Steven R. Lopez

University of California, Los Angeles

Paper Presented at National Congress for Hispanic Mental Health
March 20-21, 2000 Washington, D.C.

Acknowledgements:
The Steering Committee, Bernie Ahrons, Santo "Buddy" Ruiz, and Glorisa Canino were helpful in the writing of this paper.

The Mental Health Needs of Hispanics in the United States

Hispanics comprise a rapidly growing ethnic group within the United States. Hispanics are projected to increase in size from nearly 32 million in 1999 (11.6% of the U.S.), to 97 million, almost 25% of the 2050 population. This increase is fueled in part by high rates of immigration. For example, the number of Mexican-born persons in the United States grew from 2.2 million in 1980, to 4.3 million in 1990, and most recently to 7 million in 1997. When considering residents of Puerto Rico, the number of Hispanics currently residing in the United States increases by 4 million to nearly 36 million or 12.8% of the population. Although persons of Hispanic origin have primarily resided in the Southwest, Illinois, Florida, New York and New Jersey, as well as Puerto Rico, they are spreading now to other parts of our country, including several southern states. In fact, the states of Arkansas, North Carolina and Georgia saw the number of Hispanic residents at least double from 1990 to 1998. The increasing numbers of Hispanics throughout many regions of the United States is challenging existing mental health delivery systems to address the needs of our diverse community. In this report, I highlight some of the demographic characteristics of U.S. Hispanics. I then point out areas where mental health services are most needed. I then provide evidence that few Hispanics in need of mental health care are receiving such services. My main point today is that technology is available to address the significant mental health needs of Latinos. How to get that technology to Latinos with mental health problems is our major challenge.

Demographic Background
Hispanics are quite a diverse group of people. Considering 1996 data only from the mainland, Mexican-origin residents comprise the largest proportion of Hispanics in the United States-63%. Puerto Ricans and Cubans make up the next largest groups on the mainland, 14% and 4% respectively. As a combined group, Central and South Americans comprise 11%, and the remaining 7% are made up of other Hispanic subgroups. Each subgroup has it's own history and path to the United States which contributes to important subgroup differences noted in 1997 census data. For example, in terms of the educational attainment of persons over 25 years of age, Mexican Americans have the least amount of education. Less than one-half of Mexican origin persons have graduated from high school (48.6%) whereas nearly two-thirds of Puerto Ricans (61.1%) and Cuban Americans (65.2%) have graduated from high school. When one considers economic resources, Puerto Ricans have the least resources. Their unemployment rate of persons 16 years and older is highest (Puerto Ricans 11.4%, Mexicans 9.5%, Cubans 6.1%), as well as their percentage of persons below the poverty level (Puerto Ricans 35.7%, Mexicans 31.0%, Cubans 17.3%). In addition, Puerto Ricans' median family income is lowest (Puerto Ricans $23,646, Mexicans $25,347, Cubans $35,616). Another important dimension of diversity concerns place of birth and citizenship. Puerto Ricans are all born in the United States and are all citizens. For other Hispanics in 1996, a little over one-third (34.8%) are U.S.-born whereas nearly two-thirds (65.2%) are foreign-born. Almost all of the foreign-born Hispanics were not citizens (88%). This pattern does not hold for Cubans, however, as half of their foreign-born are citizens. Each of these subgroup differences point out the considerable diversity among Hispanics and have important implications for the delivery of mental health care. Given the objective of establishing an agenda for mental health care for all Hispanics, we will be focusing on Hispanics as a group. Nevertheless, it is important to recognize that the translation of the agenda for specific communities may vary.

As a group Hispanics are young. The mean and median age of Hispanics is the lowest of all the main U.S. ethnic groups. Hispanics are the only ethnic group with a mean age under 30 years, specifically 28.9 years. This contrasts with the considerably older group of Non-Hispanic Whites (38.6 years). In addition to their youth, Hispanics have attained low levels of education. In 1996, only 54.7% of persons 25 years and older had graduated from high school. The high school graduation rate was markedly higher for non-Hispanics-84.8%. Related to low education, persons of Hispanic-origin have fewer economic resources than most other ethnic groups. A relatively high percentage of their families (26.4%) are living below the federal government's designated poverty level. The poverty rate is even more striking when considering children under 18 years of age. Forty percent of all Hispanic children live at this level whereas only 17% of non-Hispanic children do so. Given the limited economic resources, Hispanics have the lowest rates of insurance among the major U.S. ethnic groups. During the entire year of 1998, 35.3% of Hispanics were without insurance. This is even more striking when considering the poor; 44% of Hispanic poor were without insurance. The fact that the Hispanic poor are much more likely to be uninsured than the poor from other ethnic groups suggests that factors other than poverty are important in understanding the insurability of Hispanics. The high level of poverty and the relatively low levels of educational attainment place Hispanics as a group at greater risk for health and mental health problems than non-Hispanics. The high uninsured rate is a significant barrier for Hispanics to obtain appropriate care for their mental health problems.

Mental Health and Substance Use Problems
The most recent psychiatric epidemiological study conducted with Hispanics was based on 3012 persons of Mexican descent from both rural and urban areas in Fresno County, California (Vega et al., 1998). What is most striking of these findings is that Mexican immigrants had considerably lower lifetime prevalence rates of major mental disorders than did U.S.-born Mexican Americans. The lifetime prevalence rate for any disorder for Mexican immigrants was nearly half that of U.S.-born Mexican Americans (24.9% vs. 48.1%). Moreover, when compared to data from the National Comorbidity Survey, the lifetime rates of disorders for the national sample (5384 adults) was comparable to that of the U.S. born Mexican Americans (Kessler et al., 1994). For example, the lifetime prevalence rate of any disorder for the national sample (48.6%) was nearly identical to that for the U.S.-born Mexican Americans (48.1%). The findings that immigrants have lower prevalence rates of mental disorders than do U.S. born Mexican Americans corroborates the findings of the Los Angeles Epidemiologic Catchment Area Study (Burnam et al., 1987). These findings are consistent with a growing number of studies that suggest that the health and mental health status of Hispanics decrease as Hispanics acculturate to the U.S. way of life (Vega & Amaro, 1994).

The current psychiatric epidemiological studies are limited to the specific locales under study. As a result, it is difficult to know the applicability of the obtained findings to Hispanics across the country. Some national surveys, however, have been carried out in which Hispanics were oversampled with the aim of identifying national rates of problem behaviors for Hispanics. One such survey is the National Household Survey to assess drug use (Office of Applied Studies, 1999). The most recent study was carried out in 1997. Of the 24,505 completed interviews of noninstitutionalized persons 12 years of age and older, 6259 were Hispanics (25.5%). Overall, Hispanics use of drugs was lower than non-Hispanic whites. This was particularly the case in their use of marijuana, inhalants, hallucinogens, and nonmedical use of prescription drugs. In part the low rates of Hispanics' use of these drugs are due to Hispanic women's very low use of any of these substances. Hispanics, however, did report greater use of alcohol, heroin, and cocaine than did non-Hispanic Whites and, in some cases, Blacks. With regard to the use of alcohol by persons 21 years and older, a greater percentage of Hispanics were either binge drinkers or heavy users of alcohol (16.9%, 6.3%) than non-Hispanic Whites (15.5%, 5.2%) or African Americans (10.8%, 3.9%). Binge drinking is defined as drinking five or more alcoholic beverages on the same occasion on at least one day in the past 30 days. Heavy alcohol use is defined as drinking the same five or more drinks on a given occasion but for at least five days in the past 30 days. Besides alcohol, more Hispanics (1.4%) report using heroin than Non-Hispanic Whites (0.9%) and African Americans (1.0%). Finally, in terms of cocaine, a greater proportion of Hispanic men report having used cocaine in the past year (Hispanic: 3.2%; non-Hispanic white : 2.4%) and in the past month (Hispanic 1.4%; non-Hispanic white, .7%). Although these data are generally limited by not examining nativity or acculturation, and, in some occasions, by not reporting analyses by gender, they indicate Latinos' considerable need for substance abuse treatment.

A final indication of the mental health status of Hispanics is taken from the 1997 report of the Center for Disease Control's Youth Risk Behavior Surveillance (Kann, et al., 1998). This study was based on 16,262 completed interviews of high school students in grades 9 through 12. Like the National Household Survey, African Americans and Hispanics were oversampled. This regularly conducted survey aims to generate national estimates for a range of risk-taking behaviors of adolescents (from sexual behavior to using seat-belts in automobiles). Of particular interest is that Hispanics, both young women and young men, reported proportionally more suicidal ideation and specific suicidal attempts than Whites and Blacks. This ranged from a low of over 10% Hispanics actually having attempted suicide to a high of 23% of Hispanics who considered the possibility of suicide. These data are supported by regional epidemiological studies of Hispanic adolescents and children as well. In the study of depression, depressive symptoms and suicidal ideation among middle school students (grades 6-9) in Houston, Texas and Las Cruces, New Mexico, Roberts and colleagues (1995, 1997) found that Mexican-origin youth suffered from significantly more depression and suicidal ideation than Anglo American youth. In addition, a community sample of children and adolescents in Puerto Rico were found to have significantly higher rates of problem behaviors as reported by parents and teachers than a comparison U.S. mainland sample of children matched on age, sex and socioeconomic status (Achenbach, Bird, Canino et al., 1990). Together the national and regional data indicate that Hispanic children and adolescents have considerable need for mental health services.

Use of Mental Health Services
Hispanics with diagnosable mental disorders who reside in the community are receiving insufficient mental health care in the mainland. In the early 1980s, investigators from the Los Angeles-Epidemiologic Catchment Area study surveyed 1243 Mexican Americans and 1309 non-Hispanic Whites. Mexican Americans with mental disorders within six months prior to the interview reported using either health or mental health services at a lower rate than non-Hispanic Whites--11.1% versus 21.7% (Hough et al., 1987). This was particularly true for those who sought services from mental health specialists: 16.8% for non-Hispanic Whites and 8.4% for Mexican Americans. A look at these data by level of acculturation reveals that the low acculturated Mexican Americans are particularly low users of mental health services: 16.0% for non-Hispanic Whites, 11.3% for high acculturated Mexican Americans, and 3.1% for low acculturated Mexican Americans (Wells et al., 1987). A similar pattern of usage was found in a 1996 survey based on 3012 persons of Mexican descent from both rural and urban areas of Fresno County, California (Vega, et al., 1998). These investigators found that only 8.8% of those with mental health disorders during the 12 months prior to the interview sought services from a mental health specialist. Low usage rate of mental health specialists was even lower for those born in Mexico, 4.6% vs. 11.9% of those born in the United States (Vega et al., 1999). Interestingly, more individuals used medical care providers for their mental health or substance use problems (18.4%). Together the Los Angeles and Fresno epidemiologic studies indicate that few Mexican origin persons with mental disorders are contacting mental health or health care providers for their mental health or substance use problem. Less than 1/11th (8.8%) contact mental health care specialists and less than 1/5th (18.4%) contact health care providers. The problem is much worse for immigrants: less than 1/20th (4.6%) use services from mental health specialists whereas less than 1/9th (11.0%) use services from general health care providers. It is important to note that even though contact was made with a provider the extent and quality of treatment in these studies is not known.

We know much less about the use of mental health services for Hispanic children. However, there is one recent study in which mental health utilization rates were examined in representative urban community samples from Puerto Rico, Connecticut, New York and Georgia (Leaf et al., 1996). The results showed that far fewer children receive services in the specialty mental health sector than are in need of these services. While the rate of recent mental disorder among the children in these four communities was estimated at 32.2%, only 14.9% of the youngsters received mental health services either in the specialty or general health sector within the last 12 months prior to the study. Only 8.1% of the children received services in the specialty mental health sector when analyses were made across the four communities studied. However, when the data were analyzed separately by community, the rates of mental health utilization for children living in San Juan, Puerto Rico were significantly lower (4.8%) than for comparable children living in Atlanta (7.4%), New Haven, (8.0%) and New York (11.2%). Although the data are limited to this one study, it appears that Hispanic children living in Puerto Rico have significantly lower rates of mental health utilization than non-Hispanic children living in the mainland. This study points out the considerable unmet need for children's mental health services for Hispanic children.

In addition to the limited research regarding Latino children, we also know little about service usage among Latino elderly. Also, much less research is available about Cuban Americans, mainland Puerto Ricans, and Central Americans. The Hispanic HANES survey collected data on health care utilization but specific analyses of the use of mental health services has not been reported (see Delgado et al., 1990). Thus, future services research is needed to continue assessing the accessibility of mental health care for all Latinos, especially Latino children and elderly, as well as a wider range of the subethnic groups that comprise Latinos.

Addressing the Service Gaps
Although service usage research suggests that many mental health facilities are not successful in reaching Latinos in need of mental health care, a number of steps can be taken to reduce barriers to care (Lopez, 1980; Unutzer, Katon, Sullivan & Miranda, 1999). Such steps can address policy, facility-institutional, and provider barriers. With regard to policy barriers, it is imperative that Hispanics have health insurance that provides coverage for mental health services. Without such insurance, economic barriers will continue to prevent Hispanics from seeking and following through with such care. Facility-institutional barriers exist on multiple levels. Hispanics with mental disorders are more likely to seek care from primary care providers than mental health specialists. Therefore, establishing collaborative relations between primary care providers and mental health care specialists can increase accessibility to mental health care and improve consumers' mental health status (Wells, Sherbourne et al., 2000). A critical institutional factor is the facility's linguistic and cultural competence. Staff who speak Spanish and are knowledgeable of the sociocultural basis of Hispanics' daily lives are essential. Modifying reimbursement practices to encourage changes in the type of treatments provided is another strategy that can be implemented to address institutional barriers to care. For example, Clark et al. 1995 provided evidence that changes in reimbursement led to an increase in community-based treatment and a decrease in office-based treatment. To treat persons from low-income communities, providers must be encouraged to reach out to consumers within their communities and homes. Provider barriers include the lack of training and adherence to best practice guidelines in both assessment and intervention. Consumers and their families deserve the very best care. Services offered to Latinos must reflect best practices adapted to their locale.

Considerable gains have been made in developing effective pharmacologic and psychosocial interventions for the general population (e.g., Lehman, 1999; Katon, Robinson et al., 1996). It is important that collaborative research efforts be undertaken to insure the effectiveness of these state-of-the-art treatments for Hispanics. With regard to psychopharmacological treatment, clinical trials of existing and new medications must be carried out with Hispanics to insure their effectiveness with this ethnic group. With regard to psychosocial interventions, that is, those treatments in which patients and their families learn how to successfully address their illness, it is critical that such interventions be translated both culturally and linguistically for Latinos. Among the evidence-based treatments, particularly for adults with serious mental illness, there are assertive community treatment to reduce rehospitalization of high risk patients, supportive employment to teach job skills to patients so that they can be employed in competitive jobs, family and individual treatments to reduce clinical exacerbations and to enhance social functioning, and treatments for persons with both mental health and substance use problems. For children, there are evidence-based treatments for conduct disorder, anxiety disorders, attention deficit disorder, among others. There have been some initial efforts to translate some of the psychosocial interventions for adult Latinos (e.g., supportive employment in Hartford, Connecticut, behavioral family treatment in Los Angeles, cognitive therapy in San Francisco and Washington, D.C., and illness management skills in Los Angeles), however, this is merely the beginning of such efforts. The main point is that the technology exists to treat effectively a wide range of mental health problems. It is imperative that such treatments be translated both culturally and linguistically for Latinos.

The Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Mental Health Services (CMHS) has taken a leadership role in beginning to address the noted service gaps. In partnership with the Center for Substance Abuse Treatment and the Center for Substance Abuse Prevention, CMHS is currently funding 17 Community Action Grants with a focus on the adoption and implementation of exemplary practices in mental health, substance abuse and prevention for Hispanic communities. In 2000, SAMHSA's Centers will continue to have a special initiative through the Community Action Grant Program directed at Hispanic adults with serious mental illness and substance abuse disorders and children with serious emotional disorders. In addition, the Comprehensive Community Mental Health Services for Children and Their Families Program of the Center for Mental Health Services has provided 65 five-year grants to states, political subdivisions of states, tribal communities, and territories to develop community-based systems of care for children with serious emotional disturbance and their families. Since its inception in 1993, the Program has served over 10,000 Hispanic children all across the country. This represents about one-fourth of all children served in the Program. Grant communities with a high proportion of Hispanic children and families such as Mott Haven, New York, and Las Cruces, New Mexico, were encouraged to develop systems of care that were culturally competent, linguistically appropriate, and sensitive to the needs of the Hispanic community. These programs are breaking new ground in providing much needed mental health care to Latinos, however, much work is needed to translate these innovative programs into evidence-based care that then can be disseminated throughout the country.

Conclusion
Mental health problems are a burden to the ill person, their family, and our society. In fact, mental illnesses such as depression and schizophrenia are among the most disabling of any health condition (Murray & Lopez, 1996). The social, economic, familial and personal costs of mental illness are too great to have ill persons go without treatment. Collaborative efforts are needed from policy makers, government officials, mental health administrators, providers, researchers, consumers, and their families to address the specific policy, organizational, and provider barriers encountered by Hispanics. The technology is available to provide effective treatment. We must work together to bring quality mental health care to Hispanics. Our families deserve nothing less.

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