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.

Stigma: Changing the Conversation and Changing Lives

Renee Binder, MD
APA President

I was reminded recently of the death of an acquaintance who was at the top of her career when she died suddenly after complications from surgery, according to her obituary. I later learned that she had died from suicide, possibly in response to her struggle with chronic pain and resulting depression. 


Stigma serves as a barrier to seeking treatment often because of fears of discrimination. A few years ago, a patient requested that I not keep any records and wanted to pay me in cash. He was concerned that if his psychiatric records were ever discovered, his career could be negatively impacted. Were this man’s concerns legitimate? In a more public incident Sen. Tom Eagleton was forced to withdraw as a candidate for vice president in 1972 after it became public that he had suffered from depression and undergone ECT (electroconvulsive therapy). 


According to the Merriam-Webster Dictionary, the definition of stigma is a set of negative and unfair beliefs that a society or group of people has about something; it is a mark of shame or discredit. 


How can we begin to address mental health stigma? Here are several ideas: We need courageous spokespersons who are willing to come forward and talk about mental health issues that they or their families are experiencing. Former Rep. Patrick Kennedy is one such champion. He has openly discussed his struggles with mental illness and substance abuse and how treatment has helped him lead a productive and rewarding life.

We can learn from the LGBT community and their struggles with stigma and negative stereotypes. They have taught us that “coming out” by public figures and celebrities can decrease stigma.




Another way of combating stigma is for my fellow mental health professions, psychiatrists and others, to take responsibility for examining the language that is used by the media and in our society. Words such as “lunatic,” “crazy person,” or “maniac” convey images of people who are out of control and dangerous rather than people who are experiencing a mental illness and deserve our compassion and support in getting effective treatments. 


Mental health professionals and others can take an active role in drawing attention to language and advocating for more appropriate, compassionate and less stigmatizing language. Mental health care is an essential part of health care. Almost everyone will suffer from a mental health problem at some point in his or her lifetime.. But for people to be willing to access the mental health care they need, we have to continue the fight against stigma.


If we are successful in addressing stigma, and we must be, then not only will we change the conversation, we will also change people’s lives and change the culture. We will finally reach the point where all of us can openly talk about someone’s death by suicide and encourage people with mental health problems to seek the help they need without fear of judgment or harmful repercussions.


By Renée Binder, M.D., APA President 

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.