then not only will we change the conversation, we will also change people’s lives and change the culture. We will finally reach the point where all of us can openly talk about someone’s death by suicide and encourage people with mental health problems to seek the help they need without fear of judgment or harmful repercussions.

By Renée Binder, M.D., APA President 

Know Your Rights: Fair Insurance Coverage for Mental Health

Federal law is clear that health insurance companies cannot discriminate against people seeking care for mental illness or addiction. But how do you know if your insurance company is not complying with the law? What can you do if you suspect a violation?

The American Psychiatric Association (APA) created a tool to help answer these questions. The poster titled, “Fair Insurance Coverage: It’s the Law” (Spanish-language version), clearly and simply explains the law and the steps to take if you suspect a violation.

The poster is intended to help enforce federal law and end discrimination.  Print it out and share the link (www.psychiatry.org/parity).

By understanding your rights and taking action you can help ensure fair coverage for yourself and your family, and you can help others by holding insurance companies accountable.

What Federal Law Requires

The Mental Health Parity and Addiction Equity Act requires any group health plan that covers more than 50 employees and offers mental health and/or substance use disorders coverage to provide that coverage with no greater financial requirements (such as co-pays, deductibles, annual or life-time dollar limits) or treatment limitations than the requirements the plan applies to medical / surgical benefits. 

Also, under the Affordable Care Act, new individual and small group plans in and outside of the mandated health insurance exchanges are required to offer mental and substance use disorder coverage similar to medical/surgical benefits.

In addition to federal law, 49 states and D.C. currently have laws relating to insurance coverage for mental health and substance use.  More information, including a summary table of state laws, is available from the National Conference of State Legislators.

By Deborah Cohen, senior writer, American Psychiatric Association