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Caring for Ethnic-Racial Minority Elders with Mental Health Problems
posted 08.27.2012

More Posts in This Series

ASA's Mental and Health and Aging Network (MHAN) address the shortage of professionals dealing with mental health and substance abuse among older adults and the landmark report from the Institute of Medicine, "The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands".

Help for Elders with Mental Illness and Substance Use Disorders
By Willard Mays

Geriatric Mental Health Workforce Facing a Crisis: Advocacy Needed Now
By Kimberly A. Williams

By Margarita Alegria

Mental health disorders represent 14 percent of the global burden of disease (Tomlinson et al., 2009), and approximately $150 billion in lost productivity in the United States (Rice and Miller, 1998). In June 2012, the Institute of Medicine (IOM) reported that nearly one in five elder (ages 65 and older) adults in the United States has one or more mental health and-or substance use conditions (IOM, 2012), with mood disorders being their most significant source of emotional anguish and distress (Unutzer et al., 2002). Mood disorders account for an augmented risk for premature mortality (Harris and Barraclough, 1998), increased morbidity (Kessler et al., 2007), and escalating rates of disability (Murray and Lopez, 1997), yet most elders receive no mental health treatment (IOM, 2012).

Although minority elders represent a rapidly increasing segment of an aging U.S. population, they have limited access to mental health care, lagging well behind non-Latino whites. Minority elders suffer disparities in care as great as or greater than do younger groups. This is partly because resources to treat mental disorders are scarce, with workforce shortages and limited public investment the rule rather than the exception. There are a plethora of evidence-based treatments, but such treatments are seldom adopted or offered in usual service settings (Proctor et al., 2009).

Novel approaches are needed to deal with access and quality disparities in minority elders’ mental health care, and to increase successful uptake of evidence-based interventions (EBIs) within community agencies that offer easy access for elders, trusted personnel and outreach. Such care is necessary to contend with minority elders’ lack of recognition of mood symptoms (Aranda, Lee, and Wilson, 2001), stigma surrounding mental illness (Vega and Lopez, 2001), self-reliance, and limited access to specialty mental health care (Bartels et al., 2002).

However, an IOM committee report assessing the mental health and substance abuse workforce for older adults found that “the breadth and magnitude of inadequate workforce training and personnel shortages have grown to such proportions that no single approach, nor a few isolated changes in disparate federal agencies or programs can adequately address the [mental health] issue” (IOM, 2012). One successful approach used in developing countries with similar workforce shortages and scarce resources is task-shifting, where tasks are reassigned, where appropriate, to less specialized health workers. There is evidence that a variety of community health workers (CHWs defined as either paid or volunteer members of the community who work with or in the local healthcare system) can deliver evidence-based treatments, even CHWs without professional mental health backgrounds but who are supervised and supported by clinical personnel.

Not only does using CHWs address personnel shortages, but it also increases diversity in the workforce, and makes up for the dearth of bilingual-bicultural clinicians (Malgady, Rogler, and Constantino, 1987). Further, increasing diversity in the healthcare workforce is linked to improved access for minorities, better satisfaction, superior patient-provider communication, and potential reduction of service disparities (IOM, 2004).

To provide evidence-based mental health care by CHWs also necessitates adapting evidence-based service modules (EBSMs) relevant to the cultural context of minority elders, which would be administered by CHWs. Because many effectiveness trials have not included adequate representation of minorities (Miranda et al., 2005), it is important to know if modifications in treatment protocols are needed to enhance effectiveness for minority elders. The accumulated evidence questions the effectiveness of approaches that merely translate clinical interventions developed for Anglo populations into other languages (Bernal et al., 1995). Findings also show that treatment effectiveness may vary depending upon participants’ needs (Clarke, 1995) and that clients are likely to respond to mental health services in ways consistent with their cultural socialization regarding adequate care (Alegría et al., 2008).

Also, CHW training in evidence-based treatments needs to be conducted focusing specifically on assessing the skills necessary to deliver the intervention, and determining if there is a good fit between the intervention and the capacity of CHWs to deliver it. And safety and security procedures need to be in place ensuring sufficient supervision and coaching on the fidelity of the intervention so that CHWs can provide quality mental health care.

Task-shifting service models require providing an infrastructure of clinical and social service back-up, with an understanding of culture and of the structural social disadvantages resulting from minority status. Older minorities often have low levels of education and acculturation (Angel and Angel, 2006). Many are non-English speakers at high risk of isolation and depression, as traditional family-based support systems are undermined by family disruption, occupational demands, and the growing disorganization of modern urban life. Minority elders who reach mature adulthood often face a series of emotional challenges associated with the loss of work roles and the loss of control over important aspects of their lives (finances, authority in the household) that can lead to depression. Whereas in traditional societies in their countries of origin elders may have been venerated and granted high status, in modern urban societies in the United States their social roles are less clear and their power in the family and subjective social status may decrease (Angel, 2003; Mirowsky and Ross, 1984).

Social and case management services may also be needed for this population. Recent data shows that health literacy appears to contribute to service disparities (Gazmararian et al., 2005), because of a patient’s inability to register for health insurance, difficulty in interpreting coverage benefits and rules, inability to adequately fill out forms in physician offices or difficulty following directions to service facilities. For this reason including case management appears critical as part of a mental health intervention for elder minorities.

As many challenges as opportunities lie ahead if we are to implement the recommendations of the IOM Report on Mental Health Workforce for Older Adults (2012). Yet, there is no question that now is the time to build a strong infrastructure within community agencies as a way to re-engineer and implement effective mental health services for minority elders. Community agencies can help to identify doable, pragmatic approaches to improve mental health services offered by CHWs that are accessible and relevant to elder minority communities. As such, the potential impact of this approach is broad, particularly in its goal of evaluating the effectiveness of outreach and mental health care outside traditional clinic walls. Evidence-based mental health interventions offered by community agencies hold promise. Let’s not waste time.

Margarita Alegria , Ph.D., is Director, Center for Multicultural Mental Health Research, Cambridge Health Alliance and Harvard Medical School, in Somerville, Mass.

This article was brought to you by the editorial committee of ASA’s Mental Health and Aging Network (MHAN).


Alegría, M., et al. 2008. “Evaluation of a Patient Activation and Empowerment Intervention in Mental Health Care.” Medical Care 46(3): 247–56.

Angel, J. 2003. “Devolution and the Social Welfare of Elderly Immigrants: Who Will Bear the Burden?” Public Administration Review 63(1): 79–89.

Angel, J., and Angel, R. 2006. “Minority Group Status and Healthful Aging: Social Structure Still Matters.” American Journal of Public Health 96(7): 1152–9.

Aranda, M., Lee, P. J., and Wilson, S. 2001. “Correlates of Depression in Older Latinos.” Home Health Care Services Quarterly 20(1): 1–20.

Bartels, S., et al. 2002. Community Integration for Older Adults with Mental Illnesses, Overcoming Barriers and Seizing Opportunities. Washington, D.C.: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services.

Bernal, G., Bonilla, J., and Bellido, C. 1995. “Ecological Validity and Cultural Sensitivity for Outcome Research: Issues for the Cultural Adaptation and Development of Psychosocial Treatments With Hispanics.” Journal of Abnormal Child Psychology 23(1): 67–82.

Clarke, G. N. 1995. “Improving the Transition from Basic Efficacy Research to Effectiveness Studies: Methodology Issues and Procedures.” Journal of Consulting and Clinical Psychology 63(5): 718–25.

Gazmararian, J. A., et al. 2005. “Public Health Literacy in America: An Ethical Imperative.” American Journal of Preventive Medicine 28(3): 317–22.

Harris, E. C., and Barraclough, B. 1998. “Excess Mortality of Mental Disorder.” British Journal of Psychiatry 173: 11–53.

Institute of Medicine. 2004. In the Nation’s Compelling Interest: Ensuring Diversity in the Health Care Workforce. Washington, D.C.: Institute of Medicine.

Institute of Medicine (IOM). 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? Washington D.C.: Institute of Medicine.

Kessler R. C., et al. 2007. “Lifetime Prevalence and Age-of-Onset Distributions of Mental Disorders in the World Health Organization’s World Mental Health Survey Initiative.” World Psychiatry 6(3): 168–76.

Malgady, R. G., Rogler, L. H., and Costantino, G. 1987. “Ethnocultural and Linguistic Bias in Mental Health Evaluation of Hispanics.” American Psychologist 42(3): 228.

Miranda, J., et al. 2005. “State of the Science on Psychosocial Interventions for Ethnic Minorities.” Annual Review of Clinical Psychology 1: 113–42.

Mirowsky, J., and Ross, C. E. 1984. “Mexican Culture and Its Emotional Contradictions.” Journal of Health and Social Behavior 2–13.

Murray, C. J. L., and Lopez, A. D. 1997. “Global Mortality, Disability, and the Contribution of Risk Factors: Global Burden of Disease Study.” Lancet 349: 1436–42.

Proctor E. K., et al. 2009. “Implementation Research in Mental Health Services: An Emerging Science With Conceptual, Methodological, and Training Challenges, Administration and Policy.” Mental Health and Mental Health Services 36: 24–34.

Rice, D. P., and Miller, L. S. 1998. “Health Economics and Cost Implications of Anxiety and Other Mental Disorders in the United States.” British Journal of Psychiatry 173 (Suppl. 34): 4–9.

Tomlinson, M., et al. 2009. “Setting Priorities for Global Mental Health Research.” Bulletin of the World Health Organization 87: 438–46.

Unutzer J., et al. 2002. “Collaborative Care Management of Late-Life Depression in the Primary Care Setting: A Randomized Controlled Trial.” Journal of the American Medical Association 288: 2836–45.

Vega, W. A., and Lopez, S. R. 2001. “Priority Issues in Latino Mental Health Services Research.” Mental Health Services Research 3(4): 189–200.

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