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.

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.

Racism, Discrimination, and Microaggressions: Effects on Mental Health

We know from extensive research that racism can cause significant harmful effects to the victim’s physical and mental health. In 2006, the American Psychiatric Association (APA) established a formal position against racism and discrimination, which partly states that the APA “recognizes that racism and racial discrimination adversely affect mental health by diminishing the victim’s self-image, confidence and optimal mental functioning…. APA believes that attempts should be made to eliminate racism and racial discrimination by fostering a respectful appreciation of multiculturalism and diversity.”

However, racism—prejudice or discrimination directed against someone of a different race based on a belief that one’s own race is superior—is not a mental disorder (it is not included in APA’s diagnostic manual*).

Racism may not appear in the form of clear and obvious acts, it may be in the form of less obvious, “every day” racism.  These acts, termed “microaggressions,” by psychiatrist Chester Pierce, M.D. in 1970, are subtle, often automatic, and nonverbal exchanges with negative overtones. Originally the concept referred to put-downs of blacks by whites in the post-Civil Rights era, but it has since evolved to include people with many differences.  

These subtle and even unintentional acts, can none-the-less be harmful. The effects of this on children are especially pronounced. Victims of racism often display signs of physical and emotional stress. Some victims even start behaving in self-destructive ways that conform to the negative stereotypes they are facing.

Even perceived discrimination can affect health and mental health in several ways, according to an analysis of more than 130 medical studies.** For example, the stress of ongoing perceived discrimination can lead to an increase in unhealthy behaviors, such as smoking or drinking, and decrease in healthy behaviors, such as exercising and healthy eating. If a person has a sense of hopelessness, and low self-esteem, they may be more likely to engage in risky behaviors.  

So how can people protect themselves?  Research suggests several ways to help protect yourself, including having a supportive network of friends and family you can talk to about problems; taking action to address a situation of discrimination, rather than ignoring or avoiding it; and having strong ties to the group(s) with which you identify.

We can all be more mindful of the existence and impact of even subtle and unintentional racism and racial discrimination in the lives of patients and their families and in their everyday practice.

Read more on the Microaggressions Project blog which provides many examples of everyday microaggressions from people across the country.

By Ranna Parekh, M.D.

Director, Division of Diversity and Health Equity\

American Psychiatric Association

References:

*American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.) 2013. Washington, DC:  Author.

**Pascoe EA, Richman LS. (2009). Perceived Discrimination and Health:  A Meta-Analytic Review. Pscyhol Bull; 135(4):531-554.

Diversity Mental Health Month: Why It is Needed and How It Came to Be

By Steve Koh, MD, MPH, MBA

July of 2014 is the very first APA Diversity Mental Health Month. This
emphasis on mental health needs of diverse populations is much needed. While we
have diversity oriented month observances for specific population groups like
the Black History Month (February), National Women’s History Month (March),
Asian Pacific American Heritage Month (May), Gay and Lesbian Pride Month
(June), American Indian Heritage Month (August), and Hispanic Heritage Month
(September), we have not had a dedicated month more broadly addressing diverse
populations and mental health issues.

I cannot overemphasize the importance of this month. For the first
time, together, we will bring attention to the unique and challenging needs of
the diverse populations with mental illness and substance use disorders, work
to decrease mental health disparities, and engage with diverse populations to
help promote and grow future mental health champions in the communities.

The concept for Diversity Mental Health Month came from a group of
participants in APA’s Minority Fellowship program.  The program’s goal is to eliminate racial and
ethnic disparities in mental health and substance abuse care by providing
specialized training and mentorship. The fellowship fosters those with diverse
backgrounds who have chosen to become physicians specializing in mental health
and to do this work with the diverse populations.  



But what happens when we go home? What then? We felt that it was easy to get
lost when we left our APA meetings in Washington DC. How do we galvanize our
colleagues at home to look at the importance of minority mental health issues?
To recognize the stigma of being an ethnic and cultural minority and also
suffering mental illness? To understand that many minority students do not
consider going into field of medicine let alone mental health profession? To
appreciate the importance of cultural competency and humility in working with
diverse patient population?

Without
involvement a coordinated effort by the APA, it was our belief that while we
personally benefited from the fellowship experience, our impact would be
limited. There needed to be a designated time for all of APA to bring attention
to this important patient population.  So
the idea was born to create a Diversity Mental Health Month. The APA Assembly asked
APA staff to help create a month designated to minority mental health issues
and for the APA to actively promote the month.

I hope that others are excited about this new endeavor of the APA as I
am. The challenges are great but together we can bring the needed attention to
this area of our profession.

Many resources, including an infographic with basic data on mental
health disparities, and brochures and fact sheets on specific populations,
suggested activities, video messages, and more, are available at www.psychiatry.org/diversity-month.