Mental Health Care for Latinos: Introduction to the Special Section

The mental health needs of Latinos are no longer simply the concern of a handful of states or of a particular region. Largely as a result of the growth of the Latino population, mental health care for Latinos is a national concern. The U.S. Hispanic population increased from 22.3 million, or 9 percent of the U.S. population, in 1990 to 35.3 million, or 12.5 percent of the U.S. population, in 2000 (1). Census projections estimate that by the year 2050 Latinos will constitute nearly a quarter of the U.S. population (2).

In addition, the Latino population has spread throughout the United States (3). Although most Latinos live in California and Texas, the states with the greatest proportional growth over the past decade are in the South—North Carolina, Arkansas, Georgia, and Tennessee. North Carolina had the highest increase—by a factor of almost five, from 76,726 in 1990 to 378,963 in 2000. And this growth has extended well beyond the South. The number of Hispanics more than doubled between 1990 and 2000 in 13 non-Southern states, including Delaware, Iowa, Kansas, South Dakota, Utah, and Oregon. When these demographic shifts are considered in conjunction with the large representation of Hispanics in particular states and territories, such as California, Texas, New York, Florida, and Puerto Rico—it is clear that Latinos have a significant national presence.

Within the past two years, several national initiatives have addressed the growing mental health needs of Hispanics. Key stakeholders have been brought together with researchers to develop strategies for improving mental health care for Latinos. In March 2000, the Substance Abuse and Mental Health Services Administration (SAMHSA) and its Center for Mental Health Services held a National Congress for Hispanic Mental Health. A wide range of stakeholders, from policy makers to consumers, developed a national agenda covering accessibility, relevant research, human resources, and accountability (4). As a result, the National Latino Behavioral Health Association (NLBHA) was established to carry out the national agenda. (For further information, see www.nlbha.org).

On December 3, 2000, the National Association of State Mental Health Program Directors (NASMHPD) invited a panel of experts to lead state directors in a discussion of how to address the mental health needs of Hispanics. The panel presentations and the ensuing discussion proved to be a most productive exchange that informed both researchers and service providers and that demonstrated the value of establishing dialogues between different stakeholders. The proceedings of the panel presentations and relevant resources are summarized in a publication by the National Technical Assistance Center for State Mental Health Planning, which is available at www.nasmhpd.org/ntac/reports/latinoweb.pdf.

In August 2001, the U.S. Surgeon General released a landmark report addressing disparities in mental health care for Latinos and the three other major racial or ethnic minority groups (5). The report documents the unmet mental health care needs of minority groups and lays out recommendations for how to best address those needs. The report's main point—that "culture counts" in the organization and delivery of services—has served to energize the national dialogue on how to provide high-quality services and carry out relevant research to meet the mental health care needs of our diverse nation.

The special section in this issue of Psychiatric Services was developed as part of another recent national initiative. With the support of the National Institute of Mental Health, SAMHSA, and the University of California, Los Angeles, a small conference was held May 21 to 23, 2000, to bring together researchers, service providers, policy makers, and consumers with two specific aims. (See www.latinomentalhealth.net.) The first aim of the conference was to identify disparities in mental health care for Latinos, and the second aim was to develop strategies to improve services for this ethnic group. All the papers in this special section were presented at the conference to address these two themes.

In the first article, Dr. Alegría and her colleagues describe how they used data from the National Comorbidity Survey to examine whether there are inequities in the rates of specialty mental health care for Latinos (primarily Mexican Americans) and African Americans compared with non-Latino whites. The authors report, among their many findings, that poor Latinos are less likely to use specialty mental health care services than poor non- Latino whites. In addition, they indicate that serious attention must be given to the fact that ethnic and racial disparities in specialty mental health care vary by region. Such variations can help identify policies and factors that might lead to disparities. Dr. Alegría and her colleagues encourage researchers and policy makers to consider community and system factors that may be associated with disparities in access to mental health care for Latinos and African Americans.

In the next article, Dr. Hough and his colleagues focus on disparities in the receipt of mental health services by high-risk Latino adolescents compared with white and African-American adolescents. They examined the prevalence of mental disorders and service use in a sample drawn from five public sectors of care in San Diego County: mental health services, alcohol and drug services, public school programs for children with serious emotional disturbances, the child welfare sector, and the juvenile justice sector. These authors found that although about half of the Latino youths received specialty mental health care, those with psychiatric disorders were significantly underserved compared with their white counterparts. In particular, the Latino youths entered specialty mental health services at a later age and had made fewer visits for specialty mental health services in the previous year.

Next, Dr. Aguilar-Gaxiola and his colleagues describe an innovative approach that applied epidemiologic and service use data as the basis of a multifaceted community intervention to improve services for Mexican-American adults in Fresno County, California. These authors highlight the specific activities they undertook to educate and mobilize the community, to translate the epidemiologic and service data for key stakeholders, and to influence policy. They report that their biggest challenge was to persuade local policy makers to shift resources to meet the mental health care needs of the largely Spanish-speaking rural communities. They were successful in obtaining support to expand mental health services to this underserved population. Their model is likely to be useful to members of the community who are interested in increasing the responsiveness of local policy makers to the mental health care needs of Latino persons.

In the final article, I discuss ways researchers can increase the applicability of their research to the improvement of access to and quality of care for Latinos. In particular, I recommend service research that is longitudinal, that examines social factors pertaining to consumers and service providers, and that tests new and existing interventions. I argue that collaborative research with key stakeholders, such as consumers and service providers, is more likely to result in positive system change than research that is not informed by these multiple perspectives. With more attention to the dissemination and implementation of findings, research will have a greater chance of improving services for Latinos. I illustrate these points by drawing from exemplary research in each of the recommended areas.

Given the growing presence of Latinos throughout the United States, it is imperative that systems of care in all states and locales systematically examine the use of services and quality of care by race or ethnicity. The two articles in this special section that relate to service accessibility suggest that systems of care are likely to find significant disparities in the delivery of services for Latinos. These two studies included only English-speaking Latinos; the disparities that they uncovered would likely have been greater if Spanish-speaking Latinos had been taken into account.

Such assessments can be used to guide the development of system-wide interventions for improving services to Latinos. For example, the fact that Latino youths received services at a later age than white children in the study by Hough and coauthors indicates that efforts should be directed at assessing Latino youths' needs for services at a much younger age. The results of the study by Alegría and coauthors suggest that efforts to improve access to services by poor Latinos are particularly important.

The case study presented by Aguilar-Gaxiola and coauthors is an excellent example of bridging science and practice. It illustrates how researchers can increase the public health value of science by translating research findings into specific actions for the purpose of improving access to mental health services. The study also underscores the value of bringing together different stakeholders to consider how best to improve care. It offers hope to consumers, service providers, and policy makers that corrective actions can be taken to address the service needs of Latinos.

The study of Latino mental health is a growing field. It brings together rigorous research methods with a spirit of social advocacy. This special section reflects only a small sample of the wide array of research that has been conducted in this field. All the articles point out that there is a cadre of investigators committed to working with systems of care to address the mental health needs of Latinos.

As the diverse Latino population grows and continues to disperse throughout the United States, it is imperative that we examine carefully their mental health status, their mental health care, and ways to improve both. The growth of Latino populations in areas that have not had much Latino representation means that Spanish-speaking staff are less likely to be available. This reality suggests the need for the development of a wide range of evidence-based prevention and treatment interventions, including those that can be used as adjuncts by non-Spanish-speaking staff or as stand-alone interventions, such as services delivered via mass media channels or the Internet. Innovative research informed by sociocultural factors can guide prevention and treatment services for this population. Improving the mental health status of Latinos will enhance the health of our nation.