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Mental health services concern African Americans, study says

U.S. Census Bureau

African Americans across the state have concerns that their mental health assessment and diagnoses are inadequate, according to a state-commissioned report issued today.

These inaccurate psychiatric assessments are a “part of the problem that leads to disparate outcomes,” the report said.

“People felt like they did not have a good assessment (from their provider) to understand what their particular issues are,” said V. Diane Woods,the founding president of the African American Health Institute of San Bernardino County and primary author of the study. “And if you are not getting a good assessment, you are not getting a good plan or care, and it increases the probability that you will be placed on the wrong medication.”

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This is an issue of concern for mental health professionals nationwide.

“Due to lack of cultural understanding, some clinicians may misdiagnose African American patients,” Annelle Primm, the American Psychiatric Association’s deputy medical director and director of its Office of Minority and National Affairs, wrote in an email. “For instance, it is well documented in the literature that African Americans have been overdiagnosed with schizophrenia and underdiagnosed with illnesses like major depression and bipolar disorder. Expressing 'healthy paranoia,' regarded as a survival skill among African Americans, may prompt an uninformed clinician unfamiliar with African American culture to consider this as a symptom of schizophrenia or psychosis.”

Based on 35 focus groups, 45 individual interviews, 635 surveys, and 10 public forums and meetings with residents and mental health professionals from across the state, the report aimed to provide a more complete picture of the African American community’s experience with the state's mental and behavioral health system, Woods said.

"Black people across the state wanted the population report to 'tell the entire story' so others could understand the lived experiences with and related to mental health issues," said Woods, who is also an assistant research psychologist at UC Riverside.

Among the barriers to accessing mental health care described by study participants is a lack of culturally proficient practitioners and providers.

“I should have been in counseling a long time ago,’’ Helen B. Rucker, a Monterey County resident who is African American, told researchers.  “I wish I had access to talk to someone about how I feel. But, there has never been anyone I could talk to who understood what I was going through.”

Karen D. Lincoln, an associate professor of social work at the University of Southern California, said that this dynamic can contribute to disparities in treatment and diagnosis. “There is a white norm around symptom presentation," Lincoln wrote in an email. "If you aren’t looking for the right symptoms or if the language being used to describe the symptoms is unfamiliar to you, you can have disparities in diagnosis.”

Community distrust is another barrier to accessing mental health care, said Thomas A. Parham, a past president of the National Association of Black Psychologists. 

“Historically, what has happened is African Americans are given more institutionalization and drugs as the treatment of choice as opposed to therapy,” said Parham, who also serves as vice chancellor for student affairs and an adjunct faculty member at UC Irvine. “You tend to have misdiagnosis because clinicians are not culturally competent. It diminishes confidence in the mental health system. It’s not all a function of the mental health system being unavailable; people also make deliberate decisions not to access it because they don’t trust them.”

San Francisco’s Paris Jonell Warr, 29, told researchers, for example, that “I personally need help, and I have been trying to get it from the mental health department. With my problem I’ve had since I was a child, I went to a therapist; all he did was give me medication. I need to have a good assessment of the problem. I am not getting the help I need.”   

The researchers also examined some of the government funding streams directed toward culturally tailored mental health programs for African Americans in California. Last year they reviewed the prevention and early intervention plans submitted by each county through the 2004 Mental Health Services Act, which created a 1 percent tax on millionaires to expand community-based services.

Because a disproportionate number of African Americans go to the emergency room or are hospitalized for mental health conditions, access to prevention and early intervention are especially relevant to this population, said the American Psychiatric Association’s Primm.

"When African Americans with unmet mental health needs don't have access to appropriate services early enough and wait until they reach the crisis point we have missed a window of opportunity and risk a poor prognosis and outcome," Primm wrote in an email. "The margin of error among African Americans is very narrow due to contextual factors such as the social determinants of health and mental health: disproportionate poverty and economically distressed communities, racism, mass incarceration. ..."

Although many county plans mentioned African Americans as priority populations, and Los Angeles and Alameda counties funded studies related to African Americans, only four – Butte, San Bernardino, Riverside and Monterey – counties outlined a plan to use Mental Health Services Act funds for prevention and early intervention programs tailored to African Americans.

The study describes programs tailored for African American as those that “are designed specifically for the population utilizing principles and concepts tested in scientific research and presented in peer-reviewed literature.” 

But some county officials said that they had since added tailored programs. Sacramento County, which has one of the highest African American populations in the state, has provided $135,000 in Mental Health Services Act funding to a tailored suicide prevention program this fiscal year; the program will receive an additional $100,000 in these state dollars next fiscal year.

Toni Tullys, the quality management director of the Alameda County Behavioral Health Care Services added that the prevention and early intervention plans are one – but not the only – measure of a county’s commitment to addressing the mental health needs of African Americans.

Tullys said that in Alameda County, Mental Health Services Act prevention and intervention funds are spent on underserved populations and other programs. Because African Americans participate in mental health services at high rates there, the county instead uses a different stream of money from the Mental Health Services Act to offer $1.7 million in grants to innovative community organizations working with African Americans clients and families.

The report also includes case studies of community programs that appear to be effective, such as Monterey County’s Village Project, which offers culturally competent preventive, early intervention and clinical services.

“These are tangible, realistic and viable responses,” Woods said. “What we are calling for is accountability across the state, that they no longer have to work in the dark. They can’t say that they don’t know what works with ethnic populations (when it comes to prevention and early intervention).”

In addition to directing more funding to community-based mental health organizations, the report recommends that the state support more data gathering on minority mental health utilization and outcomes, and analyze mental health screening tools used on African Americans, among other suggestions.

The study on African Americans mental health disparities is one of five state-commissioned demographic-specific studies conducted as part of the California Reducing Disparities Project, and these reports will be compiled into a statewide strategic plan that will inform how the state will spend $60 million in funds earmarked to address mental health disparities.

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