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Hawaii’s Mental Health Care Crisis

Posted: September 21, 2018

When Stephen Kemble closed his Honolulu psychiatry practice last August, he tried to match 500 patients with a new psychiatrist.

It was an impossible task — especially for recipients of Med-QUEST, Hawaii’s version of Medicaid.

Kemble found only two psychiatrists in private practice on Oahu who were willing to treat new patients covered by the state’s public health insurance for low-income people. A few of Kemble’s patients got in with these two psychiatrists — but they had to wait up to three months for an appointment, he said.

“The willingness of psychiatrists to take in new Medicaid patients has dwindled to almost nothing,” Kemble said. “Even if you do get in with someone, the doctor has five minutes to renew your prescription and that’s it. I mean, they’re trying, but the psychiatrists don’t even have time to talk to you — they’re totally overwhelmed.”

New data from the University of Hawaii reveals a health system in crisis. In 2017, Hawaii was short more than 750 physicians across the medical field, according to University of Hawaii professor Kelley Withy, who conducts an annual workforce survey. This calculation accounts for differing needs on neighbor islands and the unique demand for medical specialties like psychiatry.

Experts say filling the void is practically impossible, as it would require that the state increase its physician workforce by about 25 percent. Luring new doctors to Hawaii is complicated by myriad factors, not the least of which is the state’s high cost of living coupled with its relatively low rates for insurance reimbursement.

When it comes to psychiatrists, the UH data reveals a 10 percent statewide shortage. The gravest scarcity is on Kauai and Hawaii islands, which are tied with a whopping 33 percent shortage. But surprisingly, the Oahu data shows a slight surplus equivalent to one full-time position.

Withy acknowledges the Oahu numbers, which are based on the national statistics, fly in the face of what she sees first hand: a severe need for psychiatric services that’s not being met — on any island.

“I don’t think our model adequately represents the demand in Hawaii,” Withy said. “Perhaps people in Hawaii are more open to using behavioral health or need more services, but the model does not correspond to the anecdotal need we hear about. Also, many psychiatrists don’t take our public insurance programs, making it extra hard for those individuals, who usually need the services even more due to poverty or disability, to find services.”


3 Things to Know: Health Equity

Posted: September 18, 2018

To have a productive conversation about health equity, we need to get one thing straight: equity is not the same as equality.

Striving for equality alone can actually perpetuate disadvantage. To remedy health disparities, some communities need more—not just equal—resources. Watch this brief illustration from the Robert Wood Johnson Foundation to get clear on equity vs. equality.

Truly attaining the “highest health of all people” starts with embedding fair opportunities for well-being into the whole of community life. The factors affecting health outcomes, collectively known as social determinants of health, include everything from socioeconomic status to the availability of public transport and recreational space—a mix of structural conditions that impact the physical and mental health of individuals and their communities.

Health equity is achieved when our knowledge of social determinants is put toward the cause of eliminating health disparities. But what does a commitment of that magnitude look like, and how can it be fulfilled? Below are three things that anyone wrestling with these questions should keep in mind:

1. Access for all doesn’t mean health for all.

In the U.S., envisioning and enacting systems-wide change requires challenging a long legacy of exclusionary policies, practices and structures that, to this day, derail health improvement for all. When it comes to finding and obtaining health or mental health services, historically marginalized populations know better than anyone that injustice, and lack of opportunity, can persist even in the absence of explicitly discriminatory legislation.

2. Community context matters.

Textbook history is one thing; the true history of a neighborhood or community is quite another. In bringing the intergenerational consequences of social determinants to life, stories of trauma and resilience from the past and present provide a rich, much-needed context for health equity interventions.

3. We’re all in this together.

Without cross-sector collaboration, achieving health equity is impossible. Fragmented systems and services—education, economic development, housing and so on—are far more likely to create disparities than those working in partnership with one another.


National Latinx Leaders Address the Community’s HIV Crisis

Posted: September 17, 2018

Alarmed by increasing HIV rates among Latinx men who have sex with men and transgender Latina women of all ages, the National Hispanic Medical Association hosted a meeting in Atlanta for community leaders to address the situation. Specifically, they assessed, discussed and identified action steps to be taken to help reverse the trend.

According to a press release from the Latino Commission on AIDS, the meeting enumerated several action steps to address the unique challenges facing the Latinx community. “Participants recognized the devastation of HIV,” the press release states, “the barriers to prevention and care services, the impact of stigma, immigration, culture, race and the social determinants of health that impact Hispanic/Latinx in the United States, Puerto Rico and the U.S. Virgin Islands.”

The next steps and goals are currently being drafted, and participants will review them at upcoming meetings before they are publicized.

The meeting was not the first effort of national Latinx groups to address the HIV problem. In March 2018, a group of 147 organizations and 176 individual leaders sent a letter to Eugene McCray, MD, director of the Division of HIV/AIDS Prevention, part of the Centers for Disease Control and Prevention’s National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention.

The letter detailed the crisis in the Latinx community before spelling out a call to action.


Talking about Depression Can Be Hard for Asian Americans, but Services Can Help

Posted: September 13, 2018

The feelings of loneliness and isolation began for Glor Parong at 15 years old. She was dealing with the pressures of being the first-born child in a Filipino household, where she was expected to be a role model and caretaker for her younger siblings. Then there were her parents, who she said were going through financial difficulties and frequently arguing.

But Parong was taught not to disclose any of her problems to anyone outside of her family, she said. As a result, she carried the weight of those emotions alone. “I didn't say anything verbally, but deep down I wanted my mom's and my dad's attention. I wanted them to love me and to say it's OK,” she said.

After three suicide attempts, Parong, now 46, said she eventually sought help to come to terms with a fact that hadn’t been easy for her to accept: She was depressed. Seeing a psychiatrist was key to understanding depression, she added, which she continues to live with today.

Parong copes, among other things, by incorporating creative activities like dance into her life. She currently works at the Asian Pacific Counseling & Treatment Centers (APCTC), a mental health center in Los Angeles that was developed to meet the needs of the Asian Pacific population.

Depression and Suicide in the Asian American Community

The suicide rate among Asian Americans and Pacific Islanders in 2016 was approximately half of the general population, according to Centers for Disease Control and Prevention (CDC) data. Suicide ranks as the ninth leading cause of death among Asian Americans and Pacific Islanders and the 10th leading cause of all deaths in the U.S.

But for Asian Americans and Pacific Islanders between the ages of 15 and 19, suicide was the leading cause of death in 2016, according to CDC data, accounting for 31.8 percent of all deaths.

The pressure to succeed academically, financially, and career-wise is considered a common cause for depression among Asian Americans, Silvia Yan, program director of adult services and training director at APCTC, said.

But that pressure isn't the culprit for depression across all subgroups in the population.

In the Korean-American community, for instance, depression due to isolation is pervasive among seniors, according to Connie Chung Joe, executive director of Korean American Family Services (KFAM) in Los Angeles. “We know that the more isolated you get increases your risk factors for suicide,” Joe said. “To reduce those factors, you need ... people you can talk to and go to for help; Having places to go to whether it’s to go exercise or do hobbies. For Korean seniors, that gets very, very limited because there's not very many that are specific for the Korean community, and they also don’t know how to access them."

Southeast Asian refugees are another group that has battled depression and trauma as a result of their history with violence, according to Lan Nguyen-Chawkins, a psychologicst at APCTC. She noted that Cambodian Americans carry the experience of torture and working in labor camps, while Vietnamese Americans and Laotian Americans endured refugee camps after fleeing warfare in their countries. “What they experienced was a massive problem with trust in human beings,” she said. “It’s like, 'Well, why do I need you? I survived under a hundred dead bodies. I don’t need you.'”

Because refugees survived the war without talking, some may not see a need to talk about what they've gone through or their feelings about it, Nguyen-Chawkins said. And by the time many of them seek help, their depression is at chronic levels.

Disparity in Available Services

As the Asian-American population — the fastest growing ethnic group in the country — continues to rise, it faces the challenge of accessing the culturally sensitive mental health services it needs.

One of the barriers Korean seniors face, according to Joe, is that nearly all are limited English proficient and low-income, and rely on publicly funded health services that aren't always culturally or linguistically tailored to them.

Groups like APCTC are among those that offer culturally sensitive mental health services. The nonprofit provides services in languages clients are most comfortable with and places greater emphasis on the family as opposed to the individual than mainstream providers. Yan said the center invites family members to participate in the process, from the initial evaluation to the development of treatment plans.


Culturally Appropriate Care to Address American Indian/Alaska Native Mental Health Disparities

Posted: September 12, 2018

Non-Hispanic American Indian and Native American (AI/AN) adults and children are at greater risk than all other racial groups of experiencing poor mental health outcomes and unmet medical and mental healthcare needs. For instance, suicide rates for AI/AN adults and youth are higher than the national average

For native people, cultural differences play a crucial role in this gap as well as in the misdiagnosis. An accurate assessment is not possible without intimate knowledge of another culture; such knowledge cannot always be learned in the present educational systems, many of which do not share the same historical accounts or knowledge tribal systems have been teaching for thousands of years. 

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) states that understanding a culture means comprehending and applying that culture’s beliefs, ceremonial rituals, and customs. With the Native American culture, this would not be possible without the actual time and tutelage of an American Indian or First Nations Healer and Spiritual Person, who would be most qualified to provide the appropriate expertise. In order for native-serving providers to meet the standards set forth in the DSM-5, they must learn from outside of the Western medical education system. 

Few mental health diagnostic tools, assessments, or treatments have been studied in AI/AN communities. For instance, few mental health treatment models apply spiritual phenomena—such as spirits, ghosts, or healing—but this is an area common within Native American tribes. 


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