Disparities in Psychiatric Care: Clinical and Cross-Cultural Perspectives

In 2001, Surgeon General David Satcher published Mental Health: Culture, Race, and Ethnicity (1) as a supplement to his report on mental health (2). The supplement, which focused on the mental health disparities confronted by the four major ethnic minority groups in the United States (African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanic Americans), was followed in 2003 by the Institute of Medicine's Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (3), which also focused on health disparities defined by race and ethnicity. Disparities in Psychiatric Care, which was produced as part of former APA President Pedro Ruiz's efforts to address mental health disparities, expands the definition of disparities used in these previous reports in a variety of directions (e.g., sexual orientation and age)—all the way to the presence of psychiatric illnesses themselves—and thus represents a powerful recasting of the way we think about inequalities in illness burden and access to quality services.

The volume starts with the standard sections on the major ethnic and cultural groups, as per the Surgeon General's and Institute of Medicine's reports, but quickly moves to other ways of framing mental health disparities—gender and sexual minorities, different age groups, and special populations (such as the incarcerated). These chapters are necessarily brief given the breadth of topics covered in this volume, providing an introduction to these issues but often leaving this reader wanting more. Also, the editors clearly gave each group of authors the opportunity to shape their chapters as they saw fit. There are no standard headings, and each chapter takes a slightly different approach to addressing key issues. For example, the chapter on migrant and refugee populations is organized around the results of a qualitative study of migrant veteran responses to interviews about mental health services, while the chapter on incarcerated populations is structured around a series of barriers to effective psychiatric services (e.g., overcrowding, bias). This freedom results in many intriguing chapters (and a more engaging read as the "voices" of the chapters are so variable), but the resulting unevenness in, for example, how assertions of disparities are supported with specific statistical findings can be frustrating. And the titles of many chapters are misleading. For example, an excellent chapter on psychiatric rehabilitation is titled "Disabled Populations"; another focusing on the results of landmark analyses of the Collaborative Psychiatric Epidemiological Studies is labeled "Ethnic and Racial Groups—Special Considerations." It is thus important that readers do not depend on titles to determine which chapters may be of particular interest.

In the end, certain chapters stood out for me as being particularly thought provoking, including Drescher's chapter on gay men and Gokaldas's and Wapenyi's chapter on lesbians (both of which go far in addressing the invisibility of these two groups in the discussion of psychiatric disparities in previous reports), Pumariega's chapter on mental health disparities for children and adolescents (which builds a compelling argument for such disparities through an elegant use of descriptive statistics and an analysis of federal and state policies), and Vogel-Scibilia's chapter on the failures of the current mental health care system (by weaving in the hypothetical story of Theo, whose deteriorating mental health is exacerbated by serial service system failures).

Even those of us whose work focuses on addressing mental health disparities will come away with new insights from this book. This book would be particularly useful for training programs that are looking for engaging material to start exploring these critical issues in their curricula, but even those of us whose work focuses on addressing mental health disparities will come away with new insights from this book. Still, the most important about this volume are the chapters at its conclusion and its insights that are particularly relevant for mental health care policy. In these chapters the editors turn our attention not to the "pieces of the pie" but to the whole pie itself. Mental health disparities are not the unique purview of any single group of Americans—however we might define them. Instead, all individuals with psychiatric illnesses and their families suffer from disparities inherent in our profoundly dysfunctional health care system. These final chapters on parity and health care reform bring home this point; our nation is currently engaged in a great debate regarding our health care system, which makes this volume all the more timely. For as Maj and Baron point out in their chapter on global perspectives on psychiatric disparities, universal health care in and of itself does not guarantee the elimination of mental health disparities. Thus I hope the policymakers who are shaping the future of our health care system are mindful of the many important messages in this volume. If we are truly to have a health care system that meets the goals outlined by the Institute of Medicine—a system that is safe, patient centered, timely, efficient, and equitable [emphasis added] (4)—this volume provides a set of critical signposts on the road to a more promising future.