Researcher uncovers trends in mental health disparities

Sergio Aguilar-Gaxiola, MD, PhD, is an international researcher on a mission to identify mental health disparities, particularly among underserved populations, and provide a pathway to improvements. His research has uncovered barriers to care, gaps in appropriate treatment services and other trends that speak to the opportunity for the behavioral health provider community to improve access and care delivery for the underserved.

For example, one study Aguilar-Gaxiola completed in 2012 with the Center for Reducing Health Disparities at the UC Davis Health System found that depression, substance use disorders and anxiety disorders are among the most prevalent behavioral health conditions among Latinos. Few Latinos get the treatment they need, and youth in particular face a number of stressors that may increase their risks, including poor housing, trauma and social exclusion. The research led to community discussions and recommendations to improve access to resources and services.

Aguilar-Gaxiola has done advisory and consultation work with the World Health Organization (WHO), the Pan American Health Organization (PAHO) and the National Institute of Mental Health (NIMH) and is currently on the board of directors for the California Health Care Foundation. He is a professor of clinical internal medicine at the University of California, Davis, and is the founding director of its Center for Reducing Health Disparities.
Additionally, Aguilar-Gaxiola is the author of more than 130 scientific publications and is the recipient of multiple awards. Behavioral Healthcare recently spoke to him to discuss his research.

Barriers to care

Aguilar-Gaxiola says barriers to access mental health treatment exist at the individual level, the community level and the systemic level. Stigma, poor living conditions, lack of social resources and lack of culturally appropriate services are among the issues he’s observed.

For example, large percentages of Latino individuals who do access treatment for mental health conditions tend to end their treatment after just one session—in some cases, the number is as high as 75%. He believes that the barriers to initial treatment and discontinuation of treatment after the initial encounter signify a lack of appropriate engagement, which most patients need for optimal outcomes. Cultural and linguistic factors play a key role.

And there are many population groups that are “way underserved” when it comes to mental health, he says, and their voices are not often heard. Such disparity brings costs to the individual, their families, communities and to the country overall.

“You have seen over and over again, when there are tragedies in the United States and abroad, and when it is discovered that the person identified was suffering from a mental illness that was untreated or inappropriately treated, there is national soul searching and debate about mental illness being associated with violence,” Aguilar-Gaxiola says. “And then the myth is unduly propelled and perpetuated, and there is a lack of understanding not based on facts. It puts our profession, our area of discipline, in a bad light.”

BH: In your own words, what kind of research have you done around disparities?

Aguilar-Gaxiola: I’ve been studying health disparities for a good chunk of my life—over 30 years now. My focus has been primarily, although not exclusively, on migration and health and to what extent immigrant populations and people born here in the United States compare.

I compared the populations in terms of how they suffer from mental disorders and other health conditions. I have studied comorbidity of mental illness with physical conditions such as diabetes with depression and substance abuse. Also, I have studied the patterns of service utilization: How is it that people use services, or if they are not using services, what are the barriers? If they are using services and then they stop using them, there are reasons related to that. Also, what are the factors that keep people resilient?

More recently, we have been studying the issue of burden of disease: To what extent are those suffering from serious mental illness (SMI), such as major depression, burdened in their day-to-day life, compared to those with terminal cancer or hypertension?

BH: It’s interesting that burden of disease can be measured that way.

Aguilar-Gaxiola: Yes, I’ve been working with an initiative sponsored by the World Health Organization (WHO) we call the World Mental Health Survey Consortium. It’s the largest mental health initiative ever—almost 40 countries now. I coordinate the participating countries in Latin America.

BH: What is a recent trend you’ve identified?

One of the key pieces of big news is the treatment gap that is found across world. Between 50% to 90% of people with SMI have not received appropriate mental healthcare in the previous year.

In the United States, for example, there is a high level of unmet need for generalist or specialist care in the 12 months previous among those identified with mental illness.  For example, in Hispanics 70% have not received services. And for African-Americans, it’s about the same at 72%. For Asian-Americans, it’s a little bit worse at 78%. This gets worse when we focus on specific populations within those groups such as U.S.-born versus immigrants.

BH: What are some barriers you’ve noted?

Aguilar-Gaxiola: We have found and documented at an individual level that stigma, for example, plays a key role for people with mental illness not seeking services when needed. We can say a lot things about stigma, but one that stands out is that it is a huge barrier for people to take the step from suffering with something that needs treatment to reaching out for and receiving treatment.

One barrier I see at the community level in California, but I think it happens all over, is the lack of culturally linguistically appropriate services, for example.

BH: What are some of the reasons behind the disparities?

Aguilar-Gaxiola: I will summarize it in what we call the five As:

• Accessibility;
• Affordability;
• Availability;
• Appropriateness; and
• Advocacy.

BH: I can see how these five A’s are all intertwined. If you can’t afford services, or there aren’t any providers close by, then you don’t truly have access to them, for example.

Aguilar-Gaxiola: Exactly! With Affordable Care Act (ACA) implementation, more people have gained coverage through the exchanges or Medi-Cal [California’s Medicaid program]. They find that even though they have coverage, they are unable to find professionals who would provide the services, especially in the rural areas.

Appropriateness has to do with providers who understand the culture and sometimes even speak the language. For example, we are working with LGBTQ populations, and they have described how difficult it is to find providers who really understand them. Cultural and linguistic competence has been found to influence whether people will return for treatment. So retention in treatment is very much related to the issue of appropriateness.

BH: I can see how language barriers can affect many of those aspects, too. Mental health treatment requires so much rapport and communication between patients and providers.

Aguilar-Gaxiola: Very true! One reason for the significant lack of utilization in some groups like Latinos for example, is that for interpreters who can help with interpretation and/or translation, trying to explain what being depressed feels like is an incredible chore. I have seen people who are depressed throw in the towel, saying ‘what’s the use?’ There is all this back and forth when they have to explain to the doctor what is happening to them, and they lose faith in whether the doctor is in a position to help them. Interpretation and translation plays a key role since mental illness is, by the most part, subjective because it’s related to language and how you can express what is happening. You can’t visibly see it, like bleeding, or a fracture, or a rash, or a tumor.

When all of these barriers are combined, it may lead to the fact that some populations are not using mental health services until they are falling apart. Then they go to the emergency room where the services are 10 times more expensive and not as effective as receiving services in ongoing outpatient care.

BH: I know you’ve developed a curriculum for culturally and linguistically appropriate services. Are you also looking at broader initiatives with federal health leadership in the future?

Aguilar-Gaxiola: My team and I have presented this curriculum that we call Providing Quality Health Care with CLAS—CLAS refers to Culturally and Linguistically Appropriate Services standards—at federal agencies like NIH and other Department of Health and Human Services agencies such as the Office of Minority Health. My hope is that we are able to have outcomes and replicate efforts in a way that is not a cookie cutter but to tailor the efforts depending on the specific populations. What we develop are models that can be applicable in other places. We need to consider the unique characteristics of the specific populations and tailor our efforts to what we hear directly from groups of stakeholders.

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Video of Sergio Aguilar-Gaxiola talking about health disparities