Depression in minority populations

June 9, 2008 Vol. 24 •Issue 12 • Page 39 Minorities & Mental Health With depression, keeping up appearances can be fatal

By Claudia Stahl Gagliardi, Special to ADVANCE If you were attached to a polygraph and asked one question—How are you?—would you pass?

Terrie M. Williams, author of Black Pain: It Just Looks Like We're Not Hurting, would place her bet on no.

"It's not that we like lying about our feelings or that we even realize that we are holding them back," Williams tells ADVANCE. "It's just that for so many of us, the pain has become normalized."

Black Pain, released in January (Scribner, 2008), is a call to people of all races and backgrounds—but especially African Americans—to recognize that the "game face" they put on routinely is slowly killing them.

Williams hopes the book, which has been featured on CNN and in national newspapers like U.S. News and World Report, will help people recognize that "when you think there may be something wrong with you or someone you know, there usually is."

While the outcomes of untreated mental disorders make daily headlines, the symptoms of mental disorders do not. It took decades of suffering for Williams, a social worker by training and founder of a successful public relations business with a long celebrity client list, to connect her extended bouts of crying and compulsive work habits with depression. But when she disclosed her struggle in an article for Essence magazine, Williams became the celebrity.

"I got thousands of letters and e-mails from people who were fighting their own battles with depression," she recalls, "and that's why I decided to write the book."

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Fear and Taboo Mental disorders affect an estimated 44 -million American adults of all -backgrounds, but compared with whites, minorities have less access to mental health services and when treated, receive a poorer quality of care.1These gaps result from a complex web of factors that include cultural and social issues, racism, economic factors, mistrust of the mental health system (Tables 1 and 2), and physician bias1(For more, see "Disparities In Health Care," Jan. 7, 2008).

According to a survey by Mental Health America (formerly known as the National Mental Health Association), only a third of people with major depression seek treatment, and African Americans are among the least likely to seek it. Some of the resistance is cultural. In the historically faith-based African American culture, Williams says, "it is commonly believed that depression is something you can pray away or snap out of, with discipline." This is also prevalent in the Hispanic/Latino community, where people are often more comfortable turning to the clergy for help than to physicians.

The stigma of mental disorders still pervades most cultures. "We would rather tell someone that a relative is in jail than talk about mental illness," says Williams.

Reaching Consumers Many new efforts are under way to get people with depression into physicians' offices by reaching them within an appropriate cultural context. National public awareness campaigns such as Depression Is Real (www.depressionisreal.org) and the recently launched Men Get Depression National Educational Outreach Campaign (www.mengetdepression.com) are tailoring information to specific populations, offering content in English and Spanish, and developing content for varying levels of literacy.

Majosé Carrasco, MPA, director of the National Alliance on Mental Illness (NAMI) Multicultural Action Center—a co-sponsor of Depression Is Real, with the American Psychiatric Foundation and four other sponsors—tells ADVANCE the campaign "could greatly help multicultural communities recognize and understand depression."

Carrasco, who is involved with Spanish language activities for Depression is Real, adds that NAMI is piloting a Spanish peer-to-peer education program for Latinos with mental illness and developing a Spanish adaptation of In Our Own Voice, a program that trains consumers with mental illness to serve on an educational speakers' bureau.

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Another NAMI initiative in development is a faith-based mental health education program that will work with African American faith leaders to raise awareness of the symptoms and biological basis of mental illnesses, as well as community-based treatment and support options. Williams serves on an advisory panel for this evolving NAMI program while also directing Healing Starts With Us, a national campaign with a mission to educate the African-American community about depression.

Reaching Health Professionals While initiatives to educate the public about mental health issues fill a critical need, "it is equally important that caregivers recognize that culture greatly influences how people understand and present with an illness (Tables 3 and 4) and their help-seeking and coping behaviors," Carrasco says.

Cultural-competence education programs are demonstrating an impact in improving the knowledge, attitudes and skills of health professionals about these factors, which in turn is improving patient satisfaction.2The body of educational resources focused on cultural competence in mental health care has expanded with the Initiative for Decreasing Disparities in Depression (I3D), a collaborative effort involving national experts in minority health, managed care, psychiatry, primary care and education. The I3D educational continuum includes a comprehensive, slide-based curriculum for health professionals focused on multicultural issues in depression care and the four independent, grantfunded activities described in Table 5.

Another I3D resource, "Creating a Collaborative Intervention to Address Disparities in Depression: CME, Quality Improvement and the Community," was published last December as a supplement in the Journal of Continuing Education in the Health Professions. The supplement explores current practices in depression care, the impact of managed care in the mental health arena, disparities in care and recommendations for community-based approaches to eliminating disparities.

"This project identified some constructs for collaboration that

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may prove useful in any chronic disease in which disparities exist," says Karen Overstreet, EdD, a supplement author and co-investigator in the I3D program. She believes the model can be adopted and tested by educators and clinicians throughout the United States.

Practices such as using videotapes for patient education and welcoming family "advocates" during office visits will go a long way to enhance the clinical encounter, notes Annelle B. Primm, MD, PhD, director of minority affairs for the American Psychiatric Association. "Trust is the key to establishing an effective patienthealth professional partnership and optimal outcomes in depression care and medical care in general," she advised during a symposium at the National Medical Association's annual congress.

During her talk, Primm summed up cultural competence in a few basic tenets: "Know yourself, challenge your biases and make an effort to understand your patients' cultural contexts and belief systems."

References available at www.advanceweb.com/OT or upon request.

Claudia Stahl Gagliardi is manager of communications for Nexus Communications Inc. (www.nexuscominc.com) where she participated in a program focused on decreasing disparities in the diagnosis and treatment of depression (www.i-3d.org). Contact her at Claudia.gagliardi@nexuscominc.com.

Article link: http://occupationaltherapy.advanceweb.com/Editorial/Search/AViewer.aspx?AN=OT_08jun9_otp39.html&AD =06-09-2008

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