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CHAPTER 6
Mental Health Care for Hispanic Americans
Availability, Accessibility, and Utilization of Mental Health Services
Availability of Mental Health Services
Finding mental health treatment from Spanish-speaking providers is likely to
be a problem for many Spanish-speaking Hispanics. In the 1990 census,
about 40 percent of Latinos reported that they either didn’t speak
English or didn’t speak English well. Thus, a significant proportion
of Latinos need Spanish-speaking mental health care providers. Presently
there are no national data to indicate the language skills of the Nation’s
mental health professionals. However, a few studies reveal that there
are few Spanish-speaking and Latino providers. One survey of 1,507 school
psychologists who carry out psychoeducational assessments of bilingual
children in the eight States with the highest percentages of Latinos
found that 43 percent of the psychologists identified themselves as
English-speaking monolinguals (Ochoa et al., 1996). In other words,
a large number of English-speaking-only psychologists are evaluating
bilingual children; this becomes a problem when these children’s
English language skills are limited.
Available clinical psychology human resources data indicate that Latinos comprise
an extremely small portion of practicing psychologists. In fact, in
a recent national survey of 596 licensed psychologists with active clinical
practices who are members of the American Psychological Association,
only 1 percent of the randomly selected sample identified themselves
as Hispanic, whereas 96 percent identified themselves as white (Williams
& Kohut, 1999). Another survey found that there were 29 Latino mental
health professionals for every 100,000 Latinos in the U.S. population.
For whites, the rate was 173 white providers per 100,000 (Center for
Mental Health Service [CMHS], 1999). Clearly, Latino consumers have
limited access to ethnically and linguistically similar providers.
Accessibility of Mental Health Services
The lack of health insurance is a significant barrier to mental health care for
many Latinos. Although Hispanics comprise 12 percent of the U.S. population,
they represent nearly one out of every four uninsured Americans (Brown
et al., 2000; Kaiser Commission, 2000). Nationally, 37 percent of Latinos
are uninsured; this is more than double the percent for whites. These
high numbers are driven mostly by Latinos’ lack of employer based
coverage: Only 43 percent of Latinos are covered through the workplace,
compared to 73 percent of whites. Medicaid and other public coverage
reaches 18 percent of Latinos. Citizenship and immigration status are
other important factors that affect health insurance (Brown et al.,
1999; Hanson, 2001). For example, among Latino youth ages 0 to 17 years
in immigrant families, only 47 percent of noncitizens were insured compared
to 71 percent of citizens. Of children born to U.S.-born parents, 84
percent were insured. Compared to Asian Americans, African Americans,
and white Americans children, Latino children were the least likely
to be insured, regardless of citizenship. For example, noncitizen Latino
children had a significantly lower percentage of being insured (47 %)
than noncitizen Asian children (80 %). Thus, the lower rate of insurance
coverage for Latinos is a function of ethnicity, immigration status,
and citizenship status.
Utilization of Mental Health Services
Community Studies
The available studies consistently indicate that Hispanic community residents
with diagnosable mental disorders are receiving insufficient mental
health care. In the Los Angeles Epidemiologic Catchment Area (ECA) study,
for example, Mexican Americans who had experienced mental disorders
within the past six months were less likely to use health or mental
health services than whites (11 % versus 22 %) (Hough et al., 1987).
The study of Mexican Americans residing in Fresno County revealed similar
results. Only 9 percent of those with mental disorders during the 12
months prior to the interview sought services from a mental health specialist.
This rate was even lower for those born in Mexico (5 %) compared to
those born in the United States (12 %) (Vega et al., 1999). Furthermore,
Latinos are twice as likely to seek treatment for mental disorders in
general health care settings as opposed to mental health specialty settings.
These studies suggest that among Hispanic Americans with mental disorders, fewer
than 1 in 11 contact mental health care specialists, while fewer than
1 in 5 contact general health care providers. Among Hispanic American
immigrants with mental disorders, fewer than 1 in 20 use services from
mental health specialists, while fewer than 1 in 10 use services from
general health care providers.
The National Comorbidity Study also found that Latinos used few mental health
services, even though all those surveyed were fluent in English. For
example, only 11 percent of those with a mood disorder and 10 percent
of those with an anxiety disorder used mental health specialists for
care.
Reports on the use of mental health services in Puerto Rico are much different.
In one community survey (N = 1,551 adults), 85 percent of those
with diagnosable disorders reported using mental health care specialists
or health care providers (Martinez et al., 1991). In a second large
survey focused on poor Puerto Ricans, 32 percent of those identified
as needing mental health care received services in the previous year
(Alegria et al., 1991). Like mainland Latinos, Puerto Ricans obtained
mental health care from the general medical sector more often than from
mental health specialists.
Whereas most studies of Latinos’ use of mental health services have been
largely descriptive in nature, there have been some studies to identify
the processes that lead to accessing mental health care. One study carried
out in Puerto Rico, for example, found that low economic strain was
related to the use of specialty mental health care, suggesting that
economic barriers may con-tribute to low use of mental health services
(Vera et al., 1998). In addition, these investigators pointed out that
predictors vary with regard to the specific aspect of help seeking under
study, from recognizing a mental health problem to seeking care from
health care providers in general and mental health care providers in
particular (See Box 6-3). Another important process that may be associated
with Hispanics’ use of mental health services is stigma. Research
is needed to examine the role of stigma as it relates to their accessing
mental health care.
Mental Health Systems Studies
Several evaluations of Latinos’ use of services in care systems during
the 1980s have been published. Two were based on national data (Snowden
& Cheung, 1990, for 1980–1981; Cheung & Snowden, 1990,
for 1983; Breaux & Ryujin, 1999, for 1986), and two examined insured
populations (Scheffler & Miller, 1989, for 1979–1981; Padgett
et al., 1994, for 1983). Most show low use of inpatient services. The
results for outpatient care were equivocal. Differences between studies
of inpatient and outpatient service use could have resulted from the
study of different Latino subgroups in each sample.
Complementary Therapies
Several national studies show that Americans from all ethnocultural backgrounds
turn to alternative sources of health care, either self-administered
or given by alternative providers, to complement the general health
and mental health care that they receive from mainstream sources (Astin,
1998; Eisenberg et al., 1998; Druss & Rosenheck, 2000). However,
these studies have not included large enough samples of Latinos to give
precise estimates of the use of complementary therapies by this group.
The Hispanic Health and Nutrition Examination Survey (HHANES) found
that only 4 percent of the Mexican American sample in five Southwestern
States had reported consulting a curandero, herbalista, or other
folk medicine practitioner within the prior 12 months (Higginbotham
et al., 1990). However, some believe that the HHANES may not truly represent
the extent of use among all Mexican Americans, because the methods the
HHANES used tend to include individuals with higher education, higher
income, and telephone access, while they tend to miss subgroups that
are harder to reach (Skaer et al., 1996). In fact, studies of smaller
subgroups of Mexican Americans have found that proportions ranging from
7 percent to 44 percent of the sample use curanderos and
other traditional healers (Risser & Mazur, 1995; Keegan, 1996; Skaer
et al., 1996; Macias & Morales, 2000).
Box 6-3: Increasing use of services: Learning from
the past
La Frontera Center
With the growing number and increasing spread of Latinos throughout
the United States, some mental health systems are addressing for the
first time how to reach Latinos in need of mental health care. To
guide current efforts, there is some value in reflecting on how mental
health centers in the 1960s first began to reach out to Latino communities.
La Frontera Center, a mental health center located in South Tucson,
Arizona, is well known for its success in making services available
to Latinos (Preciado Martin, 1979).
When [La Frontera] first opened its doors, bilingual and bicultural social workers
walked through the community introducing themselves and their services.
In addition, service providers established collaborative working relations
with other community organizations such as public health agencies, juvenile
justice, public libraries, and the local Spanish-language radio station.
For example, a depression prevention program was implemented in a public
health well baby clinic where young mothers would bring their children
for a free physical exam. A Spanish-speaking mental health worker would
meet briefly with mothers and provide both educational and assessment
services. When necessary, the mental health worker would refer the mother
for an evaluation at the mental health center. The main point is that
the center developed creative approaches to engage persons in need within
their community context; clinic staff did not wait for potential consumers
to walk through the clinic doors. Evidence of the same philosophy can
be seen in more contemporary services as well, specifically those provided
to caregivers of Latinos with Alzheimer's disease (Henderson et al.,
1993).
Use of folk remedies is more common than consultation with a folk healer, however,
and these remedies are generally used to complement mainstream care.
A study of folk remedies for asthma in a mainland Puerto Rican community
found that these remedies are well known and commonly used, even though
the importance of receiving timely mainstream treatment was recognized
(Pachter et al., 1995).
Integrating complementary care with traditional mental health care was an objective
of a unique training project carried out in Puerto Rico (Koss-Chioino,
1992). Both espiritistas (Puerto Rican folk healers) and mental
health providers participated in a program to enhance mutual understanding
and communication. This model program included lectures and case presentations
by experts representing both therapeutic perspectives, as well as visits
to the healers’ facility, or centro. The avail-able evidence
suggested that this program was most successful in helping both groups
understand their differences, as well as in occasionally coordinating
their treatments. Although mental health providers and folk healers
do not often communicate with one another, this program demonstrated
that the two systems of care have the potential to complement one another.
Also, mental health service providers should be aware that in many places
these complementary sources of care have been stigmatized by the church
and by traditional medical practices. Therefore, some Latinos may be
reluctant to disclose their participation in folk healing practices.
Children and Youth
Very few studies have addressed the use of mental health services by Latino children
and youth. One exception is the Methods for the Epidemiology of Child
and Adolescent Mental Disorders (MECA) study (Lahey et al., 1996). Researchers
obtained community-based probability samples of parent and youth pairs
(N = 1,285) in four sites: New Haven, Connecticut; Atlanta, Georgia;
Westchester County, New York; and San Juan, Puerto Rico. They also administered
a structured diagnostic instrument to assess these children and adolescents.
These investigators found that Puerto Rican youth used mental health
services significantly less than children from the other sites did.
Of those Puerto Rican youth with a diagnosable mental disorder, only
20 percent reported using mental health-related services (Leaf et al.,
1996). This percentage is markedly lower than the percentages of youth
receiving care at the other sites; they range from 37 to 44 percent.
This study made a unique contribution to the under-standing of children’s
use of mental health services because it obtained a measure of unmet
need that was based both on a diagnosis and on a significant degree
of impairment, where impairment was related to key symptoms of the diagnosis
(Flisher et al., 1997). Including a level of impairment in identifying
need for mental health care is likely to reduce the risk of overestimating
need. Using this measure, 13 percent of Hispanic children, compared
to 16 percent of white children, were rated as having unmet need for
care.
Researchers conducted another study of children’s use of mental health
care in two communities in Texas: Galveston and the lower Rio Grande
Valley (Pumariega et al., 1998). Hispanics reported significantly fewer
life-time counseling visits than white youth (2 versus 4). Bui and Takeuchi
(1992) also found evidence that Hispanics were underrepresented in the
use of outpatient mental health facilities in Los Angeles County from
1983 to 1988. Specifically, they reported that although Hispanics under
18 years of age in Los Angeles County were 42 percent of the under-18-year-old
population, only 36 percent of the adolescent caseload was Hispanic.
Together these studies indicate that Latino youth use mental health
facilities less than they might.
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