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Remarks by
Dr. Robert DeMartino

Center for Mental Health Services
Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services

At the meeting on Depression:
A Health Disparity in Minority Populations—

Understanding the Issues, Creating a Blueprint and Finding the Resources

November 22, 2003
Howard University
Washington, DC

SAMHSA's Role in Integrating Depression into Agency Priorities

Good afternoon. I am Robert DeMartino, and I want to thank you for inviting me here today to represent the Substance Abuse and Mental Health Services Administration (or SAMHSA) and its Center for Mental Health Services. Charles Curie, the Administrator of SAMHSA, likes to say that SAMHSA's work is built on the principle that people of all ages, with or at risk of mental or substance use disorders, should have the opportunity for a fulfilling life that includes a job, a home, and meaningful relationships with family and friends.

SAMHSA programs and policies are driven by our mandates as determined by Congress, our evolving mission, and a national health agenda derived from science and the health needs of the nation. One of these agendas is the Surgeon General's Report on Culture, Race, and Ethnicity. This document clearly defines the barriers that we must remove to end disparities in mental health services.

Among these barriers are the social and economic inequalities faced by minorities in the United States, including racism and discrimination, violence, and poverty. Each of these conditions adversely affects both physical and mental health, placing minorities at risk for mental disorders such as depression.

Stigma discourages major segments of the population, majority and minority alike, from seeking help. Attitudes toward mental illness held by minorities are as unfavorable, or even more unfavorable, than attitudes held by whites. As a consequence, ending disparities requires changes to social, as well as health care, systems.

Mistrust of mental health services is another barrier that discourages minorities from seeking treatment. Their concerns are reinforced by evidence, both direct and indirect, of clinician bias and stereotyping. Minorities tend to receive less appropriate diagnoses and are less likely to receive effective, state-of-the-art treatments.

In addition, the cultures of ethnic and racial minorities alter the types of mental health services they use. Cultural misunderstandings or communication problems between patients and clinicians may prevent minorities from using services and receiving appropriate care.

A few months ago, the President's New Freedom Commission on Mental Health released its final report. Called Achieving the Promise: Transforming Mental Health Care in America, this document provides the vision around which SAMHSA is evaluating and modifying its programs. It describes how we must transform the current system if we are to deliver mental health care that focuses on recovery and helps all of our citizens "build resilience to face life's challenges." These words have particular relevance in terms of depression.

Achieving the Promise asserts six primary goals: goal 3 is that "disparities in mental health services are eliminated." Achieving the Promise underscores what the Surgeon General's report documented about mental health among minorities—that they bear a disproportionately higher burden of disability from mental disorders. This higher burden is not due to a higher rate or severity of illnesses among minorities. Instead, it is the result of less care and poorer quality of care. As called for in Achieving the Promise, changing the mental health system means increasing access, quality, and outcomes of care for minorities.

Well, now to the heart of the matter. What is SAMHSA doing related to depression, particularly among minority populations?

SAMHSA programs and their guiding principles demonstrate our efforts to eliminate disparities in mental health care for minorities. The Surgeon General's Report on Culture, Race, and Ethnicity (copies of which I've also brought for you) lists six requirements for improving mental health care for minorities. As I discuss these requirements, I'd like you to note their links to SAMHSA's programs and guiding principles. I'll also describe just one or two of our ongoing efforts that respond to each requirement, with an emphasis on depression or improving mental health care for minorities.

In its "Vision for the Future," the Surgeon General's report mandates:

1. Expansion of the research base. Good science is an essential underpinning of the public health approach to mental health and mental illness. SAMHSA's Survey of Mental Health Organizations takes a biennial inventory of all mental health organizations and provides information on access to care and on service use by minority and ethnic populations.
   
   All of SAMHSA programs are guided by the principles of hastening science to service, expanding evidenced-based practices, and improving data collection. One important and recent advance is the expansion of NREP—the National Registry of Effective Programs. As you may know, NREP conducts expert evaluations of programs to determine model and promising evidence-based interventions. These programs are then included in a national registry. Last year, we expanded NREP by adapting its criteria to mental health and co-occurring disorder treatment programs. Within the NREP evaluation criteria is one that grades a program's adaptations for ethnic-racial, gender, or age groups.
   
   
2. Improved access to treatment. The Surgeon General's report noted that minorities are more likely to be poor, uninsured, and live in areas with inadequate mental health care. The report also pointed out that minorities are over-represented among high-need populations, such as those in foster care, jail, homeless shelters, and refugee resettlement programs. SAMHSA has designed its programs to respond to these conditions. For example, two of SAMHSA's suicide prevention programs target young Latinas in the Los Angeles area and Alaska Natives and American Indians in rural Alaska.
   
   Two of our priority program areas are Homelessness and Criminal Justice, through which we conduct numerous activities targeted at the mental health of high-need populations. As an example of SAMHSA outreach to high-needs populations, we fund targeted capacity grants for jail diversion. The objective of these grants is to see that persons with mental illnesses and who have run afoul of the law are placed in facilities where they will receive mental health care, and not in jail, where their illnesses may go unrecognized or untreated.
   
   
3. Reduce barriers to treatment. Shame, stigma, and discrimination are major reasons why people with mental health problems don't seek treatment, regardless of their race or ethnicity. SAMHSA is promoting several activities aimed at reducing stigma and other barriers to service. One example is our newly created Center for Addressing Discrimination and Stigma, or the ADS Center. This center assists public and private organizations in the design and implementation of activities to reduce discrimination and stigma associated with mental illness.
   
   This past summer, the ADS Center sponsored "Not In My Backyard"—a training session about strategies for getting residents to accept housing for mental health consumers within their communities. The ADS Center also sponsored two training sessions in conjunction with the National Association of Rural Mental Health Conference. These sessions focused on techniques for communicating anti-discrimination and anti-stigma messages to the media and the public.
   
   
4. Improve quality of care. Minorities are not receiving the same level of care as other groups. This inequity needs to be addressed through appropriate, evidence-based treatments that respond to a person's language and culture. All SAMHSA programs emphasize the expansion of evidence-based treatments that are culturally competent and help eliminate health care disparities.
   
   An example of this is the SAMHSA-funded program called, "Prevention Intervention Project for Families with Depression." This brief, family-focused intervention for families with significant parental mental illness has already been adapted for single-parent, urban, and African-American families. SAMHSA is now adapting this program for the Latino population, which has shown a disturbing surge in diagnosed depressive disorders over the past decade.
   
   
5. Support capacity development. The Surgeon General's report calls for greater representation of minorities among health care providers and more culturally informed providers. SAMHSA activities target both of these areas. Our Minority Fellowship Program is built around improving cultural competence in health care delivery. Minorities make up approximately one fourth of the population, but significantly less than one-tenth of mental health providers. The goal of this program is to increase the pool of minority professionals qualified to provide leadership and expertise to public and private organizations responsible for programs for ethnic minority persons with mental disorders.
   
   Another SAMHSA resource aimed at expanding capacity at the community level is the National Suicide Prevention Resource Center. This center is helping Federal, State, local, and tribal organizations implement community-based suicide prevention programs using culturally appropriate best practices. Thirty thousand people a year commit suicide in the United States, and among those at greatest risk are persons with untreated depression. We can help prevent this tragedy if we reduce the stigma of as well as cultural barriers to seeking mental health treatment.
   
   
6. Promote mental health. The Surgeon General's report describes the need to reduce the effects of social inequities and to promote community and family strengths. It cites chronic social conditions that disproportionately affect America's minorities, such as poverty, racism, and discrimination. It calls for programs that build on natural supports within communities, such as spirituality, and that strengthen families as the primary source of care for adults and children with mental illness.
   
   SAMHSA can only indirectly work to end chronic social conditions. We are, however, engaged in numerous efforts to prevent or reduce the poverty, unemployment, violence, and discrimination related to mental illness. Next week, for example, we are sponsoring a national training conference on ending homelessness among persons with mental illnesses and substance use disorders. Workshops at the conference will focus on providing housing, treatment, employment, and other supports needed by this population—which is disproportionately minority— to provide a first step towards recovery and a full life in the community.
   
   Community and faith-based approaches are an important focus of SAMHSA activities. Oftentimes, a spiritual leader may be the first to know of a person's depression or other mental illness. Through its Faith-based and Community Workgroup, SAMHSA is working to engage faith-based organizations in promoting mental health care. We currently are developing materials to help faith-based organizations understand and expand their role in helping their communities deal with the trauma and anxieties following natural and human-induced disasters.

I have mentioned just a few of SAMHSA's programs aimed at reducing depression and minority health disparities. To successfully fight depression, we must understand its causes, potential treatments, and barriers to treatment within the context of what makes each person unique…their age, gender, culture, and race.

One of the issues raised by this session is how organizations can elevate depression and a focus on minority health care issues in agency priorities and funding. Activities that impact depression, cultural competence, and minority access to quality care do have their place within SAMHSA priority programs, but more needs to be done.

Your organizations can help to raise national attention given to depression through two overlapping means: public engagement and collaborative partnerships. Legislation and funding follow public demands. You can increase public awareness of the seriousness of depression by working to educate the public about its prevalence and to involve the public in efforts to decrease stigma and increase treatment options.

One of the most effective means of raising public awareness is to form collaborative partnerships with other groups. These groups need not be specifically involved in mental health care. One productive path is to involve groups, such as businesses, that may not count mental health care among their objectives. Think how many more people would seek treatment for depression if we could get community and business leaders to end policies that stigmatize treatment or that fund mental health care at lower rates than other health care.

Collaborative partnerships also create larger resource pools that offer a stronger workforce and the power of combined funding. As stated in Achieving the Promise, "no level or branch of government, no element of the private sector, can accomplish needed change on its own." It is up to us to unite in giving to all persons with depression the hope for recovery that makes believing in themselves and in tomorrow possible. Thank you.

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