In order to understand what we know about Latinos’ access to mental health services, we need to examine the methods used to produce this evidence. Several methodological issues related to the design, sampling, and measurement were observed across the sixteen articles. First, the majority of studies reviewed were cross-sectional in nature. While this design has some strength, cross-sectional studies prevent us from predicting which factors enable or restrict Latinos in need of care from accessing mental health services. It also makes it difficult to disentangle the social and cultural processes that influence help-seeking behaviors and pathways to services (López, 2002
). There is a paucity of longitudinal and prospective access studies in the Latino mental health services literature (López, 2002
; Rogler & Cortes, 1993
Longitudinal studies that follow Latinos from the community as they access mental health services and track their use of services and outcomes can provide a better picture of the predictors and barriers of service use. Although these studies are costly and can incur high attrition rates, they can produce valuable information about the pathways Latinos and their families take to use formal and informal mental health services and how they combine these different sources of care overtime. Studies of pathways to services can also identify gatekeepers to the mental health system of care. Resources can then be allocated to train these gatekeepers to identify those Latinos who are in need of care and then make appropriate referrals. Longitudinal studies can also track how Latino adults move in and out of the mental health system and how they navigate and combine the use of mental health services with other service sectors, such as the general medical, judicial, welfare, housing, and informal (e.g., religious institutions, folk healers) sectors. This information can be used to describe the sectors of care that Latinos use, identify barriers that may prevent them from accessing these sectors, and provide policy makers a framework as to how these different sectors need to work together in order to provide continuity of care.
Furthermore, longitudinal studies can be used to track service use outcomes across systems of care. Service use outcomes must include not only clinical outcomes (e.g., reduction in symptomatology, functional impairment, rehospitalization) but also examine continuity of care, employment histories, educational attainments, housing, and quality of life. In order to develop effective and high quality mental health services for Latinos, we need a better understanding of which programs and services produce the best outcomes. Lastly, longitudinal studies can begin to examine the social, economic, and emotional consequences that result from the underutilization of mental health services among Latinos. A fundamental question that needs to be addressed is: What are the economic, social, and emotional costs to Latino individuals and families in need of care for underutilizing mental health services and for receiving poor quality mental health care? Understanding the costs that these disparities have to our society can help garner support for more public and private funding to eliminate these inequalities in care (López, 2002
The second methodological issue relates to studies’ sampling strategies. Although the national random samples used in several of the articles reviewed enable generalization of results to the non-institutionalized adult population of the U.S. or Puerto Rico, several limitations in these samples must be noted. For instance, the NCS excluded adults who did not speak English and only sampled individuals between the ages of 15 and 54, excluding children and elders. Conducting interviews only in English created a serious bias in the Latino sample of the NCS since it is estimated that one out of four Latino individuals live in linguistically isolated households and approximately 7.7 million report not speaking English “very well” (IOM, 2003a
, Shin & Bruno, 2003
). Moreover, the exclusion of Spanish-speaking Latinos may overestimate the service use rates in this population since Spanish-speaking Latinos tend to be those at higher risk for underutilizing mental health services due to low levels of insurance coverage, education, income, and being less acculturated (Vega & Alegría, 2001
The recently completed National Latino and Asian American Survey (NLAAS) will address this limitation by reporting findings from a nationally representative sample that includes both English and Spanish speaking Latinos. The NLAAS is also designed to compare the mental health service use rates of Latinos and Asians with other national representative samples of non-Latino Whites and African Americans taken from the National Comorbidity Study-Replication and the National Survey of American Life (Alegría et al., 2004
). These cross-ethnic and racial comparisons will pave the way for future studies to identify and isolate which disparities in access and quality of care are unique to Latinos, which are common to racial and ethnic minorities, and which are due to socioeconomic factors regardless of race and ethnicity. The evidence from these studies will help clarify how the sociocultural, economic, geographic, and political context influence health and mental health care disparities and shape public policies aimed at eliminating these inequities in care (Williams & Jackson, 2005
Furthermore, most studies reviewed used samples that either collapsed different Latino groups into one group (e.g., Wells et al., 2001
; Young et al., 2001
) or examined the service use rates of a single Latino group (e.g., Vega et al., 2001
; Vera et al., 1998
). Only one study reviewed disaggregated the Latino sample into Mexicans, Central/South Americans, Puerto Ricans and other Latinos and compared their service use (Harris et al., 2005
). Given the diversity of the Latino population and the different demographic profiles of these groups, studies that include samples big enough to make within group comparisons are needed. For instance, 11.2 million Latinos lack medical insurance, making them the largest uninsured group in the U.S. (33.4%), followed by Native Americans (27.1%), African Americans (20.8%), Asians (20.8%) and non-Latino Whites (11.6%; Doty, 2003
; Mills, 2000
). Yet, within Latino groups varying rates of health insurance exist, with Central and South Americans having the highest proportion of uninsured individuals (39%), followed by Mexicans (38%), Cubans (22%), and Puerto Ricans (19%; Schur & Feldman, 2001
). Moreover, levels of health insurance within the Latino population also vary by place of birth with foreign-born being more than twice as likely to be uninsured than their U.S.-born counterparts, and recent immigrants are the least likely to have insurance (Schur & Feldman, 2001
). These differential insurance rates highlight the important within group differences in the Latino population that may influence access to care.
Most epidemiological studies have focused on the three largest, most represented Latino groups - Mexicans, Puerto Ricans, and Cubans. Yet, in the past decade the growth of Latino immigrants from the Dominican Republic, Colombia, and other Latin American countries have been large but most studies do not include analyses of this group mainly due to their low numerical representation that reduce statistical power. More studies that over sample Latino immigrants from these countries and directly examine within Latino group differences are needed to understand and account for the diversity of the U.S. Latino population.
Third, all of the studies reviewed relied on self-report measures of service use and did not report the reliability and validity of these measures. Wang, Lane, Olfson, Pincus, Wells, and Kessler (2005)
argued that “recent studies ... suggest that self-reports of mental health service use overestimate administrative treatment records, especially concerning the number of visits and among respondents with more distressing disorders” (p. 633). In other words, self-report measures of service use are subject to biased recall that distorts the reporting of the actual number of visits respondents made during a specified period of time, particularly among those with the most serious disorders. One way to address this limitation is to combine self-report measures with other sources of service use data (e.g., medical records, insurance claims). This combination of service use data must be done with caution since administrative records are also plagued with limitations (e.g., incomplete or missing information) and are not designed for research purposes. The careful triangulation of self-report measures and reliable administrative data, such as treatment records under prospective payment schemes, can help address these measurement limitations and enable researchers to test the reliability and validity of service use measures.
Fourth, only three articles (Ortega & Alegría, 2002
; Wells et al., 2001
; Young et al., 2001
) examined the type, amount, and quality of mental health care that Latinos received in a specified period of time. We know very little about the quality of treatments provided to Latinos in the current mental health system (López, 2002
). An important area of future research is to examine the adequacy of care that Latinos receive in service encounters. Studies in this area can begin by estimating the proportion of Latinos in care that receive guideline congruent care for common mental disorders (e.g., major depression, anxiety disorders) and the factors that influence these trends in care. Qualitative methods, such as in-depth interviews, focus groups, and ethnographic studies, can be used to directly examine Latinos personal experiences in accessing and using mental health services.
What Findings Show: Implications for Policy and Practice
Consistent with past reports and literature reviews, findings from these 16 articles suggest several trends in mental health care for Latino adults. Compared with Non-Latino Whites with similar mental health needs, Latinos underutilize specialty mental health services. Latinos who suffer from common mental disorders (e.g., depression and anxiety disorders) are less likely than non-Latino Whites to receive guideline congruent care. Moreover, Latinos who suffer from a mental disorder in the U.S. and Puerto Rico tend to rely more often on the general medical sector than on specialty mental health services and use a combination of professional and lay advisors to cope with their disorders.
Findings also suggest that a complex interplay of structural, economic, psychiatric, and cultural factors influence Latinos’ access to mental health services. These findings indicate that interventions aimed at improving access to mental health services must take a multidimensional approach that target modifiable individual and structural factors. Barriers to care reported in these studies included lack of health insurance, low acculturation, endorsing self-reliant attitudes, not knowing where to seek services, high economic strains, and having large supportive networks. Some of these barriers can be targeted for interventions through policy initiatives, such as increasing health insurance coverage, particularly among low-income Latino immigrants (USDHHS, 2001
). The integration of service modalities, such as providing mental health services within primary health care centers or combining mental health treatments with case management services to help individuals meet their basic economic needs and help them navigate the system of care, have been suggested as possible solutions to reduce barriers to mental health care among Latinos (Miranda, Azocar, Organista, Dwyer, & Areane, 2003
Other barriers can be targeted through public health campaigns aimed at increasing awareness in the Latino community about the signs and symptoms of common mental disorders, disseminating information about available treatments, and dispelling misconceptions about treatments. These campaigns can use social marketing techniques, such as featuring public figures (e.g., actors or athletes with high social status in the Latino community), and presenting mental health information through public announcements and/or commercials during peak television viewing hours in both mainstream and ethnic media. Another technique effective in disseminating health information to the public and positively influencing individuals’ health behaviors is to incorporate health information into the storylines of popular television programs (IOM, 2003b
). A similar approach could be developed and adapted for Latinos by incorporating information about common mental illnesses and treatments into storylines of popular television programs, such as telenovelas
and talk shows.
Policies, services, and interventions aimed at eliminating Latinos’ disparities in mental health care must be informed by sound research that not only documents these trends in care but explains why and how these inequities occur. This systematic review of epidemiological access studies is a step toward this goal by providing policy makers, administrators, and service providers a map of the existing evidence and highlighting areas for future research and development needed to improve Latinos’ access and quality of mental health care. As the Latino population continues to grow, it is in our nation’s best interest to produce a better understanding of the causes of disparities in mental health care and translate this knowledge into practices and policies aimed at creating an equitable system of care for all Americans.