A monolingual Spanish-speaking patient from Ecuador
was injured on his job in the northeastern US. He was prescribed medicine for
multiple physical injuries and had been previously diagnosed with depression
prior to the incident. He carries shame about his history of depression and a
suicide attempt before he was left unemployed, struggling financially as head
of household, with physical injuries. Now the patient begins to experience
mental health symptoms again; depressed mood, lethargy, low self-esteem. He
begins to meet with me weekly in a pain management clinic for psychotherapy
sessions. And he develops suicidal and homicidal ideation … voices telling him
to hurt himself and a family member. My question to you is: how many barriers
does this man face to obtaining appropriate and comprehensive, collaborative
care to ease his suffering?

 

Let’s be sure to separate barriers to
comprehensive, collaborative care that result from mental illness and barriers
that result from health inequality. To address the first set of barriers, he
carries shame that he is experiencing mental health symptoms which he perceives
others aren’t experiencing, and self-stigma that he shouldn’t be feeling the
way he is. But apart from these mental health roadblocks to comprehensive,
collaborative care, this patient experiences barriers related to health
inequality. He speaks a different language than I do and only with the help of
a translator can we communicate effectively. He lacks funds to pay for medical
services and can only see me because our visits are paid for by workers
compensation. Furthermore, men from his country do not show “weakness” or a
need for medical help, let alone mental health services, which are stigmatized.
He doesn’t recognize that he is being denied certain medications by insurance
because they are very expensive, not due to a personal flaw. The barriers posed
by health inequality make it likely that this patient will not obtain
comprehensive, collaborative care. A white male patient with adequate financial
means may not face the same barriers.

 

This case example is not unique,
unfortunately. Health outcomes often differ across groups, a term commonly
referred to as health disparities. Factors such as poverty, economic barriers, limited
access to healthcare, neighborhood problems and lack of education are just a
few which lead to unequal
health outcomes between groups. What about other reasons for different health outcomes? Do
some individuals not seek effective healthcare because they turn to their own
remedies or they don’t know what beneficial treatments might be out there? Or perhaps
they don’t want someone in the Western medical establishment telling them how
to get well? Or maybe the medical provider is of a different cultural
background? Power dynamics between patient and provider plus history may make
some groups not want to be “experimented upon.”

 

Recent accumulated evidence suggests
that there is a longevity difference between the rich and poor in America,
which is a continuing trend, attributed to economic and social inequality. When
certain treatments are too expensive for some, they miss out on potentially life-saving
solutions. The question ultimately is: can
collaborative care, in its least restrictive definition (the integration of
behavioral and physical health services and communication between care
providers), help to reduce these health disparities and barriers to beneficial healthcare?

 

Although we lack sufficient research
in this area, I propose that collaborative care can help to reduce health
disparities. Collaborative care is geared towards focusing on the whole person,
their biopsychosocial status, and not just on a mental health diagnosis or
physical symptoms. A collaborative care team can first address whether certain
biological factors predispose a patient to specific diseases or disorders. To address
social factors which impact health such as poverty, unemployment, and access to
healthy food, the treatment team can work together to assess nutritional needs,
find financial benefit programs and unemployment resources. Collaborative care
also brings the treatment to where the patient is physically located, which can
ease financial burden for transportation costs. Behavioral health providers can
assess for factors (i.e., depression, trauma) which may impede upon patient
self-care or lead the patient to avoid health clinics for treatment. By
focusing collaboratively on the whole patient, perhaps we can help reduce the health
disparities that exist based upon someone’s race, education, and financial
status.

 

We have an aging population to contend with for the next few decades. The
Healthy
People 2020 project is a national endeavor aimed at
improving the health and longevity of Americans. Specifically, with regard to
health disparities, this
program aims to “achieve health equity, eliminate
health disparities, and improve the health of all groups”. To meet this aim, we
ultimately need to minimize barriers to healthcare for all people: economic,
transportation, education, medical, and nutrition barriers. The list goes on. We
need to work as a team to help the patient take care of their own health.
Collaborative care is one way to break down these
barriers. Let us, as the CFHA community, conduct more research to demonstrate
how effective collaborative care can be in the fight to end health disparities
and health inequality.

Randi Dublin, Ph.D. is a licensed clinical psychologist with particular interests in mental health advocacy and destigmatization, dissemination of evidence-based psychotherapy, integrated behavioral health & primary care, and promotion of psychological science in the community. She has worked across urban settings treating adults with psychological and health-behavior issues. Currently, she works with injured workers who are struggling with chronic pain, trauma, depression and other issues. She hopes health disparities will be addressed by collaborative care.