According to the 2020 National Survey on Drug Use and Health (NSDUH), nearly eight million (18.4 percent) Hispanic/Latino adults reported having a mental illness. Among those with a mental illness, 1.9 million (24.4 percent) had a serious mental illness or a mental illness that affected their ability to function.
Although the prevalence of a major depressive episode (MDE) was lower among Hispanic/Latino youth, a greater proportion of those with MDE reported suicidal ideation compared with non-Hispanic white youth. In 2020, 18.7 percent of non-Hispanic White and 15.7 percent of Hispanic/Latino youth reported MDE. Among non-Hispanic white youth with MDE, the rate of suicidal ideation decreased from 71.6 percent in 2019 to 69.4 percent in 2020. In contrast, the rate increased for Hispanic/Latino youth – 67.1 percent in 2019 to 72.1 percent in 2020.
The data show that efforts to eliminate health behavior disparities must continue. This blog will highlight additional data, present culturally appropriate approaches, and provide a framework for doing so.
Treatment gaps
In addition to differences in prevalence, it is important to consider differences in treatment. For MDE, non-Hispanic white youth received treatment at rates 12–13 percentage points higher than Hispanic/Latino youth. In the 2019 NSDUH, nearly half of non-Hispanic white youth with MDE did not receive treatment compared to 63.2 percent of Hispanic/Latino youth. This remained relatively unchanged in 2020 at 49.1 percent non-Hispanic white youth and 37.0 percent Hispanic/Latino youth. Additionally, in 2019, 18 percent of Hispanic/Latina females ages 12 to 17 with MDE had a severe disability (PDF | 4.2 MB), a sharp increase from 11.5 percent in 2016.
Treatment gaps for Hispanic/Latino youth with MDD were exacerbated for those with suicidal ideation. Serious treatment gaps exist for Hispanic/Latino youth with MDD. In 2020, 57.3 percent of non-Hispanic white youth with MDE and suicidal ideation received treatment. However, only 39.6 percent of Hispanic/Latino youth received treatment, a gap of nearly 18 percentage points.
Suicidal Behavior in Youth
A closer look at suicidal behaviors reveals a disturbing trend in Hispanic/Latino youth. Between 1991 and 2015, Latinas outperformed other teenage girls in suicide attempt rates. In 2019, 18.8 percent of youth reported suicidal ideation compared to 17.2 percent of Hispanic/Latino youth. However, 22.7 percent of Hispanic/Latino youth reported suicidal ideation, nearly four percentage points higher than the overall sample. Similarly, 2.5 percent of youth reported suicide attempts that resulted in injury compared to 3 percent of Hispanic/Latina youth and, more specifically, 3.6 percent of Hispanic/Latina female youth.
Understanding suicidal behaviors in Hispanic/Latino youth requires a cultural lens. It is important to consider cultural characteristics, beliefs and values which may be risk factors or protective factors for suicidal behavior. Cultural factors Like greater acculturation, greater exposure to mainstream United States culture and racial/ethnic discrimination have been associated with increased risk of suicide.
Gaps in evidence-based practices and treatments
Evidence-based practices and treatments (EBP and EBT) are considered the gold standard for delivering behavioral health care services. EBPs/EBTs have gone through rigorous evaluations and clinical trials and are reproducible. The use of EBP/EBT supports countless individuals in accessing life-saving behavioral health services. However, gaps in equitable service for diverse and underserved communities remain.
Many EBPs/EBTs are based on a Western medical model that may not reflect perceptions of health in different cultures. Culturally adapted EBP/EBT for Hispanic/Latino populations tend to add cultural elements such as personalism and familismo with existing conventional treatment methods. In contrast, culturally defined interventions are developed and delivered with culture embedded in specific and intentional ways. Culturally defined concepts of healing utilize the healing value intrinsically embedded in Hispanic/Latino cultural practices.
Latinos often are based on the cultural context understand and address their health needs. This may include assessing progress in psychotherapy with relationship improvement rather than internal or individual growth. Understanding relational or collective needs in Latino culture is important for effective and equitable behavioral health care.
Understanding and encouraging storytelling
Many Latinos use storyor narrative, to answer questions in narrative form. Narrative preserves collective memory and shares historical knowledge. Through story, Latinos can find healing through the intersections of their culture and personal histories. Storytelling allows people to learn, share and better understand each other’s culture. When used correctly, Storytelling is beneficial for behavioral health wellness, healing and recovery. Digital storytelling, or the use of images to describe experience, has been effective for many different communities, such as peers in recovery, Indigenous youthand members of the immigrant/refugee community. Among Latinas, photonovelas, or soap opera narrative images, have been effective as a health education tool to reduce the stigma associated with accessing treatment. For more culturally appropriate strategies, providers should consider incorporating storytelling into all aspects of Latino care.
Utilizing the Culturally Formulated Interview
A clinical tool for encouraging storytelling is the Cultural Formulation Interview (CFI). The CFI was developed from years of research focusing on culture and its relationship to behavioral health. The tool is intended to gather detailed information based on an individual’s experiences and understanding of their culture. Clinicians can also use the informant CFI (I-CFI) to gain cultural knowledge from those close to the patient. There are additional CFIs for even more unique experiences based on subcultures such as older or younger patients. Most health assessments ask general, closed-ended questions. Instead, the CFI combines general and probing questions allowing the provider and patient to explore deeper issues.
Implementation Support
It is important to understand the positive impact of culturally responsive tools such as the CFI in achieving health behavior equity for Latinos. However, this understanding is only the first step. Behavioral health professionals serving Latinos must take meaningful, proactive steps toward providing culturally and linguistically appropriate care. Beyond a one-time assessment, the use of tools such as the CFI should be a requirement for all patients throughout the continuum of care. Ensuring that these culturally responsive changes are sustained will require a sense of urgency and broad support from behavioral health leadership and policy makers.
Organizational leaders and decision makers are urged to adopt it National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health. Incorporating tools like the CFI into behavioral health practice achieves CLAS Standard #4: “Educate and train governance, leadership and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis.” To ensure sustainability, behavioral health leaders must advocate for increased accountability, ongoing education, and motivation of providers to leverage culturally and linguistically responsive care.
Challenge for Change
EBPs/EBTs are not “one-size-fits-all.” Equitable, patient-centered care is required of behavioral health providers consider community determined evidence (CDE). CDE is an evidence base that uses cultural and/or community indicators to determine successful practices. Using the CFI and other culturally responsive assessment tools can help providers learn what might best serve the unique needs of an individual, their family, and their community. The use of such cultural strategies provides a better understanding of the experiences and origins of distress. They also allow individuals to draw strength from cultural protective elements on their own.
For providers, the challenge is an ongoing commitment to learn how a person’s cultural experiences shape their behavioral health. However, real change happens at the system level. Behavioral health leaders can replace outdated, discriminatory organizational values and policies with ones that reflect and honor diversity, equity, inclusion, and accessibility.
When everyone accepts these challenges, we will eliminate behavioral health disparities like those affecting young Latinas. We will create a behavioral health system that has a genuine interest in the Latino experience and achieving the long-term positive outcomes they have chosen.
