Transcript

Jonathan Stein I'm Jonathan Stein and this is Talk Policy to Me.

A number of Americans seeking mental health treatment is on the rise in United States. For decades, mental illness has been one of our thorniest issues. It can be difficult to diagnose and it often goes untreated. The stigma around seeking help is intense and disparities are dramatic. Researchers found that racial minorities, older adults, immigrants and those from lower socioeconomic backgrounds are much less likely to seek help. And today, anxiety diagnoses among young people are skyrocketing. In the last decade, University of California health centers have witnessed a 54 percent increase in students seeking access to mental health services. Our guest today is Dr. Lonnie Snowden, a professor at the School of Social Welfare at UC Berkeley and a leading expert in mental health policy. He's currently on the advisory board of a Goldman School of Public Policy Studies about the rise of anxiety among millennials. Among other things, Dr. Snowden's research looks at the disparity in mental health access for racial minorities and a wide range of reasons why those disparities exist. Dr. Snowden, thank you for joining us today.

Dr. Lonnie Snowden Thank you. Good to be here.

Jonathan Dr. Snowden, let's start with you. How did you come to focus on mental health?

Dr. Lonnie Snowden You know, I, even as an undergraduate, was quite interested in people, what made them tick and the sorts of psychological and psychiatric problems that I could observe in those around me. People I grew up with, people in my family, and it just occurred to me that this was something...Well, I was drawn to it and it occurred to me this was something I wanted to specialize in and learn more about.

Jonathan And you knew at a young age.

Dr. Lonnie Snowden I did. Yeah. And I'm not sure why but I did.

Jonathan You've been at it for a while. Forty years.

Dr. Lonnie Snowden I have been yes.

Jonathan How have you watched our country's attitudes towards mental health change over that time?

Dr. Lonnie Snowden Profoundly. There's much more and I think for the most part, favorably. There's much more recognition these days that mental health problems are real, that they affect people in very profound ways and compromise their ability to get on with their lives, that they should be taken seriously. I think that the stigma associated with mental illness has abated, to some extent, it remains. It's still too large, but it has it has receded. I think that well...you kno, so I can remember I was an adult when Thomas Eagleton, who was a vice presidential candidate, got treatment for depression. And so, this was such a scandal.

Jonathan He was run out of the race.

Dr. Lonnie Snowden He was run out of the race. That's correct. Which wouldn't happen now, I don't think. You know, now I see professional athletes acknowledging episodes of depression. So I think that the acceptance and the recognition have grown. I think more remains to be done in that direction. But I think in that regard, that's really happened. And I think also the willingness of health care plans and health care systems to acknowledge and treat mental disorders, depression, and anxiety. The fact that one of the big developments now is the mainstreaming of, especially, depression and anxiety. Screening and treatment into primary care is now a major development. Whereas 30 years ago, none of these things were taken very seriously at all.

Jonathan Let's talk about disparities. About one in three Americans with severe depression, and just one in five with moderate depression, actually seek treatment.

Dr. Lonnie Snowden Right.

Jonathan Disparities between racial groups and age groups can be extreme. Give us a sense of the landscape. Who seeks treatment less and why?

Dr. Lonnie Snowden You know ethnic minority groups, Asian-Americans probably least...Well, some of this varies with levels of acculturation of course limited English proficiency among immigrants and refugees is a big barrier because mental health treatment is especially dependent on language. And so anything that interferes with communication, like limited English proficiency, is going to be an issue or a particular barrier. Latinos, Mexican-Americans and other Latino groups, African-Americans...all utilize mental health treatment, including for problems like depression, which are treatable and where treatment rates have have risen overall. So some of the problems, I mentioned limited English proficiency. There's also a problem of sometimes greater stigma in communities of color. There's a problem, too, of the fact that the things that we regard as mental illness, the symptoms can be interpreted in other ways. And so in some communities, for cultural reasons, the way of framing the things that we consider mental illness are framed in alternate ways, which don't lend themselves to treatment seeking from traditional mental health specialty providers.

Jonathan I heard from a friend, that in certain Asian languages, I think with South Asian languages, there's no word for depression. That may be apocryphal, I don't know. But, coming from a family that is South Asian myself, it's not in the construct. When somebody is undergoing a mental health challenge, there are ways that you might talk about that. None of them involve seeking medical help. Medical help for issues of seeking a psychiatrist, seeking a therapist. That's for crazy people, and that's not part of a thing that normal people do.

Dr. Lonnie Snowden That's exactly right. That's right. And that those views are more prevalent... They remain prevalent throughout the United States, but they're more prevalent in some communities than others.

Jonathan I really want to dig in on this question of stigma. So extreme in certain communities. It's your pride, your dignity is in question if you seek mental health treatment, but also, your family's dignity or pride might be in question if you seek mental health treatment. How do we change stigma? You said you've seen it lessen over the course of your career. What contributes to that? 

Dr. Lonnie Snowden So let me, just a couple of points, you touched on something that we actually talked about that I teach in class in mental health problems, systems, programs and services. Well anyway, I teach that and I teach a disparities class as well. And in the disparities class this year, we just talked about honor orientation and how some communities, in particular more than others, are particularly attuned to matters of honor. Anything that is seen as potentially bringing dishonor to the family or the community, is reacted to in a very strong way. Mental illness is one of those problems that elicits the strong reaction, having to do with honor. And so what you are describing, I think can be seen in those terms, and it's a war. Honor orientation is a worldwide way that we can characterize differences between cultures. So it's a widespread thing. Some cultures are really committed to it more than others and it is one of the things that's related to stigma. And it's a cultural way of describing those differences between groups that get in the way of seeking mental health treatment.

Jonathan How do we reduce stigma?

Dr. Lonnie Snowden Psycho education. There are a number of ways, especially with severe mental illness, but with other kinds of mental illnesses as well, there are programs that involve orienting people to mental illness. Teaching them what the names and terms are, what the treatments are, what to expect, what the advantages are of seeing it in these in these terms and so on. And those programs can be delivered by community health workers and others who are circulating in communities... For cultural reasons, mental health either isn't understood in the way that we understood it or is stigmatized, highly stigmatized.

Jonathan Racial disparities in the utilization of mental health care...It's not all stigma, it's not all cultural attitudes towards mental health. Talk about the structural, the economic barriers that some communities might face that might result in those disparities.

Dr. Lonnie Snowden Yes. Well one of them of course that I've been saying a fair amount these days because of the Affordable Care Act and other things, is insurance coverage. So if it's paid for, people are more likely to go. It's price sensitive and with mental health treatment, having the some of the cost deferred by insurance coverage makes a difference. So one of the things I'm most interested in, in fact I'm writing a proposal now to look into this in fairly great detail, is the question of how, for African-Americans and Latinos, how much Medicaid expansion under the Affordable Care Act improved access and quality of mental health care for those two groups. So there's Medicaid expansion. And in addition, what's interesting there for me is that, and unfortunate, is that African-Americans are overrepresented in states that did not expand into southern states. So I mean, there's a lot to look at there and there's a contrast that I hope we can really learn from. Another group is people between 140 percent of poverty,that are poverty level, who got subsidies to purchase on exchanges. And so, there are now people, a number of I think working poor people, who are disproportionately minority African-American, Latino, Native American, who really didn't have the means to seek mental health care before and now do. Furthermore, who are plugged into a health care system more than before where mental disorders are a lot more likely to be recognized now. So I'm hopeful that we will see some closing of disparities nationwide.

From at least the first few years the Affordable Care Care Act, of course there's been some selective rolling back of it. So I think financing and their impact of greater systemic awareness are partial answers, but they're only partial answers. Because again, this recognition, both self-recognition and provider recognition across racial and ethnic lines, is tricky and isn't always done well.

Jonathan share an example of for audience of how culturally competent treatment might be essential for success.

Dr. Lonnie Snowden Did some work Chinese immigrant women and it turns out that they're symptoms of depression include both the psychological parts and some of the somatic parts that we're more accustomed to seeing and are reflected on sanity screening instruments. Also more bodily concerns about having heart attack, that sort of stuff, and also concerns about the impact of the condition on the family and the community, "I'm letting people down, I can't pull my load." That sort of thing which don't show up on mainstream depression screeners but this is how Chinese immigrants partly report their depression to a greater extent. So part of the problem is recognition.

Jonathan In the academic research and in the world of mental health advocacy, are there consensus solutions for reducing these disparities?

Dr. Lonnie Snowden So outreach, you know, you find working with community-based organizations, churches, going where people...community leaders. Getting, as I was describing earlier, sometimes putting in place standardized programs for protocols for screening. Community health workers who are trusted community members and who are out there anyway talking to people about their health, those are pretty much accepted ways. What I find most interesting is that–and by the way, there's some law, as I said, there's some literature to suggest that those things work. But for me, the biggest difference is the Affordable Care Act. Millions and millions of people, that's one of the reasons why I'm going after it. And you know, in such last couple of years I've done a lot of Affordable Care Act work which is only now coming to fruition. It's a moving target anyway. But I mean the numbers, first, it's already happening, no matter what, one way or another and second, the numbers of people who are affected is so big that you can either through the act itself or through some of the collateral provisions, that were in the Act originally but that have kind of fallen by the wayside as it's had to fight for its life. So there was an increase for community health workers and the Affordable Care Act. But just because of the scope, I think it has a huge chance for leverage.

Jonathan Is it safe to say that the Affordable Care Act represents the single greatest increase in medical health care coverage for–sorry–mental health care coverage for Americans in the country's history?

Dr. Lonnie Snowden Yes, it's because of the act itself. But also because mental health, physical health parity, as a requirement is part of the act. And because, among the essential benefits, the 10 essential benefits, mental health and substance abuse treatment are among the essential benefits. So it's very hard for insurers to escape providing coverage, which they have in the past major ways. In fact, that's another thing that's really changed for the better. I mean I know it's still far from perfect but insurance just didn't want to deal with mental health issues. Even so even if you were covered, I mean it was not worth a lot historically.

Jonathan Let's talk about young people. The increase in treatment for young people suffering from anxiety, it's enormous. Is that because of an increase in anxiety,  an increase in students willingness to step forward for treatment, or an increase in the rate at which the condition is being recognized and diagnosed?

Dr. Lonnie Snowden That's a very good question.

Jonathan Thank you so much.

Dr. Lonnie Snowden [laughter] I don't know that we know the answer. In fact, when we had a board meeting of the study that that was a key question and and whether we talked about we don't have the data yet to really be able to sort out how much is what. I mean, we get this a lot. How much of it is in other conditions as well? Autism, for example. How much of it is a true difference in increased prevalence, how much of it is differences in recognition and awareness, et cetera. So those those are those are tricky questions they're hard to sort out. I suspect, my hunch is that at least some of it is a true prevalence. But again, hard to say.

Jonathan Tell us more about that anxiety study at the Goldman School.

Dr. Lonnie Snowden Oh so you know, it's just that we are trying to attack it from a number of...Take this as a problem in trying to attack it from a number of the directions you would want to. You know, what is the prevalence both among college populations and elsewhere among millennials? Has it really increased as much as we think it has? Trying to document some of these things, trying to sort out the explanations, looking at treatment resources, looking at cost. What's the societal cost of an untreated anxiety disorders among millennials? What are the treatment resources on college campuses, how are they changing, and elsewhere in the general health care system? Just taking a very comprehensive look.

Jonathan Any preliminary findings?

Dr. Lonnie Snowden Not that I'm aware of, but we should. You know, economic insecurity and unpaid debt are known to be... So one of the one of the things that we know from the Affordable Care Act is that people...There was a reduction in unpaid medical bills and the stress that's associated with that.

And so, yeah I think there are other things too. Millennials are facing a society that's very different from the economy, a society that's very different from what I faced when I was coming up. I think unpaid debt is one characteristic that is huge and important in its own right. But also housing prices in the Bay Area...I don't know anybody...and elsewhere. You know, there was a time when it was within reach for people starting out, sort of a standard right of passage. I just don't know that can be true anymore. I think the labor market has changed. I think long term employment security with defined benefit retirement is a thing of the past.

Jonathan Yeah it feels like if you want long term economic security having an undergraduate degree means almost nothing. You have to go and get a graduate degree in sort of a high leverage field which isn't for everyone, which isn't within reach for everyone, and the sense that you're going to put in years of higher education, accumulate debt along the way, and it's no sure thing, is just crushing.

Dr. Lonnie Snowden Yeah I think that's right. And by the way, even with an advanced degree... I mean the structure of once upon a time, you could sort of... If you stuck it out and did well, you could be assured of a job with a leading law firm or whatever. And those have shrunk too. I mean they don't do as much of that anymore with kind of a lifetime commitment after a few years. So the whole thing, there's just much more insecurity now than there was for my generation and I can't imagine that doesn't have some impact.

Jonathan Dr. Snowden, thank you so much.

Talk policy to me is a production of the UC Berkeley's Goldman School of Public Policy and the Berkeley Institute for the Future of Young Americans. For show notes, visit us and talkpolicytome.org. Music heard on today's episode is by Pat Mesiti-Miller. Talked policy to news executive producers are Bora Lee Reed and Sarah Swanbeck. The fabulous Alyssa Jeong Perry is our producer and engineer. I'm Jonathan Stein with Jasmine Jones.