Commentary: APA's Efforts to Eliminate Disparities

Health and mental health disparities among diverse ethnic, racial, cultural, and linguistic groups in the United States are harsh realities that have been well documented (1,2,3,4). Disparities are manifested in many ways, such as different rates of certain disorders or conditions and discriminatory and biased diagnostic patterns; underutilization of services by various ethnic, racial, or cultural groups; inappropriate use of pharmacologic agents; inadequate psychiatric care by primary care practitioners; communication problems between practitioners and patients; issues pertaining to acceptability of treatment and adherence to treatment; prejudices, discrimination, and racist practices and patients' mistrust of practitioners; and deficiencies in the use of interpreters. The growing recognition of disparities has led to some changes, particularly in the area of quality and effectiveness of services, but it has not resolved the problem. Disparities need to be addressed until they disappear.

As Drs. Atdjian and Vega note in their Open Forum in this issue of Psychiatric Services (5), psychiatrists and organized psychiatry have an important role to play in the elimination of disparities. To provide effective care, psychiatrists—and all mental health professionals—must have personal sensitivity and insight, must be aware of life's conflicts, and must have a commitment to heal, to understand, and to relate to and identify with personal suffering. Over the years, the American Psychiatric Association (APA) and allied organizations have advocated for the rights and benefits of people with mental illness and have fought to eliminate prejudice, discrimination, and stigma. Much has been gained, but much more still needs to be achieved. We can ill afford disunity and fragmentation among mental health professionals, which will dilute our collective efforts to achieve the ultimate goal of high-quality mental health care and optimal quality of life for all Americans.

APA's focus on solutions

Council on minority mental health and health disparities

For many years, APA has been at the forefront of the issue of health and mental health disparities. Over the past 30 years, APA has had a council that has focused on issues related to diverse ethnic, racial, and cultural populations and other marginalized groups. The name of the council has changed over the years, but since May 2002 it has been called the council on minority mental health and health disparities. The council initiates APA actions that promote the mental health of underserved and marginalized populations and advocates for the representation and professional advancement of members of underrepresented and marginalized groups in psychiatry. These groups include African Americans and people of African descent; Asian Americans and Pacific Islanders; Hispanics; Native Americans; women; gay, lesbian, and bisexual persons; and international medical graduates.

The council seeks to eliminate mental health disparities in clinical services and research, which disproportionately affect women and nonwhite populations. The council aims to increase awareness and understanding of the impact of culture on mental health and to foster the development of attitudes, knowledge, and skills in the area of cultural competence. These goals are accomplished through consultation, education, and advocacy within APA and in a variety of other settings, including undergraduate and graduate medical education, faculty development, research, psychiatric administration, and clinical practice. The council is also focused on promoting the recruitment and retention of psychiatrists from underrepresented groups in the profession and in APA.

Steering committee to reduce disparities

APA leaders actively participated in the development of the U.S. Surgeon General's report Mental Health: Culture, Race, and Ethnicity (4). When the report was published in 2001, the APA steering committee to reduce disparities in access to psychiatric care was created to develop a strategic plan to be used internally and externally to actualize and implement as much as possible the recommendations made in the Surgeon General's report. APA's strategic plan to eliminate mental health disparities was finalized and approved by the APA board of trustees in December 2004. The plan focuses on four major areas: expanding the science base; supporting education, training, and career development; enhancing access to care and reducing barriers; and promoting mental health through collaboration and advocacy.

In the area of expanding the science base, several goals will be pursued, including the development of a practice guideline on the assessment and treatment of diverse racial and ethnic groups; the creation of performance and outcome measures to enable meaningful analysis of results by socioeconomic status, race, and ethnicity; examination and publication of results of research on racial and ethnic disparities in mental health; promotion of the systematic inclusion of cultural issues in DSM-V; examination of issues related to the misdiagnosis of mental disorders in diverse populations; formal establishment of journal publication policies to include the consideration of race, culture, and ethnicity; creation of expert panels to identify and create evidence-based best practices to reduce stigma in diverse populations; and recruitment of members of underrepresented groups to become psychiatric researchers.

The second goal of the action plan—to support education, training, and career development—is crucial, because mental health disparities are directly linked to the underrepresentation within psychiatry of members of diverse groups. The plan emphasizes that APA must strengthen its efforts to recruit members of underrepresented groups into psychiatry, starting as early in the educational pipeline as possible. Mentorship resources should be developed to support this recruitment and retention process. Promoting faculty development in cultural competence, cultural diversity, and the reduction of mental health disparities is also a key recommendation of the plan. Strengthening efforts to include cultural competence in residency and medical school curricula is essential in raising awareness and nurturing cross-cultural assessment and treatment skills early on. Providing continuing medical education (CME) opportunities in the areas of cultural competence and diversity with a specific focus on addressing mental health disparities is also important. APA's office of minority and national affairs (OMNA) has taken the lead in increasing the number of CME offerings for psychiatrists at APA's annual meetings that are focused on cultural, ethnic, and racial issues in psychiatry.

Among the recommendations related to the third goal of the action plan—to enhance access to care and reduce barriers—are promoting the development of cost-effective, evidence-based, and culturally competent mental health services; fostering the development of multicultural and multilingual services; establishing programs geared toward eliminating stigma among persons with mental illness who are members of underserved ethnic and racial groups; coordinating national efforts of the district branches and relevant allied mental health associations and advocacy organizations to secure adequate federal and state funding to improve access to high-quality care for underserved racial and ethnic groups; directing APA components to engage in legislative advocacy on behalf of diverse ethnic and racial populations to expand Medicaid and Medicare eligibility and coverage; implementing universal health insurance; and achieving full and comprehensive parity for physical and mental health services.

The fourth goal outlined in the action plan—to promote mental health through collaboration and advocacy—includes recommendations to convene meetings with outside organizations to develop collaborative initiatives related to disparities in access to care and to research and advocacy issues. In March 2005, OMNA and the American Psychiatric Foundation convened the Disparities Action Roundtable, to establish APA's leadership in collaboration with various national organizations to take action against disparities. The American Psychological Association, the National Medical Association, the American Association of Community Psychiatrists, the National Urban League, the National Alliance for Mental Illness, and the National Hispanic Medical Association were among the groups that participated. The ongoing communication and collaboration of the participating groups have already proved invaluable in the Hurricane Katrina relief effort to promote the mental health of survivors.

APA's office of minority and national affairs

In 2004 OMNA established an aggressive agenda to eliminate mental health disparities in keeping with the steering committee recommendations and the APA strategic plan. The agenda has three major goals: to establish APA as the leader in efforts to eliminate mental health disparities among underserved groups and to ensure high-quality mental health care for all Americans; to increase diversity in psychiatry; and to increase understanding and delivery of culturally appropriate care to diverse populations. To accomplish these goals, OMNA has undertaken and expanded upon a number of initiatives that have direct impact on eliminating disparities. OMNA offers fellowships and mentoring to help psychiatric residents become future leaders in the provision of culturally competent mental health and substance abuse care and to undertake research on diverse populations. OMNA provides travel scholarships and summer internships in psychiatry to medical students from diverse backgrounds.

In 2004 OMNA produced and disseminated a videotape called "Real Psychiatry: Doctors in Action," which features four psychiatrists from diverse backgrounds in their work and family life to entice young people to consider careers in psychiatry.

OMNA has worked with Francis G. Lu, M.D., to disseminate information about standards that address cultural competence in psychiatry for medical student education. For example, APA's liaison committee on medical education has taken a leadership role by including explicit discussion of health care disparities, cultural competence, and diversity in its accreditation standards. Such standards provide guidance for decision making, admissions criteria, curriculum development, and other actions that will help to foster the development of a culturally diverse and culturally aware health care workforce. Faculty and students must demonstrate an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments. To promote this understanding all instruction must stress the need for students to be concerned with the total medical needs of their patients and the effects that social and cultural circumstances have on their health. To demonstrate compliance with this standard, schools should be able to document objectives related to the development of skills in cultural competence, indicate where in the curriculum students are exposed to such material, and demonstrate the extent to which the objectives are being achieved

In January 2005, OMNA staff, along with members of the Washington Psychiatric Society and the American Association of Community Psychiatrists, convened the first "OMNA on Tour" event in Washington, D.C., at Howard University Hospital. The event brought together people from various ethnicities, disciplines, and stakeholder groups—including psychiatrists, primary care physicians, consumers, substance abuse treatment providers, social service providers, legislators, policy makers, faith community leaders, representatives of governmental agencies, and employers—to discuss mental health disparities and how they are manifested in Washington, D.C., and to hear about models that show promise in addressing unmet mental health needs in diverse, underserved populations.

One of the models showcased was the Institute for Mental Health Ministry (IMHM), based in Baltimore and led by Michael Torres, M.D., an APA member and an ordained minister. IMHM helps to reduce stigma and increase psychiatric help seeking by combining mental health care with spiritual concepts. Many individuals from various cultures and faiths feel more comfortable seeking mental health care when it is informed by spiritual principles.

A goal of "OMNA on Tour" is to foster collaboration among various stakeholder groups, including psychiatrists, to take action against mental health disparities in an effort to improve overall health, well-being, and quality of life in diverse communities. More information about "OMNA on Tour" and about the models highlighted at the conference is available from the second author at [email protected].

Conclusions

This summary description of APA's efforts toward the goal of ending disparities is not intended to push aside criticisms of the profession or of APA. However, it is clear that these efforts are not enough and that more work needs to be done to achieve this critical goal.

Dr. Ruiz, who is president-elect of the American Psychiatric Association (APA), is professor and vice-chair in the department of psychiatry and behavioral sciences of the University of Texas Medical School, 1300 Moursund Street, Houston, Texas 77030 (e-mail, [email protected]). Dr. Primm is director of APA's department of minority and national affairs.