NAMI CA 2014 Annual Conference “Growing Minds in Changing Times”

NAMI CA 2014 Annual Conference “Growing Minds in Changing Times”

Sergio Aguilar-Gaxiola, MD, PhDProfessor of Clinical Internal Medicine

Director, Center for Reducing Health Disparities University of California, Davis

Newport Beach, CAAugust 2, 2014

If You Build It, Will They Come? Addressing and Reducing Mental Health Treatment

Gaps in Underserved Populations

I have no relevant financial interest/arrangement

or affiliation with

any organizations related to

commercial products or services

to be discussed at this presentation

I have no relevant financial interest/arrangement

or affiliation with

any organizations related to

commercial products or services

to be discussed at this presentation

Disclosure

Mental and/or substance abuse disorders are major drivers of suffering, disability, cost and are associated with poverty

Mental and/or substance abuse disorders are major drivers of suffering, disability, cost and are associated with poverty

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The “Treatment Gap” The “Treatment Gap”

Between 50 to 90% of people with serious mental disorders have not had received appropriate mental health care in the previous year

Between 50 to 90% of people with serious mental disorders have not had received appropriate mental health care in the previous year

Treatment Gap in the U.S.Treatment Gap in the U.S.

Levels of unmet need (not receiving specialist or generalist care in past 12 months, with identified diagnosis in the same period)

–Hispanics – 70%

–African Americans – 72%

–Asian Americans – 78%

–Non-Hispanic Whites – 61%

Levels of unmet need (not receiving specialist or generalist care in past 12 months, with identified diagnosis in the same period)

–Hispanics – 70%

–African Americans – 72%

–Asian Americans – 78%

–Non-Hispanic Whites – 61%

Source: Alegria et al., 2006

Who Utilized Services?

38% of U.S. born received care

15% of immigrants received care

9% of migrant agricultural workers received care

Mexican American Prevalence Mexican American Prevalence and Services Survey (MAPSS)and Services Survey (MAPSS)

Source: Aguilar-Gaxiola, Vega, et al., 2000

Treatment Gap: Is it Only in the U.S.Serious cases NOT receiving treatment during the past12 months

0

10

20

30

40

50

60

70

80

90

Developed countries Developing countries

Lower range Upper range Lower range Upper range

35%

61%

76%

85%

Source: Saxena, 2011; Alegria, 2006; WHO World Mental Health Consortium, JAMA, June 2nd, 2004

Why the Treatment Gap?Why the Treatment Gap?

■ Multiple barriers

1. Individual level (e.g., stigma)

2. Community level (e.g., Lack of culturally and linguistically appropriate services)

3. Systemic level (e.g., Lack of social and economic (e.g., Lack of social and economic resources and poor living conditions)resources and poor living conditions)

■ Lack of Engagement in Behavioral Healthcare

■ Multiple barriers

1. Individual level (e.g., stigma)

2. Community level (e.g., Lack of culturally and linguistically appropriate services)

3. Systemic level (e.g., Lack of social and economic (e.g., Lack of social and economic resources and poor living conditions)resources and poor living conditions)

■ Lack of Engagement in Behavioral Healthcare

Workforce Challenges in Mental HealthWorkforce Challenges in Mental Health

■ High caseloads, “burn out”■ Prescribers■ Lack of adequate training and graduate

preparation programs■ Limited training in providing family-centered or

recovery-oriented care■ Lack of positions in the public mental health

system for consumers and family members■ Limited opportunities for advancement

■ High caseloads, “burn out”■ Prescribers■ Lack of adequate training and graduate

preparation programs■ Limited training in providing family-centered or

recovery-oriented care■ Lack of positions in the public mental health

system for consumers and family members■ Limited opportunities for advancement

Source: Alonzo-Diaz. 2014

Latinos’ Lack of Engagement in Behavioral Healthcare

Latinos’ Lack of Engagement in Behavioral Healthcare

Latinos are more likely than non-Hispanic Whites to terminate treatment prematurely, with as many as as many as 60-75% dropping out after just one session (McCabe,

2002)

Mode number of visits Mode number of visits is 1 is 1 and median is 3 median is 3 to both psychiatrists and psychologists (Alegria, 2007)

Action Needed: Consumer Engagement

Latinos are more likely than non-Hispanic Whites to terminate treatment prematurely, with as many as as many as 60-75% dropping out after just one session (McCabe,

2002)

Mode number of visits Mode number of visits is 1 is 1 and median is 3 median is 3 to both psychiatrists and psychologists (Alegria, 2007)

Action Needed: Consumer Engagement

Untreated Mental IllnessUntreated Mental Illness

Intensify over time…can reduce life expectancy

Causes intense and prolonged suffering to individuals and their families

Limits individuals’ ability to reach social and educational normative goals

Leads to expensive costs to individuals, families, and communities

Intensify over time…can reduce life expectancy

Causes intense and prolonged suffering to individuals and their families

Limits individuals’ ability to reach social and educational normative goals

Leads to expensive costs to individuals, families, and communities

Key Issues In Mental Health CareKey Issues In Mental Health Care

■ The 5 A’s:

1. Accessibility

2. Affordability

3. Availability

4. Appropriateness

5. Advocacy

■ The 5 A’s:

1. Accessibility

2. Affordability

3. Availability

4. Appropriateness

5. Advocacy

How can we transform services and supports to prevent high risk behaviors and improve

outcomes especially in underserved populations?

How can we transform services and supports to prevent high risk behaviors and improve

outcomes especially in underserved populations?

Going Beyond Services and Supports

Going Beyond Services and Supports

Integration of Primary and Behavioral Health Care

Adaptations and Practice-based Evidence

Community-based Partnerships

Community Outreach and Engagement

Prevention and Early Intervention and Health Promotion are Key

Integration of Primary and Behavioral Health Care

Adaptations and Practice-based Evidence

Community-based Partnerships

Community Outreach and Engagement

Prevention and Early Intervention and Health Promotion are Key

Source: Huang, 2007

“No mass disorder afflicting humankind has been

eliminated or brought under control by attempts at treating the affected individual, nor by

training large numbers of individual practitioners”

George AlbeePast President, American Psychological Association

Health care is not the primary determinant of health

Improving health access is only part of the solution to improving health outcomes and reducing health disparities;

There are three reasons why improving access to health care alone will not close the treatment gap:

1. Clinical care treats one person at a time;

2. Intervention often comes late;

3. Clinical care is usually sought after people are sick (“fail first”).

The Role of Prevention inThe Role of Prevention inReducing the Treatment GapReducing the Treatment Gap

Source: Mikkelsen, Cohen, Bhattacharyya, Valenzuela, Davis, & Gantz, 2002

Prevention and Early Intervention can make a vital contribution to current efforts to reduce disparities in health.

By addressing the underlying factors that negatively influence health and mental health, prevention has the power to reduce the incidence of poor mental health and disability and premature death.

The Role of Prevention inThe Role of Prevention inClosing the Treatment GapClosing the Treatment Gap

Source: Mikkelsen, Cohen, Bhattacharyya, Valenzuela, Davis, & Gantz, 2002

IOM Public Briefing March 25, 2009Washington DC

Report of the Committee on the Prevention of Mental Disorders and Substance Abuse

Mental, Emotional and Substance Abuse Disorders Are Common and Costly

Around 1 in 5 young people (14-20%) have a current disorder

Estimated $247 billion in annual costs

Costs to multiple sectors – education, justice, health care, social welfare

Costs to the individual and family

Preventive Opportunities Early in Life

Early onset (75% of adult disorders had onset by age 24; 50% by age 14)

First symptoms occur 2-4 years prior to onset of a diagnosable disorder

Common risk factors for multiple problems and disorders

Prevention Window

Core Concepts of Prevention

1. Prevention requires a change in thinking

2. Mental health and physical health are inseparable

3. Successful prevention is inherently interdisciplinary

4. Mental, emotional, and behavioral (MEB) disorders are developmental

5. Developmental perspective is key

Preventive Intervention Opportunities

Parenthood

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Two Approaches to Targeting Interventions

Target specific disorders -- depression, substance abuse, schizophrenia

Target risk and protective factors for multiple disorders -- poverty, maltreatment, family disruption, community and school risk factors

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Impressive Evidence of Efficacy

Interventions show effects on wide range of serious problems such as substance abuse, depressiondepression, antisocial behavior, child abuse

Interventions improve positive outcomes such as school success, self-esteem

Multi-year effects of some interventions

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Evidence from Studies that Target Specific Disorders

Indications that incidence of adolescent depression can be reduced

Emerging evidence to prevent onset of full-blown schizophrenic episodes

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Long-term Impact of Prevention

Teacher training in classroom instruction and management, child social and emotional skill development and parent workshops were the intervention. A significant multi-varied effect across all 16 primary outcome indices were found. Specific effects included significantly better educational and economic attainment, mental health and sexual health by age 27 years. So prevention is possible.

Hawkins JD, Kosterman R, Catalano RF, Hill KG, and Abbott RD. Effects of Social Development Intervention in Childhood 15 Years Later. Arch Pediatr Adolesc Med. 162(12), pp 1133-1141, 2008.

Community-Defined Solutions for Reducing Mental Health

Disparities

California Reducing Disparities Project

California Reducing Disparities Project

Main goal is to develop a Statewide Comprehensive Strategic Plan.

Identify community-defined promising practices, models, resources/approaches helpful for county program planners, practitioners, and policy makers in designing programs to better address the needs of these communities.

Contribute culturally relevant recommendations from each ethnic/cultural group to develop a comprehensive statewide strategic plan towards the reduction of mental health disparities

Source: Guerrero, 2009

CA Reducing Disparities Project: Latino SPW

• The Latino Statewide Reducing Disparities Project started July 1, 2010.

• The main goal was to produce a community-defined, strength-based, culturally and linguistically appropriate report on reducing disparities in mental health services for Latinos.

• Identified and engaged a diverse range of Latino stakeholder representatives at the state, regional, and local levels.

• Stakeholders included consumers, providers, public agencies, and representatives of community interests, and have diversity in terms of gender, age, and mental health and health issues.

CA Reducing Disparities ProjectLatino SPW: Governance and

Structure

The Concilio

Latino Strategic Planning Workgroup – LATINO CONCILIO

Website: http://www.latinomentalhealthconcilio.org

Forum Sites by City, Region & CountyExhibit 5: Forum Sites by City, Region, and County

California Reducing Disparities Project

Full report (PDF) available at: http://www.latinomentalhealthconcilio.org/mhsa/crdp-latino-population-report/

Spanish version will be soon available

Three Major Types of Barriers

1. Individual-Level Barriers – Stigma – Culture – Gender (masculinity)– Violence and trauma – Knowledge and awareness

2. Community-Level Barriers – Lack of culturally and linguistically appropriate services– Shortage of bilingual and bicultural mental health workers– Lack of school-based mental health programs– Organizational and systemic barriers

3. Systemic-Level Barriers – Lack of social and economic resources and poor living conditions– Inadequate transportation – Social exclusion

Strategic Directions to Improve Access, Availability, Appropriateness, Affordability, and Advocacy

1. School-based mental health programs;

2. Community-based organizations and co-location of resources;

3. Community and social media;

4. Culturally and linguistically appropriate treatment;

5. Workforce development to sustain culturally and linguistically competent workforce;

6. Community capacity building and community outreach and engagement.

* CRDP Latino Population Report, UC Davis Center for Reducing Health Disparities, 2012

Ventura County Demographics

Faith-Based Collaborations• Guadalupe Church, Project Esperanza• St. Paul’s Baptist Church• Word of Life: Community Coalition for Stronger

Families

Co-located Integrated Primary Care• Health Care Agency: Fillmore, Oxnard, Santa Paula,

Simi Valley, Thousand Oaks, Ventura• Clinicas del Camino Real

Mixteco Indigena Community Organizing Project (MICOP)

Services: Community Coalition for Stronger Families (CCSF)

• Training - Mental health training for Mixteco Health Promotores to reduce stigma and other barriers to seeking services

• Outreach & Engagement – Sharing mental health education and raising awareness in Mixteco community

• Education – Presentation for partners and community agencies about Mixteco mental health needs, culture, and community

• Violence Prevention – Developed culturally appropriate training curriculum with The Partnership for Safe Families & Communities of Ventura County

• Promotores and Promotoras Training

• Mixteco Engagement & Farm-worker Outreach & Treatment Project

• City Impact – Community Coalitions for Stronger Families

• Kids & Families Together – Foster Youth Kinship Project

Is it possible to improve Is it possible to improve community mental health community mental health

by focusing primarily by focusing primarily in access to care? in access to care?

Source: Green LA, et al. N Engl J Med 2001;344:2021-5.

The “Ecology” of Medical CareThe “Ecology” of Medical Care

Source: Schroeder, 2007

“Even if the entire U.S. population had access to excellent medical care — which it does not — only a small fraction of these deaths could be prevented. The single greatest opportunity to improve health and reduce premature deaths lies in personal behavior. In fact, behavioral causes account for nearly 40% of all deaths in the United States” (p. 1222).

Determinants of HealthDeterminants of Health

48Source: Miller, 2014

The Affordable Care Act (ACA)The Affordable Care Act (ACA)

Source: Figueroa, 2013

ConclusionsConclusions

Mental health care disparities in access to care (for those who need treatment) exist in the U.S.

They are a major public health problem at the national, state, and local levels.

They lead to significant burden of unmet mental health needs.

This translates into ill health, prolonged suffering, premature death, diminished productivity, and social and economic disparities.

Mental health care disparities in access to care (for those who need treatment) exist in the U.S.

They are a major public health problem at the national, state, and local levels.

They lead to significant burden of unmet mental health needs.

This translates into ill health, prolonged suffering, premature death, diminished productivity, and social and economic disparities.

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ConclusionsConclusions

Globally and locally, most persons with mental substance use disorders and do not receive any specific health care.

The challenges on delivery of effective interventions are large.

We need to generate knowledge on scaling up effective care, especially in low-resource settings.

People who are carrying the disease burden need help now!

Will we respond?Source: Saxena, 2011

If You Build It, Will They Come?If You Build It, Will They Come?

Well…It depends on:■ Who builds it

■ How is it built

■ Where is built

■ Why is built

““Go in search of people. Begin with Go in search of people. Begin with what they know. Build on what they know. Build on

what they have”what they have”

Chinese proverbChinese proverb

““Go in search of people. Begin with Go in search of people. Begin with what they know. Build on what they know. Build on

what they have”what they have”

Chinese proverbChinese proverb

We need to focus… We need to focus…

NAMI CA can play a significant role closing the treatment gap

NAMI CA can play a significant role closing the treatment gap