Sacramento County aims mental health effort at hard-to-reach groups
The Sacramento Bee

Psychologists across the country have grappled for years with a thorny problem: While every demographic group has mental health problems, certain groups tend not to seek treatment.

Now, Sacramento County is using an infusion of state cash to try to close that gap locally.

The county Department of Health and Human Services has contracted community agencies across the county – one for each of eight specific ethnic or age groups – to evaluate what mental health services those groups need and what obstacles block them from getting help.

In the next 30 months, those agencies will use the evaluation results to try to build programs that better meet those needs.

The initiative also includes a “warm line,” a phone number established several months ago that people can call when they need support or information but aren’t necessarily in crisis.

While the immediate goal is to get more residents the treatment they need, the county ultimately aims to reduce the number who attempt or commit suicide.

“We really want to provide choices for people, so that they will feel comfortable accessing our services in the way that they feel is appropriate for them, their family and their community,” said Jo Ann Johnson, cultural competence and ethnic services manager for the county’s behavioral health services.

The initiative will cost $1.6 million this fiscal year and a similar amount in years to come, all from the state Mental Health Services Act. California voters approved the law in 2004 to enhance services through a 1 percent tax on personal income over $1 million.

The Sacramento effort targets groups that data show tend not to either seek or stick with treatment: Latinos; Hmong, Vietnamese and Cantonese speakers; Slavic and Russian-speaking residents; youths transitioning from adolescence to early adulthood; older adults; African Americans; American Indians; and college-age youths.

The county offers outpatient counseling and inpatient care for residents who have major psychological disorders, such as schizophrenia or severe depression, and have Medi-Cal or no medical insurance.

In 2009, only about 6.4 percent of the residents eligible for Medi-Cal used the county’s mental health services.

That percentage plummeted to 3.9 for Hispanics, 3.5 for Asians, and 3.4 for people age 60 and older. County officials suspect many more needed help but didn’t seek it.

The local rates of mental health care for Asians, Indians, blacks, whites, and seniors fall well below the average for other large California counties.

Suicide rates themselves aren’t the reason for the new county program. Data from the National Institutes of Mental Health indicate that suicide is substantially less frequent among blacks, Latinos and Asians – around 5 or 6 suicides per 100,000 people – than among whites, whose rate is over 13.

American Indians and Alaska natives have the highest rates of all, at more than 14 suicides per 100,000.

Sacramento County is targeting suicide prevention, Johnson said, because in planning sessions for how to spend state MHSA dollars, community members ranked it as a major concern.

County officials believe the disparities in care stem from the fact that, in mental health services, one size does not fit all.

“The mental health system historically has been developed on a European model of treatment,” Johnson said. “We find that that model doesn’t always work well with cultural, racial and ethic groups, because of differences in beliefs and experiences.”

African Americans, for instance, tend to cycle in and out of treatment quickly, which Johnson believes is because the services don’t satisfy them.

So in the African American community, the county’s contractors are working to launch a program of “kitchen table talks,” where family members and neighbors gather to eat and talk with a counselor about issues of concern.

“For some groups, that’s much more natural and comfortable than coming to your local mental health agency,” said Johnson.

There are other cultural barriers. For example, whereas U.S. clinicians naturally focus counseling on the individual, people who come from more collectivist cultures may need treatment that involves the patient’s family and community, said Nolan Zane, a psychologist and chair of Asian American Studies at Davis.

Research has consistently shown that Asian Americans “drastically underutilize” mental health services, he added. Negative views of mental illness are prevalent in many Asian cultures, both in Asia and the United States, and that can make it feel shameful for people to admit they’re distressed and need help, Zane said.

Also, mental illness may look different in people from different cultures, said Zane.

While Western medicine tends to see mental and physical disorders separately, East Asian cultures view health holistically. So people from those cultures tend to express their psychological problems more through physical symptoms such as pain and fatigue, Zane said.

Those variations may make it harder to spot mental illness in certain groups of people, he added. And even if they get into treatment, cultural divides could make them feel that Western-style counseling isn’t helping them.

If a patient complains of a headache and the doctor responds, “Do you think the headache is due to the fight you had with your husband?” Zane explained, “That’s a reason why they may leave treatment early or politely stop coming.”