Utilization of Behavioral Health Services Among the Latino Population

Limited research exists examining the effectiveness of an integrated primary care model of behavioral health service delivery among the Latino population. This descriptive pilot study addresses this gap in the literature by exploring the mechanisms that influence whether Latino integrated primary care patients who receive a Warm Hand-Off (WHO) will or will not pursue further Behavioral Health Services (BHS). Participants were recruited from Clinica Tepeyac, an integrated primary care clinic located in Denver, Colorado. Results showed that the majority of participants engaged in BHS at the suggestion of their medical provider, as opposed to initiating BHS involvement by their own accord. Additionally, participants overwhelmingly indicated that having a behavioral health provider (BHP) that was Latino/a was somewhat important to very important. Future research should focus on more rigorous approaches to exploring ways to facilitate transition from WHOs to further BHS participation for patients that identify as Latino within an integrated primary care setting. BEHAVIORAL HEALTH SERVICES FOR LATINOS 3 Literature Review Introduction to the Latino Population The Latino population in the United States represents individuals that have ancestry in Mexico, Puerto Rico, the Dominican Republic, Cuba, and various countries located in Central and South America. Latino individuals share important commonalities including the Spanish language, music, food, and cultural values, while retaining differences based on country or region. Additionally, the Surgeon General’s Report and its Supplement “Mental Health: Culture, Race and Ethnicity” (2001) emphasize the varied experiences Latinos have when it comes to their migration, stating, “To understand their mental health needs, it is important to examine both the shared and unique experiences of different groups of Hispanic Americans” (p. 1). Mexican-origin Latinos have consistently accounted for the largest Latino-origin group in the United States. However, it is worthy to note that between 1930 and 1980, Latinos from places other than Mexico almost doubled their representation among U.S. Latinos, from 22.4% to 40.6% (Pew Research Center, 2015). According to the 2000 U.S. Census, nearly two-thirds of Latinos were born in the United States. In turn, this large growth has implications for future research focused on the Latino population’s utilization of mental health services, particularly around migration experiences and U.S. residency status. Latinos are estimated to comprise 12 percent of the U.S. Population, but represent almost one out of every four uninsured Americans (Brown et al., 2000; Kaiser Commission, 2000). Mental Health Disparities and Barriers Among Latinos BEHAVIORAL HEALTH SERVICES FOR LATINOS 4 Research has consistently indicated that Latinos experience disparities in mental health care utilization and quality of care (US Department of Health & Human Services, 2001; Young, Klap, Sherbourne, & Wells, 2011). Alegria et al. (2007) found that the lifetime prevalence of psychiatric disorder among Latinos living in the United States is 28.1% for males and 30.2% for females. Additionally, Latinos who are born in the United States, are proficient in English, or are third-generation are more likely to experience a psychiatric disorder. According to the 2010 National Health Care Disparities Report, non-Latino Whites were twice as likely to receive mental health treatment as Latinos (U.S. Department of Health and Human Services, Agency for Health Care Research & Quality, 2011). Pincay and Guarnaccia (2007) found that Latinos identify various barriers to mental health services for depression including lack of insurance, cost of treatment and medications, lack of Spanish-speaking staff, and worry around immigration status. This highlights the importance of providing culturally sensitive interventions and access to care that can address these specific barriers to service utilization. The Surgeon General’s Report (2001) indicates that, “Historical and sociocultural factors suggest that, as a group, Latinos are in great need of mental health services. Latinos, on average, have relatively low educational and economic status” (p. 5). Bridges et al. (2017) explored structural and attitudinal barriers that affect an individual’s decisions and abilities to seek mental health services. Bridges et al. (2014) collected data from 793 participants seen for behavioral health services in 2 primary care clinics. They found that Latino patients had significantly lower self-reported psychiatric distress, significantly higher clinician-assigned global assessments of functioning scores, and fewer received a psychiatric diagnosis at initial visit compared to non-Latino White BEHAVIORAL HEALTH SERVICES FOR LATINOS 5 patients. However, they found that both groups had comparable utilization rates along with comparable and clinically significant symptom improvement and high satisfaction with behavioral health services. Bridges et al. (2007) view their results as preliminary evidence that integrating behavioral health services in primary care may help reduce mental health disparities for Latinos. Willerton, Dankoski, and Martir (2008) propose that an effective method of reaching and treating more Latinos is through medical family therapy. They point to the research indicating that Latinos are more likely to receive their first intervention for mental illness through a physician (Diaz-Martinez & Escobar, 2002). Additionally, Vega et al. (2001) found that immigrant and U.S.-born Mexican Americans disproportionately utilized general medical providers for the treatment of mental health concerns. Guarnaccia, Martinez, and Acosta (2005) point out that Latinos are more likely to somaticize mental health issues than other ethnicities. They report that Latinos tend to have specific experiences that can result in issues of misdiagnosis by medical providers or behavioral health professionals. The cultural syndrome of ataque de nervios (panic) can include trembling, heart palpitations, numbness, loss of consciousness, and difficulty breathing; it is a dramatic expression of deep sadness and distress seen mainly among Caribbean Latinos. Ataques can be viewed as culturally normative ways to express deep sadness such as during a funeral. However, they can also signal the presence of an anxiety or depressive disorder (Romero, 2000; Guarnaccia et al., 2005). Mental Health Stigma Ortega and Alegria (2002) found a self-reliant attitude to be a barrier in seeking care among a Puerto Rican sample. Participants who felt they should be able to cope with BEHAVIORAL HEALTH SERVICES FOR LATINOS 6 mental health problems by themselves were less likely to seek care, even when they reported symptoms that indicated the presence of mental illness. Guarnaccia et al. (2005) refer to this self-reliant attitude as ponerse de su parte (contributing one’s part). They define this attitude as “the feeling that one should be strong enough to cope with life’s problems on their own and with the help of family and not need to depend on the mental health system” (p. 37). This touches upon the concept of familismo, the idea that a Latino individual’s social life is centered around family. This concept can be explored within the context of courtesy stigma, a term developed by Erving Goffman. Courtesy stigma refers to “stigma by association,” where someone can be stigmatized for merely associating with an individual with a mental health concern (Goffman, 1963). Families, therefore, may be reluctant to encourage mental health treatment given that it may reflect poorly and lead to stigmatization and social isolation. Given the impact of immigration on one’s support system, it is interesting to explore ways familismo can look differently among recently immigrated Latinos compared to Latinos that were born or grew up in the United States. Corrigan (2004) tries to understand why people with mental health problems fail to engage in treatment. He proposes that stigma plays a large role in those individuals not seeking psychological help. Corrigan discusses two types of stigma: public stigma and self-stigma. Public stigma is society’s perception that an individual is socially unacceptable, and typically leads to negative reactions toward that individual. Corrigan and Matthews (2003) propose that people hide psychological concerns and avoid treatment in order to limit harmful consequences connected with public stigma; this is called label avoidance. Corrigan (2004) defines self-stigma as the reduction of an BEHAVIORAL HEALTH SERVICES FOR LATINOS 7 individual’s self –esteem/self-worth due to the individual labeling himself or herself as someone that is socially unacceptable. Psychological and psychiatric services utilize diagnoses and labels that can be stigmatizing. Latino consumers of integrated primary care services can be further divided into the subgroup of those who utilize behavioral health services and those who not. It seems reasonable to wonder what intra-group stigmatization might take place among the different subgroups, based on overall public stigma connected to mental health. Cheng, Kwan, and Seving (2012) investigated stigma associated with seeking psychological services by using a sample of African American, Asian American, and Latino American college students. They found, for all three groups, that higher levels of psychological distress and perceived racial/ethnic discrimination predicted higher levels of perceived stigmatization by others for seeking psychological help, which predicted higher self-stigma around seeking psychological help. Additionally, higher levels of other-group orientation (attitudes, feelings, and orientations toward other racial/ethnic groups) predicted lower levels of self-stigma for seeking psychological help. Finally, higher levels of ethnic identity predicted lower levels of self-stigma around seeking psychological