We found far less variation by race in mental illness beliefs and treatment preferences than expected. There were no significant differences in any of the measures between African-Americans and whites, either before or after controlling for demographic, socioeconomic, and health status covariates. Asians’ beliefs also did not differ significantly from whites’ on most measures. This finding is especially interesting considering that Asians were the group most likely to have been born outside the US; therefore, they may have been the least acculturated group. Perhaps most importantly, we found very few statistically significant associations between beliefs and past six month medication and counseling use across all races/ethnicities. The few significant race-belief interaction terms led to interesting and contradictory findings of low medication use among people of color (African American, Hispanic, and Asian participants vs. white participants) who reported positive beliefs about medications in the treatment of anxiety—a clue that suggests there are other systematic or cultural barriers at play among minority groups when seeking and accessing mental health care.
Compared to whites, Hispanics’ views of both medication and therapy were less positive, yet Hispanics were the most positive about the chances of being helped by a mental health professional. Hispanics who strongly disagreed with the statement, “Medications are an important part of the treatment of anxiety” were much more likely than whites with the same response to have used psychotropic medications (OR 3.35; p<0.05). These seemingly conflicting responses and reported actions may reflect poor communication between provider and patient about desire for medications, or perhaps they represent a simultaneous cultural respect for authority, or for “professionals,” and a cultural discomfort with available biomedical and psychotherapeutic treatments. Previous research has indicated that Hispanics may prefer to manage mental health problems at home with family assistance rather than seeking formal mental health care (Snowden, 2007
), but concurrently, a large national survey with a population-based sample demonstrated that cultural factors among Hispanics only played a significant role in service use when the respondents did not meet criteria for a psychiatric disorder (Alegria et al, 2007
). It is important to note that all participants in this CALM study had a diagnosed mental health condition; therefore, we would expect smaller effects of cultural influences on mental health service use among this particular sample.
Native Americans were generally positively disposed toward medication as a treatment modality but were, by far, the least convinced of the benefits of psychotherapy. At the same time they tended to believe in a less severe natural course of mental illness -- that is, they believed that about one in three persons with mental illness would recover without treatment. In the US, Native Americans’ views of mental health treatment are complicated by centuries of political and cultural imperialism (Gone, 2007
; Grandbois, 2005
). Further, many Native cultures hold a collectivist worldview that emphasizes mind-body holism and harmony, making little distinction between mental and physical health (Hill, 2006
). Native Americans may use biomedical treatments to address acute symptoms but may be more likely to turn to traditional health practices rather than psychotherapy to address the causes of these symptoms (Grandbois, 2005
Because the CALM study population was drawn from treatment settings where the majority was receiving some type of mental health treatment, participants’ prior experience of mental health treatment likely impacted to some extent their beliefs about treatment. Perhaps even more importantly, they represent only that sector of each racial group that seeks and obtains primary medical care, and so cannot be considered representative of the broad spectrum of individuals from each racial group, some of whom do not seek or are unable to obtain any medical care. While acknowledging these limitations with generalizability, the treatment sample could also be considered a study strength; this study provides important initial data on how previous and current treatment experiences are related to beliefs and preferences regarding treatment. As lack of experience with mental health treatment becomes less common over time, these results provide insight into the beliefs and preferences of the treatment-seeking population. Also, it is important to note that the primary care setting is critical when examining racial/ethnic disparities since minority patients are more likely to seek their mental health care in primary care than in specialty mental health care clinics (Alegria et al, 2002
). The homogeneity of the participants in CALM might account to some degree for our detection of few differences across racial groups, but it is crucial to recognize that similar results have been found in large community-based, epidemiologic studies, such as the NCS-R, where African Americans and Latinos were found to have similar and sometimes even more positive beliefs toward mental health treatment than whites (Shim et al, 2009
). Our findings regarding race, beliefs, and service use should be interpreted with caution, especially our findings for Native Americans (n = 34) and Asian Americans (n = 45), groups with very small sample sizes. Results related to the Asian and Pacific Islander group are of particular concern since this group was likely comprised of many different ethnic sub-groups (e.g., Japanese American, Chinese American, Pacific Islander) with distinctive cultures, making it difficult to interpret findings in an meaningful way (Phinney, 1996
; Zane and Sasao, 1992
). Regarding Native Americans, many have argued persuasively for inclusion of data about Native Americans and mental health in published reports -- even when the sample size is small -- because of the dearth of information on this population (Burhansstipanov et al, 2000
), and we present this data in that spirit. Another caution is that underlying our comparison of beliefs across racial groups was the assumption that beliefs about mental illness and treatment might be a function of culture. While this is a common approach in the literature, our measures of culture (categorical self-designation of race) are rudimentary at best, especially among the Asian American and Hispanic groups that are particularly diverse. About 13% of participants claimed more than one racial group, yet we placed each subject in a single racial category, an approach that does not fully reflect the actual racial diversity. Also, we have no way of knowing the extent to which persons in each of the racial groups actually identify with a given culture. Ideally, the CALM dataset would have included more nuanced measures of generation, social class, and acculturation in the U.S. In some groups, especially the Asian Americans and Native Americans, a high percentage reported being bi-racial (48% of Asians and 82% of Native Americans) and by far the second racial group most commonly reported was white. Consequently, we were surprised to find any significant differences between Native Americans and whites. Despite having large numbers of biracial members, the Native American group is clearly different from whites in some key ways. While we suspect these differences reflect underlying cultural beliefs, we cannot be certain that these differences are not attributable to other, unmeasured factors. However, the fact that we found significant differences even with small sample sizes suggests that we may have underestimated the magnitude of these differences whatever their exact etiology.
A strength of this study is that it included a large, diverse cohort of primary care of participants with anxiety disorders—a population that has not been studied sufficiently with respect to attitudes about mental illness and treatment. Also, the 17 participating clinics from 4 separate geographic areas varied considerably and included large-scale HMOs, free-standing private clinics in the community, some of which were associated with hospital chains, federally funded community-based clinics, and clinics located in university settings. Although this geographic dispersion and clinic diversity might increase the finding’s generalizability relative to some other studies, we are still uncertain as to how generalizable our findings are. As a whole our study population was relatively wealthy and insured and, therefore, may represent a more well-to-do segment of each of the five ethnic groups.