Policy Brief on Mental Health Disparities in Colorado – Summary

INTRODUCTIONINTENT & CONTENTSThe <strong>Policy</strong> <strong>Brief</strong> on Mental Health Disparities in Coloradowas commissioned by The Colorado Trust to inform itsongoing grantmaking activities related to advancingquality mental health care for the people of Colorado.It is based on an extensive literature review on mentalhealth disparities, input from community members andan advisory group comprised of Colorado communitymental health leaders (see listing on back page), as wellas recommendations received from participants in the2006 Colorado Mental Health Disparities Summit.IMPACT & OPPORTUNITIESGood mental health enables individuals from allracial and ethnic backgrounds to pursue healthyrelationships, advance their education, succeed in theworkplace and cope with adversity. The consequencesof inadequate or inappropriate mental health services areserious, resulting in such things as an overrepresentationof communities of color in government systems like juvenilejustice, criminal justice and child welfare; decreasedproductivity in the workplace; increased homelessness; andincreased physical health care costs. The effect of mentalillness on both quality of life and economic productivityexceeds many physical illnesses, such as heart diseaseand diabetes. Impacts on quality of life include failedrelationships, significant dysfunction and distress, suicideand suicidal ideation, and limited ability on the part ofparents to care for their children. And, lost productivitydue to mental illness cost U.S. employers $105 billion in1990 alone.A successful mental health system serves the diverse needsof different racial and ethnic communities by working withproviders who are linguistically and culturally competent.It also integrates culturally-traditional and -specific services,and providers into the mainstream system to address themental health needs of communities of color within thebroader context of their lives.UNDERSTANDING DISPARITIESUnlike health disparities, studies have shown minimal truedifferences in incidence and prevalence rates of mentalillness across racial and ethnic groups. Although there isa lack of effective data on mental health disparities, thedata show differences in access and utilization of mentalhealth services across ethnic groups. Additionally, the studyof historical and current trauma has connected historicalgenocide, assimilation, oppression and disparate treatmentto such symptoms as depression, suicidal thoughts, anger,anxiety, low self-esteem and difficulty in both recognizingand expressing emotions.ACCESS AND UTILIZATION BARRIERSWhat existing data do show is that – due mainly toa lack of culturally-ethnic providers and relevant treatment– there exists numerous barriers to both access andutilization, specifically:• A lack of access to services due to systemic factors,such as the unavailability of private insurance, lackof mental health coverage in health plans, limitationsof public insurance programs, unavailability or lackof funding for culturally-specific services and thegeographic location of mental health services• A lack of knowledge of available services• Underutilization of psychiatric andpsychological services• Problems with treatment engagement and retention• Misdiagnosis, premature termination of treatment andself-discharge• Culturally-ethnic inappropriate treatments and overuseor -prescribing of medications• Very high rates of substance use disorders and suicide• Increased physical symptoms of mental illness(i.e., somatization)• Limited availability of interpreters and linguisticallycompetent providers and culturally–traditional or–specific providers.

POLICY RECOMMENDATIONSMany of the barriers that lead to mental health disparitiescan be addressed through mainstream, as well as culturallytraditionaland -specific services with policy changes infinancing and systems integration, education and directservice delivery, and data and research.FINANCING AND SYSTEMS INTEGRATIONRECOMMENDATIONSThe policy issues most frequently identified by participantsat the 2006 Colorado Mental Health Disparities Summitwere financing and integration. Integrated financingincludes reimbursement practices of culturally-traditional,indigenous, faith-based or alternative services within themainstream mental health system. Participants felt thiscould be addressed in a variety of ways, including thedevelopment of:• Legislation to support payment for culturallytraditionaland alternative services• Methods for integrating culturally-traditionalservices within mainstream service delivery• An expanded definition of health care thatincludes holistic health care services integratingmind, body and spirit in the reimbursementpractices of public and private insurance• Pilots to demonstrate success of culturallytraditionalor alternative services.Reimbursement and integration of culturally-traditionaland other alternative services has been demonstrated inother states and is supported by the literature, including:• In 1998, the Navajo Nation and Carl T. HaydenMedical Center agreed to reimburse traditionalceremonies through the Veteran’sAdministration.• The Yup’ik and Cup’ik Eskimo of SouthwestAlaska fund tundra walks and time with elders,as well as culturally-traditional treatmentsof mental health and substance abuse, throughMedicaid.• Some social work and divinity schools providecross training to increase the capacity of clergyand social workers to identify and providemental health services within churches.• Cultural brokers serve as a bridge betweenmainstream services and communities of color, andmay help guide the mental health system in its effortsto enhance services.Summit participants recommended improving systemsintegration by removing financial and regulatorybarriers, providing incentives, encouraging collaborationand rewarding communities that integrate and utilizeculturally-traditional services and best practices. Researchsupports integration of services across primary health care,mental health care, substance abuse treatment, educationand other social services and systems of care to meet theindividualized needs of communities of color, as follows:• Recent research strongly supports integrated treatment,with services provided through one centralizedprovider, or a team of providers, to ensure consistencyin treatment planning and coordination as the besttreatment response.• Specific to diagnostic issues, mental and primaryhealth care providers need to be trained to recognizephysical symptoms of mental illnesses. Primary carephysicians should be trained in early detection andtreatment and be ready to help patients access services.• In Colorado, schools partner with regionalmental health centers and private therapiststo provide onsite services. A Wisconsin modelprovides training in education-based mental healthinterventions for therapists located in schools.• Policies that address mental health disparities bysupporting social factors, such as Section 8housing assistance programs and the Earned IncomeTax Credit, have been shown to help in the recoveryof people with mental health needs.• Systems of care create an integrated, holistic, familycentered, individualized and culturally-responsiveapproach that build bridges between different systemsand natural supports, providing services in a cultural,family and community context for individuals.Additional financing and integration areas identifiedby Summit participants included:• Completing a cost-analysis study to look at theimplications of health care parity (equal coveragefor mental health and behavioral services with physicalhealth services) through public and private financingstreams. The study could help demonstrate the needfor an expansion of Colorado parity laws. A study onVermont’s parity law found improvements in accessto outpatient mental health services, reduction ofspending on mental health and substance abuseservices, and no consequent increase in employersdropping coverage.• Addressing financing issues for mental and physicalhealth care services for offenders (individuals convictedof a state felony) transitioning out of correctionswho currently are ineligible for public health insurance.Without such health coverage, offenders would notbe able to receive health care services and maypurposefully return to correctional facilities. In otherstates, including New York, Massachusetts and Texas,re-entry programs that provide continuity of medicationand access to health care after release reduce recidivismand improve individual outcomes.

EDUCATION AND DIRECT SERVICE DELIVERYRECOMMENDATIONSSummit participants identified the need to enhanceeducation and expand the cultural competency ofthe current and future workforce at all levels of care.Recognizing that Colorado’s cultural competency standardsare limited, participants recommended:• Re-introducing and strengthening the 2006 culturalcompetency legislation (Senate Bill 2006-111) byincorporating enhancements to higher educationcultural competency curricula and developingmarkers for progress toward a more culturallycompetent workforce.• Forming a community-based cultural competencyboard to help develop legislation to minimizethe negative implications for communities ofcolor, and review and develop futurelegislation that is culturally competent.• Enhancing curricula and developing minimum standardsfor cultural and linguistic education competency – asvalidated by the research – to:Recognize the historical and socio-politicalimplications that are inextricably linked to the mentalhealth and well-being of communities of color andthe implications for diagnosis, treatment and deliveryof culturally appropriate care.Ensure that minimum standards, certificationsand regulations for cultural and linguistic competencyare clearly articulated in contracts and otheragreements between providers and funding agencies.For example, Colorado currently has no certificationor other regulation of interpretation and translationservices, resulting in the quality and knowledgeof interpreters and translators varying widelythroughout the system.Assist immigrants’ adjustment to American societyand the tremendous quality of life improvementsthat result from appropriate, early diagnosis andtreatment of mental illnesses.Participants also felt that creating a more diverseworkforce was necessary to enhance the mental healthof communities of color. In addition to the integrationof culturally-traditional and alternative providers into themainstream mental health system, other recommendationsto improve services for communities of color and decreasemental health disparities include:• Recruitment of more psychiatrists, psychologists andother mental health practitioners from diverse racialand ethnic backgrounds. States such as Florida, Ohioand Virginia have developed effective recruitmentprograms for providers of color.• Increased reliance on social workers and nurses toexpand the number of racial and ethnic minority,and female mental health workers, as well asflexible use of non-physician providers, includingreimbursement policies and quality indicators.“The teachings of our ancestors are very important inkeeping the circle whole. These teachings guide thedelivery of care in a more holistic and less individualisticway. The collective approach works because if one personis sick in the family, everyone is sick.”

POLICY RECOMMENDATIONS, continuedDATA AND RESEARCH RECOMMENDATIONSSummit participants recommended convening diversestakeholders to develop culturally appropriate guidelines.Stakeholders – including universities and communitycolleges, state agencies, providers and communities of color– would develop the guidelines with community input andparticipation, and use them to enhance data collection,research, evaluation and grant processes. This is key, asresearch findings show that:• Historical neglect of cultural issues by researchershas resulted in minimal scientific knowledge focusingon mental health differences by culture, acculturationand generational status, race or ethnicity demonstratingthe need for improved research. In Colorado, similarissues have resulted in some information beingavailable, but gaps exist due to attempts to simplifythinking by grouping people of color into larger racialand ethnic categories, and the inability to capture datarelated to acculturation and culturally-specific services.• To incorporate cultural and linguistic issues fully,research of quality mental health must include activecollaboration and participation of communitiesof color at every stage of research – in the development,analysis, review, recommendations and dissemination.Feedback mechanisms for researchers should also beincluded to help them gain information and share itwith communities so that they, in turn, can improveservices. For example, in the aftermath of HurricaneKatrina, the Colorado Division of Mental HealthServices created a partnership between formal andculturally-traditional mental health providers andsubcontracted with the Black Psychologists Associationto conduct a needs assessment.In addition to the above recommendations, Summitparticipants identified a range of other policyrecommendations for further exploration. The full report,Mental Health Disparities in Colorado (available atwww.coloradotrust.org), explores these recommendations.<strong>Policy</strong>makers, providers, government and other communityleaders and stakeholders are encouraged to review all ofthe issues and recommendations as they work together toidentify comprehensive policy solutions to address mentalhealth disparities in Colorado.PLEASE NOTE: To view the citations from the extensiveliterature review used for this <strong>Policy</strong> <strong>Brief</strong> and the fullreport, please see the on-line versions of these reports(www.coloradotrust.org).

THE COLORADO TRUST is dedicated to advancing the health and wellbeingof the people of Colorado.ADVISORY MEMBERS• Asian Pacific Development Center –Frank Kim, Ph.D. and Carey Ann Tanaka, Ph.D.• Association of Black Psychologists –Robert L. Atwell, Psy.D.• Association of Black Psychologists; Denver Chapter –Carnita M. Groves, MA• AstraZeneca – Dyan Alexander, MAS• Colorado Asian Health Education and Promotion –Alok Sarwal, Ph.D.• Colorado Behavioral Healthcare Council –Doyle Forrestal, JD• Colorado Community Church – Pastor Keita Andrews• The Colorado Trust – Carol Breslau, MPA andGinger Harrell, BA• Denver Indian Family Resource Center –Isabelle Medchill, LCSW and Theresa Halsey, BA• Division of Mental Health, Colorado Department ofHuman Services – Curt Drennen, Psy.D. andJane Crowley• Denver Mayor’s Office for Education and Children –Susan M. Gallo, Ph.D.• El Centro Esperanza – Maria Evelyn Morreo, MA• Family Agency Collaboration, Mental Health Center ofDenver – Deborah Ward-White, LCC• Federation of Families for Children’s Mental Health;Colorado Chapter – Lily Boyce• Office of Health Disparities, Colorado Department ofPublic Health and Environment – Cerise Hunt, MSW• Research Evaluation Associates for Latinos –Theresa Rosner-Salazar, Psy.D.• University of Colorado at Denver and Health SciencesCenter & Colorado Psychological Association –Chad Morris, Ph.D. and Cynthia Wang-Toxby, Psy.D.The research, outreach and writing of thispublication was a partnership between:The Center for Systems Integration (CSI)Pilar Ingargiola, MPH; Denise McHugh, JD; Jewlya Lynn,BA; Melissa Guzman, MSW - a public policy think tank thatbrings together research with input from communities,policymakers, leaders and the public to find solutions tocomplex policy problems (www.csi-policy.org)andBridging Cultures, Improving PerformanceLucy Trujillo, BS - a consultancy working to developand implement a process of organizational changefor improving the climate for diversity(lucy.trujillo@comcast.net).A special thank you to AstraZeneca for its support of the2006 Colorado Mental Health Disparities Summit.The Colorado Trust1600 Sherman StreetDenver, Colorado 80203www.coloradotrust.org“The Colorado Trust” is registeredas a trademark in the U.S. Patentand Trademark Office. CopyrightDecember 2006. The Colorado Trust.All rights reserved.The Colorado Trust is pleased to have organizations and individualsshare its materials with others. To request permission to excerpt fromthis publication, either in print or electronically please contact TheColorado Trust: 303-837-1200 or receptionist@coloradotrust.org.