Priority Issues in Latino Mental Health Services Research

(1)

Priority Issues in Latino Mental Health Services Research

William A. Vega

^1,3

and Steven R. Lopez

²

This paper identifies issues and trends affecting the quality and comprehensiveness of Latino mental health research and services. These issues include current patterns of need and services use, rapid expansion of the Latino population, extraordinary rates of uninsured, social and language barriers to care, transformation in treatment science and technology, and the sheer complexity and rapid changes in the delivery system. Progress in the field requires coordina- tion and investments from both public and private sectors. Scientific journals should provide assistance for creating a high quality knowledge base and rapidly disseminating this information to students, practitioners, and policy makers. Vigorous activity is needed to (1) augment the supply of people entering the “pipeline” for researcher and practitioner training, and (2) support research in priority areas such as outcome studies for diverse treatments and different sectors of care, cultural competence, treatment models for youth and aging populations, quality of care, and barriers to mental health care.

KEY WORDS: Latino; Hispanic; mental health services.

After nearly four decades of research activity, a review of Latino mental health literature reveals a lengthy list of inadequately studied issues and limited consistency of empirical findings (Acosta, 1979;

Barrera, 1978; Castaneda, 1994; Dworkin & Adams, 1987; Gaviria & Arana, 1987; Greenblatt & Norman, 1982; Lopez, 1981; Padilla & Ruiz, 1973; Rogler, 1996;

Rogler, Malgady, & Rodriguez, 1989; Ruiz, 1985, 1997; Telles & Karno, 1994; Vega & Alegria, 2001;

Vega & Rumbaut, 1991; Woodward, Dwinelle, &

Arons, 1992). This review is not intended to rehash these themes. The fields of mental health and psychiatry are changing rapidly, and it would be imprudent to use yesterday’s litany of research gaps to set to- day’s agenda. Transformations in the organization of health care and in the science underpinning mental

1Department of Psychiatry, Robert Wood Johnson Medical School, New Brunswick, New Jersey.

2Department of Psychology, University of California, Los Angeles, California.

3Correspondence should be directed to William A. Vega, De- partment of Psychiatry, Robert Wood Johnson Medical School, 335 George Street, RM. 317, New Brunswick, New Jersey 08901;

e-mail: [email protected].

health treatment will revolutionize the field in the next 20 years. Tomorrow will bring technological innova- tions that fundamentally alter clinical practice such as neuroimaging, genetic counseling, pharmacogenetics, and pharmacotherapy; and who delivers care and how it is administered, including telepsychiatry and vari- ations of managed mental health care (Halbreich &

Montgomery, 2000; Sabin, 2000; Schreter, 2000). Ex- tensive changes in policies and laws governing who receives care, where they can receive it, and how much they are entitled to, are also expected (Bachrach, 2000; Geller, Fisher, McDermeit, & Brown, 1998). It is impossible to fully anticipate how mental health care will be restructured over the next 20 years. Our purpose is to identify research and policy issues that constitute a viable foundation for the future of Latino mental health care.

A recent study surveyed six leading psychology journals published over the past 25 years and found that fewer than 1% of papers were about Latinos (Castro & Ramirez, 1997). In contrast to this mea- ger growth in the knowledge base, the U.S. Census Bureau (2001; Fig. 1) has estimated that 12.5% of all Americans were Latinos in the year 2000, or about 35,305,818. They constitute the most numerous 189

1522-3434/01/1200-0189/0°^C2001 Plenum Publishing Corporation

(2)

Fig. 1.U.S. Population-2000 (in Thousands).

ethnic minority in the nation, followed by African Americans, 34,658,190. This Latino estimate does not include over 4 million people on the island of Puerto Rico. This represents a 58% increase since the 1990 U.S. Census and projections are for 100 million or more Latinos in the United States by 2050.

Two subgroups comprise three quarters of the U.S. Latino population, Mexican origin (66.1%) and Puerto Ricans (9%). Nearly one third of individuals in both groups met poverty criteria (U.S. Census Bureau, 2000). Educational attainment is dismal.

Among those over 25 years, only one half of Mexican origin and two thirds of Puerto Ricans have completed high school. Given these significant need indi- cators and the demographic explosion now underway, a strategy is needed to increase the quantity and quality of Latino mental health research and researchers interested in the field. Most recently, the National In- stitutes of Health responded with a strong emphasis on addressing disparities in health. Private foundations have not yet shown the same concerted effort, but there are signs of change. An aggressive, inte- grated, national strategy is needed to make genuine progress.

Meeting Latino’s mental health needs on a national scale cannot be done without (1) greater support for professional training, and (2) linking the future research agenda to trends in patient care, including the reorganization and financing of services delivery. In the absence of a coordinated and persistent national effort, we do not expect significant improvement to occur in the quality of mental care for Latinos. A breakthrough is needed in attaining a credible knowledge base for conveying information taken from empirically grounded, replicated research designs. This will reduce the practice of resorting to dubious cultural assumptions as de facto guidelines, as is now the case, or relying on highly contradictory

findings that offer no clear path forward for evidence- based practices (Lopez, 1988; Lopez & Hernandez, 1987). In short, we hope the current decade will result in more adequate research coverage, accompanied by a body of research for training practitioners and researchers that leads to documented improvements in quality of care. There is persuasive evidence that this process is now in its early stage.

HOW BIG IS THE PROBLEM?

Frequently, human services providers contend with the recurring and often frustrating requests for

“needs assessments” to justify program activities, policies, and expenditures in the mental health field.

We use benchmark criteria for this purpose. The need for mental health services is often quantified using two methods. One is to measure true prevalence of mental health problems, including social functioning and dis- abilities, in the population and to use this information to estimate service requirements and gaps in delivery (Warheit, Vega, & Buhl, 1983). A second method is to evaluate rates in treatment to detect shortfalls in delivery of services to specific demographic or diag- nostic groups.

Although even the most optimistic human services professionals do not assume that all people with mental health problems (including chronic conditions and impairments) will receive treatment for them, ac- curate population estimates of individuals with disorders who received or failed to receive treatment provide a baseline for evaluation. At this writing the World Health Organization has organized the World Mental Health 2000 initiative, a series of large population studies in two dozen nations (Kessler et al., 2000). This represents the most encompassing com- parative epidemiologic research ever attempted in the history of mental health research. As part of this initiative, the largest and most exhaustive U.S. national studies are also being conducted. Demonstrating a strong commitment, the National Institute of Mental Health is supporting national field studies that include Latinos, with subsamples of Mexican, Puerto Rican, and Cuban origin people that are sufficiently large to permit independent estimates ofDSM-IVdisorders, impairments, and services patterns. In the near future, it will be possible to provide reliable estimates of unmet need in the Latino adult population based on national data, and to place those estimates in the context of other U.S. ethnic groups and other national populations.

(3)

There is no near term solution for estimating unmet need among either Latino children or elderly. Although epidemiologic studies of psychological distress of Latino elderly have been conducted, their limited number and scope pose a serious defi- ciency, given the rapid expansion of this demographic group (Black, Markides, & Miller, 1998; Markides, Martin, & Sizemore, 1980). No epidemiologic studies of mental disorders have been conducted. There are a number of measurement problems in accu- rate assessment of mental functioning in this age group, complicated by cross-cultural validity issues, which continue to delay the deployment of large scale community studies (Loewenstein, Arguelles, Aguelles, & Linn-Fuentes, 1994). Similarly, little information is available about need for mental health services among Latino children despite the striking fact that 40% of the Latino population is 18 years or younger. Most studies of mental health problems in Latino children conducted in the continental United States have generally reported normative rates of problem behaviors, and higher depressive symptoms and suicidal ideation rates when compared to youth of other ethnic backgrounds (Achenbach et al., 1990;

Kann et al., 1998; Roberts & Chen, 1995; Roberts, Roberts, & Chen, 1997; Roberts & Sobhan, 1992;

Vega, Khoury, Zimmerman, Gil, & Warheit, 1995). In most instances, these studies have not used diagnos- tic or impairment criteria to make assessments. This limits their use for estimating unmet treatment needs or identifying the types of services required (Shaffer et al., 1983). The fact that many problem behavior and symptom measures have not been restandardized for the Latino population creates a danger of measurement nonequivalence and potential misinterpretation of meaning when comparing scores with other ethnic groups (Rogler et al., 1989). Equivalence problems have appeared with cognitive (Escobar et al., 1986; Loewensten et al., 1994; Lopez & Taussig, 1991) and psychodiagnostic assessments as well (Velasquez, Ayala, & Mendoza, 1998).

Past epidemiologic surveys and clinical studies of adults have estimated the prevalence ofDSM-III andDSM-III-Rpsychiatric disorders among regional Latino populations in California, the state that con- tains one third of all Latinos residing in the United States (Alderete, Vega, Kolody, & Aguilar-Gaxiola, 2000; Burnam, Hough, Karno, Escobar, & Telles, 1987; Karno et al., 1987; Vega et al., 1998). Three important conclusions are warranted by these studies that will be confirmed or refuted by current national studies. First, due to lower rates of psychiatric

disorders among immigrants, Latinos have lower overall population rates of psychiatric disorders than do White non-Hispanics or African Americans.

Puerto Ricans residing in the Northeastern United States may be exceptional and have significantly higher rates (Moscicki, Rae, Regier, & Locke, 1987).

Second, rates of disorders increase with time in residence in the United States among immigrants, especially for those who arrived as children. Therefore, the lower need for mental health services among immigrants will gradually shift toward higher need rates over time. Third, Latinos who have had recent psychiatric disorders are seriously underserved in the mental health treatment sector and are less likely to receive any type of care for their mental health problems when compared to non-Latinos (Hough et al., 1987;

Vega, Kolody, Aguilar-Gaxiola, & Catalano, 1999;

Wells, Hough, Golding, Burnam, & Karno, 1987). The problem of unmet need is most acute among immigrants; only about 4% with recent disorders have received mental health services. Latinos require fewer services per capita, but treatment volume will increase over time, and those who require treatment are much less likely to receive care when compared to non-Latinos.

The actual number of individuals seeking care in the mental health sector in the future can be estimated with greater precision when the Latino national mental health survey is completed. The base rates of treatment and utilization will vary among subgroups, for example, Cubans, Puerto Ricans, Mexicans, and other Latinos. These rates could be multiplied by antici- pated population growth for each subgroup over the next decade. However, even assuming a constant rate of utilization, the driver will be the rapid population growth creating an urgency for preparing an adequate body of literature, training mental health professionals to treat this population, and evaluating existing policies and financing mechanisms for providing access to care for low income populations.

A second method used to assess need com- pares treatment rates for ethnic groups with their proportional representation in the population based on the tacit assumption that mental health problems are fairly evenly distributed in all groups. When we examine “rates-in-treatment” information, we find wide divergences in use of mental health services by Latino adults and children. In state mental health systems, utilization rates vary by county, by region (urban vs. rural), and by modality of services (Swanson, Holzer, & Ganju, 1993). A tentative conclusion is that mental health sector utilization by

(4)

Latinos is influenced by two tiers of organizational factors and, in turn, these are manifested differently according to the form of governance and unique his- torical arrangements in each state. One factor is state level policies and procedures governing financing, quality assurance, and eligibility for services. The second factor consists of county or, in some cases, municipal procedures governing implementation of state policies combined with characteristics of local providers, for example, availability of providers, penetration of managed care, and bilingual/bicultural staffing (Aguilar-Gaxiola et al., 2001). Research is needed to examine the interplay of these factors on Latino services use.

The combined impact of these factors is partially seen in total utilization rates for Latinos in the public mental health system. From mid-year 1997 to mid-year 1998, Latinos represented about 29% of the California population (California Department of Finance, 1999). California Department of Mental Health services data for that time period show that Latinos received 19.5% of the total volume of nonresidential care in the state (Department of Mental Health, California, personal communica- tion, 2001). For the three most frequently occurring types of care, Latinos received (statewide) 15.4% of inpatient/residential care, 19.7% of outpatient care, and 16.9% of partial day care. However, utilization rates varied widely among California counties. For example, total mental health services use was pro- portionately higher in Los Angeles County than in Fresno County in 1997–98. The former is an urban county with greater availability of bilingual administrative and treatment staff. The latter is a combined rural and urban county with low levels of bilingual staff and inadequate distribution of mental health services (Aguilar-Gaxiola et al., 2001). Underutilization of outpatient services is suspected of contributing to a serious deterioration of functioning when Latinos are voluntarily or involuntarily hospitalized (Swanson et al., 1993).

The low socioeconomic position of many Latinos, and lack of insurance, lessens the likelihood of using private providers for mental health care. As a result, unmet need in the public sector is not likely to be displaced to the private sector. A recent study in San Diego County reported underrepresentation of Latino children in private sector mental health care (Hough et al., 2001). A high priority research issue is to identify who receives private mental health care, and the volume, modality, and referral into services received. No information is available at this time.

Regrettably, a persistent problem in getting adequate data on these topics is that many federal surveys are not conducted in Spanish and miss a high proportion of potential respondents.

IMPROVING ACCESS TO MENTAL HEALTH CARE

There are several key factors that may struc- ture access to care and represent targets for research.

Latinos have the lowest rate of health insurance coverage, depressed by low socioeconomic status and a high rate of immigration. Low rates of health insurance coverage among immigrants pose a particu- larly difficult barrier to surmount because it affects all members of a household and often quite differently.

The problem of parents without insurance often ex- pands to include their children (Flisher et al., 1997).

On the other hand, children may qualify for public insurance, yet one or more parents may not qualify.

About 35% of Latinos in the United States were believed to lack health insurance in 1998 (Campbell, 1999). Employment sectors such as laborers and other unskilled service workers, which employ many Latinos including undocumented immigrants, are the least likely to provide stable work or insurance coverage (Bennefield, 1998). Predictably, one result is a low rate of enrollment in managed care plans for Latinos (Leigh, Lillie-Blanton, Martinez, & Collins, 1999).

A contributory factor to limited health care access is the disturbing finding that no improvement in median income was reported in 1997 between the second ($32,200) and the third generation ($32,008) Mexican Americans (U.S. Census Bureau, 1998). This income stagnation is linked to low educational attainment and overrepresentation in low wage employment sectors. The end result is reduced likelihood of insurance and no regular source of health care (Lewin-Epstein, 1991). Another consequence is a reliance on charity care, usually primary care doctors, often in public health clinics, and emergency rooms.

These are problematic for diagnosing and treating psychiatric problems.

The administrative process is another potential source of access problems for Latinos. What are those experiences like for Latinos and how do they influence future utilization? Information derived from research is scant on this topic. There are certain contextual issues that have reduced utilization of mental health services by some Latinos. Federal and state initia- tives to limit access to health services for immigrants

(5)

have had far-reaching consequences on help-seeking behavior for mental health problems. In California, anti-immigrant attitudes, behaviors, and policies have distanced Latinos from the health care system and resulted in greater emergency room use (Fenton, Catalano, & Hargreaves, 1996). Although we have little empirical evidence about how pervasive fear and apprehension are as barriers to care, it is evident that this issue is worthy of research in different regions of the nation. There are probably other administrative and culture/linguistic problems that may affect Latinos trying to enter the care system. The lack of information extends to the experiences of serious and persistently mentally ill Latinos, about whom we have little empirically derived information about issues associated with the health care system and its interac- tions with family life and support, continuity of community care, or treatment compliance and outcomes (Karno et al., 1987).

Barriers and personal experiences of Latino children with the mental health system are inadequately documented (Castaneda, 1994). A Los Angeles study of inner-city Latino children showed that only about 40% of them had continuous Medicaid coverage since birth, and about 39% had only episodic coverage.

The authors of this study concluded that because of welfare reform and a hostile atmosphere toward immigrants in California, access to care was likely to worsen (Halfon, Wood, Valdez, Pereyra, & Duan, 1997). Some research suggests that the insurance dif- ferential is attributable to Latino’s immigrant status (Ku & Matani, 2001), whereas others have pointed out that the high uninsurance rates are prevalent among noncitizen children and citizen children within immigrant families (Brown, Wyn, Hongjian, Valenzuela, &

Dong, 1999).

The same unfamiliarity and distrust may also im- pede use of children’s services by Latinos. The recent difficulty that California had implementing the Children’s Health Insurance Program (CHIPS) program exemplifies the problems. Another barrier is stigma. Although it has not been studied, the degree and dimensions of stigma and misunderstand- ing about mental illness within Latino culture are likely to produce fear, anxiety, and denial if and when Latino parents are confronted with this type of information about their children. Albeit limited, the research about mental illnesses or personal accept- ability of individuals suffering from chronic or substance abuse disorders suggests that Latinos share the same apprehensions and negative attitudes as other ethnic groups (Link, Phelan, Bresnahan, Stueve, &

Pescosolido, 1999). Therefore, it stands to reason that discussion about mental health problems of children could trigger underlying fears. The shortage of bilingual/bicultural human services and health professionals that could educate the Latino community, as well as their patients, limits community education and outreach. Latino children who require and seek mental health care are most likely to be treated by personnel from other ethnic backgrounds for many years to come. This accentuates the importance of research on cultural competency skills and language translation standards for mental health care.

Acaveatis needed at this juncture regarding the differences in national subgroups that compose the Hispanic population. Latino subgroups differ dra- matically on demographic and sociopolitical factors that are very consequential for mental health care access. Therefore, they cannot be lumped together in research without creating significant distortions.

Puerto Ricans and Cubans are more likely to be eligible for either publicly funded health services (Medicaid/Medicare) or private care than are individuals of Mexican or Central American origin.

Although Puerto Ricans have very high poverty rates, they are U.S. citizens at birth and entitled to publicly assisted health care benefits. It is likely that their use of mental health services within the public sector is considerably greater than among Mexican or Central America origin people because of the higher proportion of immigrants, including undocumented, in the latter two groups. Cuban Americans have higher socioeconomic status than other Latinos, and many arrived in the United States with official refugee status. This made them eligible for public mental health care upon arrival in the United States. The naturaliza- tion rate of foreign-born Latinos from the Caribbean (41%) is much higher than that from Mexico (15%) (U.S. Census Bureau, 2000). Cubans are the most likely to be enrolled in managed care plans and to possess private insurance (De la Torre, Frus, Hunter,

& Garcia, 1996).

The primacy of insurance and economic hardship in limiting the use of mental health services by Latinos does not rule out the possibility that additional, non- economic factors are implicated in moderating access to mental health care. Rates of using physicians and mental health providers to treat mental health problems are higher among insured (Vega, Kolody, &

Aguilar-Gaxiola, in press). In Puerto Rico, where uni- versal access to care is available, rates of using mental health services are higher than among Latinos living in the continental United States (Alegria et al.,

(6)

1991). However, is insurance availability the singular or primary barrier to access to care? Are other factors such as language problems, the lack of fit between lay conceptions of mental illness and providers conceptions, stigma, high rates of unexplained medical symptoms-somatization, fear among immigrants of detection, and a lack of information about where to find services also important?

Fine grain research is needed to answer these ques- tions definitively. These research approaches require identifying key factors that (a) improve access to men- tal health care, and (b) increase appropriate utilization.

This type of information could lead to more effective practices and policies within the delivery system.

ALTERNATIVE HELP SEEKING FOR MENTAL HEALTH PROBLEMS

Thus far the discussion has focused on the use of mental health specialty providers. In actuality a much greater volume of total services is received for mental health problems outside of the specialty sector. Use of multiple providers in different service sectors is common. The most recent epidemiologic survey of Mexican origin respondents in California showed that medical doctors were twice (19.9%) as likely to be consulted by individuals with a recent (past year) DSM-III-Rdisorder as were mental health specialists (9.3%; Vega et al., in press). Other professionals such as counselors, ministers/priests, and chiroprac- tors were also more likely (11.2%) to be consulted than were mental health specialists (9.3%). Because many individuals receiving care do so in more than one sector, these utilization proportions are not addi- tive. Seventy three percent of individuals with recent DSM-III-Rdisorders received no form of treatment in this study (Vega et al., in press).

It is difficult to reliably ascertain the steps in the help-seeking process from problem recognition to the chain of contingencies that follow to provider selec- tion and treatment. The process is so complex that it may never be possible to fully disentangle it to our satisfaction (Anderson, 1995). In the study dis- cussed above, only 1.0% of those with recent disorders used only a mental health specialist, 3.0% used both medical doctors and mental health specialists, 1.2%

used other professionals and mental health specialists, and 3.1% used all three sectors. By way of contrast, 9% received treatment exclusively from medical providers, compared to 1% for mental health specialists! However, this type of cross-sectional data do not

provide insights into patterns and time sequences associated with help-seeking (Miranda, Hohmann, Attkisson, & Larson, 1994). At a minimum, we need studies that will provide information on lag times between problem onset and treatment, type of provider most likely to provide initial assessment and treatment, and the likelihood and lag time for referral to a mental health provider.

The course of recovery from a psychiatric episode is time dependent. For example, early treatment of schizophrenia reduces the likelihood of a second episode, and by extension reduces treatment costs. It should be a major research and policy goal to min- imize the time between onset and treatment. It is equally critical to assess effectiveness of treatment received in different care sectors and factors affecting referral patterns. These last two points are basic to establishing optimal combinations of outcome and cost of care, as well as treatment alternatives for Latinos that may be more feasible and culturally acceptable.

It may be very difficult to alter Latino preferences for consulting physicians and steer them en masse toward mental health providers. This has never been accomplished for any U.S. ethnic group (Regier, Goldberg, & Taube, 1978). This being the case, we need research that increases quality of mental health care in general medical and family physician settings.

Logically, attitudes held by Latinos about mental health services are influenced by information received from others. Immigrants have already had health care experiences that could be expected to shape current knowledge, attitudes, and behavior about mental health care utilization in the United States (Salgado de Snyder, de Jesus Diaz-Perez, Maldonado, & Bautista, 1998). To what extent is there intergenerational transmission of these patterns? Be- cause mental illness is often recurrent, some of those with recent psychiatric disorders have already used mental health providers in the past, and may or may not want to do so in the future. Individuals who are experiencing serious mental health problems for the first time and seeking assistance may decide not to use mental health specialists on the basis of information they receive within their social networks. This information may have been shaped by frustration with administrative hurdles, inconveniences at work or with travel, long waiting periods, staff demeanor, or the actual clinical experience (Anderson, 1995). We have very little empirical information about treatment experiences of Latinos or what they will say to others about it (Pescosolido & Boyer, 1999). From community research data, we find that Latinos with mental

(7)

health problems report not knowing how or where to access mental health providers (Vega, Kolody, &

Aguilar-Gaxiola, 2001). There does seem to be a knowledge or information gap, perhaps further ag- gravated by low education and literacy levels.

There are a few studies suggesting that ethnic similarity of other consumers and staff in the clinics, Spanish language competence of staff, and the ethnic matching of patients and therapists reduce dropout (e.g., Sue, Fujino, Hu, & Takeuchi, 1991).

While these findings are logical and plausible, it is not known whether they are sufficient or even neces- sary elements for improved treatment outcome. With increasing reliance on pharmacogenetics and pharmacotherapy in the future treatment agenda, especially in managed mental health care, less importance may accrue to social and environmental factors in the clinic setting than was the case in the past. Nevertheless, the need for establishing clinical rapport, accurately listening, and communicating with patients will not diminish if patients are expected to be engaged, com- pliant, and remain in treatment.

In addition to examining the role of service providers and the experience of Latino consumers using such services, it is equally important to examine how Latino communities and families define, understand, react to, and cope with mental health problems (see, e.g., Guarnaccia & Parra, 1996; Jenkins, 1988). The provision of care and the promotion of mental health must not be conceived as solely within the purview of health and mental health professionals. Many Latino families and communities have been promoting mental health and coping and dealing with (severe) mental illness without professional care for years. The study of natural support systems and the consideration of how to enhance family and community based caregiving is critical to the development of optimal care for Latinos (e.g., Cox & Monk, 1993;

Wallace, Campbell, & Lew-Ting, 1994).

CULTURAL COMPETENCE: WHAT IS IT AND HOW DOES IT AFFECT QUALITY OF CARE?

Cultural competency refers to the providers’ and institutions’ ability to incorporate in the provision of mental health services a respect and understand- ing of consumers’ sociocultural context. This per- spective can be operationalized into specific skills, knowledge, and organizational factors that promote quality of care for consumers from culturally diverse backgrounds. Perhaps the most widely cited cultural

competence model is that of Cross, Bazron, Dennis, and Isaacs (1989) that was developed in the context of care for serious emotionally disturbed children and adolescents. A number of other models have been offered since (e.g., Falicov, 1998; Koss-Chioino &

Vargas, 1999; Lopez, 1997; D. W. Sue & D. Sue, 1999;

S. Sue & Zane, 1987). Although there have been efforts to develop group specific cultural competence guidelines (e.g., for Latinos, Western Interstate Com- mission of Higher Education, 1996), most cut across several ethnic groups.

Cultural competence has received widespread attention across the nation. In some places, policymakers are requiring that their practitioners receive training in cultural competence. In other parts of the country, practitioners are mobilizing political support to ensure that systems of care adopt clinical and insti- tutional guidelines that reflect cultural competence.

Annual conferences are being held in some states (e.g., California and Texas) to address the various dimensions of cultural competence. Federal agencies are also supporting the development and implementation of such guidelines (e.g., Center for Mental Health Services, 2000).

Despite the several models and the growing interest in cultural competence, much work needs to be done before cultural competence will positively impact mental health service delivery for Latinos and other ethnic groups. Currently, cultural competence is largely an ideology or a set of guiding principles that lack empirical validation. For example, one of the guiding principles from the recently released Cultural Competence Guidelines from the Center of Mental Health Services states that

Recovery and rehabilitation are more likely to occur where managed care systems, services, and providers have and utilize knowledge and skills that are culturally competent and compatible with the backgrounds of consumers from the four under served/underrepresented racial/ethnic groups, their families, and their communities.

Despite the apparent importance of the princi- ple, there are no existing data to support its validity.

Thus, an essential step in advancing culturally competent services for Latinos is to carry out research to test guidelines, standards, or models derived largely by expert clinicians and administrators. Although expert guidelines can be useful in suggesting direc- tions for the provision of mental health services, they lack the authority that empirically based guidelines currently have. In the development of empirically based guidelines, an important issue to address is

(8)

whether such guidelines should cut across disorders and treatment approaches or whether the guidelines should focus on specific disorders with specific treatment approaches (e.g., multifamily group treatment for schizophrenia, Lopez, Kopelowicz, & Canive, in press; McFarlane, et al., 1995). At this early stage of development, multiple approaches, generic and specific, are warranted. Ultimately, outcome data will help determine the utility of any given cultural competence approach.

In addition to the lack of evidence to support the notion of cultural competence, there is also great vari- ability in its operationalization. In part, this reflects the complexity of the construct. Cultural competence can have different foci from individual clinicians and delivery systems to the communities in which clinicians and delivery systems reside (Cross, Bazron, Dennis, & Isaacs, 1989). Considering clinicians, one can examine language skills—the degree to which clinicians speak the language of their clients, whether clinicians understand idiomatic expressions even when expressed in a common language, and how clinicians use language to elicit additional information from consumers and their families. In addition to language skills, the clinicians’ knowledge, values, beliefs, and other “cultural” skills can each be further delineated pointing out the complexity of cultural competence at the individual practitioner level alone. Thus, given the many facets of cultural competence, researchers would do best to target the as- pects of cultural competence that matter most to the quality of care. Careful conceptualizations of culture, quality mental health care, and cultural competence will contribute to such research, as well as simple but meaningful correlates of care. Sue, et al. (1991) have led the way in pointing out, for example, the importance of a simple index of linguistic and ethnic match for Mexican Americans that is associated with contin- uing in treatment and improving in patient functioning. Future research will do well to tie similar indices to important processes of care.

The pressing demand for cultural competence requires that immediate attention be given to this important problem. Research-based approaches to cultural competence that require clear operational- izations and empirically based guidelines take time.

An important challenge is to establish and main- tain dialogues between those in the policy arena who want immediate action with those in the research arena who require more time. Efforts to im- plement cultural guidelines prematurely before they are well-established risk failure in implementation or

in outcomes. Such experiences could set back efforts to incorporate cultural competence in mental health practice. In contrast, waiting until guidelines have been formally tested may miss the political and social window of opportunity that is currently open among many systems of care. Support by federal agencies and private foundations for this much-needed research could expedite this line of inquiry so that it can be delivered on a timely basis. Including the involvement of service providers, families, and consumers in the research process facilitates its future implementation.

HUMAN RESOURCE: WHO WILL DO THE WORK?

The identified areas of research will require a cadre of investigators as well as a growing number of professionals motivated to address Latinos’ increasing needs for mental health services. Professional contributions are needed from persons of all ethnic groups. Many of the cultural and linguistic skills nec- essary to serve Latinos can be learned, given proper training. Three demographic trends have important implications for who will address Latinos’ increasing needs for mental health care: (a) decline in the proportion of non-Latino Whites in the U.S. work force, (b) the increase of Latinos and other minority group members, and (c) the relatively poor educational outcomes of Latino students.

The number of White Non-Latinos within the U.S. workforce (18–64 years of age) is projected to decrease in size from 73% in 2000 to 52% in 2050 (National Science and Technology Council, 2000).

This declining representation will result in a corresponding decrease in their representation among all professional groups, including mental health researchers and providers. Given that whites comprise such an overwhelming majority of both scientists (83% of scientists and engineers, National Science and Technology Council, 2000) and mental health providers (e.g., 96% of licensed psychologists who are members of the American Psychological Association, Williams & Kohout, 1999), their decreasing proportions will result in a significant shortfall in the nation’s future mental health professional workforce.

A corresponding demographic shift, as noted earlier, is the increasing number of ethnic minorities within the U.S. workforce, from 27% in 2000 to 47% in 2050 (National Science and Technology Council, 2000). To avert the projected shortfall of

(9)

Fig. 2.Minority Group Representation in Graduate and Professional School Enroll- ment, College Enrollment, and U.S. Census 1997. (Sources: U.S. Census Bureau, Pop- ulation Estimates, Population Division, August 23, 2000; and The Chronicle of Higher Education Almanac, September 1, 2000, p. 24.)

researchers and practitioners, it is imperative that ethnic minorities fill the void (see Fig. 2). This is not without difficulty as African Americans, American Indi- ans, Asian/Pacific Islanders, and Latinos make up a small proportion of this nation’s scientists and engineers (17%) and mental health providers (e.g., 4%

of psychologists who are licensed APA members).

Moreover, among ethnic minority groups, the educational achievement of all but Asian/Pacific Islanders falls short of their representation in the nation’s population. Latinos fare worse than the other ethnic groups. For example, census data indicate that since 1972, the high school graduation rate of Latinos ages 18–24 has hovered around 60% (National Center for Education Statistics, 1999). This contrasts to the high school graduation rate of Black non-Hispanics that has increased from 70% in 1970s to 81% in 1998. A total of 90% or more Asian/Pacific Islanders and White non-Hispanics graduate from high school. Although not as dramatic, Latinos in particular, and African Americans to some extent, are not well represented among students in colleges and graduate/professional schools (Newburger & Curry, 2000; see Fig. 2). Thus, significant steps to improve the educational attainment of Latinos and African Americans as a whole are going to contribute significantly to the growing need for mental health researchers and providers to address Latino mental health needs. Given that Latinos are likely to have knowledge of the critical linguistic and cultural skills as well as the motivation and passion to serve other Latinos, special efforts are needed to ensure that the pool of Latino investigators and clinicians are increasing in number and in strength.

WHERE DO WE GO FROM HERE?

Strong and consistent support for mental health research about Latinos is needed now. This is only attainable through public and private sector commitment. Part of this support must include increasing the number of Latinos in the research and training pipeline. Training minority mental health providers is no longer simply a matter of affirmative action or of making up for past discrimination. Although there are divergent views about the methods that should be used for attaining these social goals, one cannot deny the clear demographic trends and the need to train more minority mental health professionals. The United States must take important steps to reach the potential latent in the population.

The problem of increasing the highly trained la- bor pool of Latinos in the mental health sector is a formidable challenge. The shortfall of trained bilingual professionals is especially acute in education and the human services sectors. Better educational outcomes require reaching youth early in the school experience. Latino and other minority youth need improved educational outcomes that boost their high school completion rates. Programs are needed to en- gender occupational aspirations that are specific to the human services, using summer internships for high school students and other methods to give Latinos first hand experiences. Only a coherent strategy will supply sufficient numbers for professional training to replace a decreasing proportion of white non- Latino researchers and practitioners in an aging U.S.

population. It is in the nation’s best interest to act now so as to improve the educational status of Latinos and

(10)

other ethnic groups who are underrepresented among mental health professionals.

Improved services require viable linkages between researchers, practitioners, and policymakers.

The emphases must be on research that improves services and is fostered by rapid information dissem- ination to practitioners, training institutions, and to policymakers when it is appropriate. By extension, this implicates the academic journals that must take a more active role in moving the research agenda ahead and do their part to give Latino mental health researchers a voice and greater visibility to the issues they identify. The mechanisms for communicating Latino mental health information to professionals are inadequate at this time, and as a result, the mental health field is poorly informed about these issues. This paper provides a baseline for future comparisons. In another decade, we can, hopefully, doc- ument the significant advances in publications, researchers, practitioners, and improved quality of care for Latinos.

REFERENCES

Achenbach, T., Bird, H. R., Canino, G., Phares, V., Gould, M., & Rubio-Stipec, M. (1990). Epidemiologic comparisons of Puerto Rican and U.S. mainland children: Parent, teacher, and self-reports.Journal of the American Academy of Child and Adolescent Psychiatry,29,84–93.

Acosta, F. (1979). Barriers between mental health services and Mexican Americans: An examination of a paradox.American Journal of Community Psychology,7,503–520.

Aguilar-Gaxiola, S., Edmondson, C., Garcia, B., Alejo-Garcia, C., Zelezny, L., & Vega W. A. (2001).Linking mental health re- search to practice and policy to reduce mental health disparities in Mexican Americans. Manuscript submitted for publication.

Alderete, E., Vega, W. A., Kolody, B., & Aguilar-Gaxiola, S. (2000).

Lifetime prevalence of and risk factors for psychiatric disorders among Mexican migrant farmworkers in California.

American Journal of Public Health,90,608–614.

Alegria, M., Robles, R., Freeman, D. H., Vera, M., Jimenez, A. L., & Rios, R. (1991). Patterns of mental health utilization among island Puerto Rican poor.American Journal of Public Health,81,875–879.

Anderson, R. M. (1995). Revising the behavioral model and access to medical care.Journal of Health and Social Behavior,36, 1–10.

Bachrach, L. (2000). The past and future of mental health services:

An interview with Leona Bachrach.Psychiatric Services,51, 1511–1512.

Barrera, M., Jr. (1978). Mexican American mental health service utilization: A critical examination of some proposed variables.

Community Mental Health Journal,14,35–45.

Bennefield, R. L. (1998).Who loses coverage and for how long? Dy- namics of economic well-being: Health insurance, 1993 to 1995 (Current Populations Reports, Household Economic Studies, pp. 70–64). Washington, DC: US Census Bureau.

Black, S. A., Markides, K. S., & Miller, T. Q. (1998). Correlates of depressive symptomatology among older community dwelling Mexican Americans: The Hispanic EPESE.Journal of Geron- tology: Social Sciences,53B,S198–S208.

Brown, R., Wyn, R., Hongjian, W., Valenzuela, A., & Dong, L. (1999). Access to health insurance and health care for children in immigrant families. In D. Hernandez (Ed.),Chil- dren of immigrants: Health, adjustment and public assistance.

Washington, DC: National Academy Press.

Burnam, M. A., Hough, R. L., Karno, M., Escobar, J. I., & Telles, C.

(1987). Acculturation and lifetime prevalence of psychiatric disorders among Mexican Americans in Los Angeles.Journal of Health and Social Behavior,28,89–102.

Campbell, J. A. (1999).Health insurance coverage 1998: Consumer income(Current Population Reports, P60–P208). Washington, DC: U.S. Census Bureau.

Castaneda, D. M. (1994). A research agenda for Mexican–

American adolescent mental health.Adolescence, 29,225–

239.

Castro, A., & Ramirez, M., III. (1997).The Latino representation in the psychological literature: A 25-year review of 6 APA journals.

Unpublished manuscript.

Center for Mental Health Services. (2000).Cultural competence standards in managed care mental health services for four under served/under represented racial/ethnic groups. Rockville, MD:

Substance Abuse and Mental Health Services Administration.

Retrieved from http://www.samhsa.gov/centers/cmhs/cmhs.

html

Cox, C., & Monk, A. (1993). Hispanic culture and family care of Alzheimer’s patients. Health and Social Work, 18, 92–

100.

Cross, T. L., Bazron, B. J., Dennis, K. W., & Isaacs, M. R.

(1989).Towards a culturally competent system of care(Vol. 1).

Washington, DC: CASSP Technical Assistance Center, Georgetown University.

De la Torre, A., Frus, R., Hunter, H. R., & Garcia, L. (1996). The health insurance status of US Latino women: A profile from the 1982–1984 HHANES.American Journal of Public Health, 86,533–537.

California Department of Finance (1998).Race/Ethnic Population with Age and Sex Detail, 1970–2040. Sacramento, CA.

Dworkin, R., & Adams, G. L. (1987). Retention of Hispanics in public sector mental health services.Community Mental Health Journal,23,204–216.

Escobar, J. L., Burnam, A., Karno, M., Forsythe, A., Landsverk, J.,

& Golding, J. M. (1986). Use of the Mini-Mental State Exami- nation (MMSE) in a community population of mixed ethnicity.

Journal of Nervous and Mental Disease,174,607–614.

Falicov, C. J. (1998).Latino famlies in therapy: A guide to multicul- tural practice. New York: Guilford Press.

Fenton, J. J., Catalano, R., & Hargreaves, W. A. (1996). Effect of Proposition 187 on mental health service use in California: A case study.Health Affairs,15,182–190.

Flisher, A. J., Kramer, R. A., Gorsser, R. C., Alegria, M., Bird, H. R., Bourdon, K. H., et al. (1997). Correlates of unmet need for mental health services by children and adolescents.Psy- chological Medicine,27,1145–1154.

Gaviria, M., & Arana, J. D. (Eds.). (1987).Health and behavior:

Research agenda for Hispanics. Champaign, IL: University of Illinois Press.

Geller, J. L., Fisher, W. H., McDermeit, M., & Brown, J. M. (1998).

The effects of public managed care on patterns of intensive use of inpatient psychiatric services.Psychiatric Services,49, 327–332.

Greenblatt, M., & Norman, M. (1982). Hispanic mental health and use of mental health services: A critical review of the literature.

American Journal of Social Psychiatry,2,25–31.

Guarnaccia, P. J., & Parra, P. (1996). Ethnicity, social status, and families’ experiences of caring for a mentally ill family mem- ber,Community Mental Health Journal,32,243–260.

Halbreich, U., & Montgomery, M. D. (2000).Pharmacotherapy for mood, anxiety, and cognitive disorders.Washington, DC:

American Psychiatric Press.

(11)

Halfon, N., Wood, D., Valdez, B., Pereyra, M., & Duan, N. (1997).

Medicaid enrollment and health services access by Latino children in inner-city Los Angeles.JAMA,277,636–641.

Hough, R. L., Hazen, A. L., Soriano, F. I., Wood, P., McCabe, K., & Yeh, M. (2001).Mental health services for Latino ado- lescents with psychiatric disorders. Manuscript submitted for publication.

Hough, R. L., Landsverk, J. A., Karno, M., Burnam, M. A., Timbers, D. M., Escobar, J. I., et al. (1987). Utilization and health and mental health services by Los Angeles Mexican Americans and non-Hispanic whites.Archives of General Psychiatry,44, 702–709.

Jenkins, J. H. (1988). Conceptions of schizophrenia as a problem of nerves: A cross-cultural comparison of Mexican-Americans and Anglo-Americans.Social Science and Medicine,26,1233–

1243.

Kann, L., Kinchen, S. A., Williams, B. I., et al. (1998). Youth risk behavior surveillance—United States, 1997.Morbidity Mortality Weekly Report,47,1–89.

Karno, M., Hough, R. L., Burnam, A., Escobar, J. I., Timbers, D. M., Santana, F., et al. (1987). Lifetime prevalence of specific psychiatric disorders among Mexican Americans and non-Hispanic whites in Los Angeles.Archives of General Psychiatry, 44, 695–701.

Karno, M., Jenkins, J., de la Selva, A., Santana, F., Telles, C., Lopez, S., et al. (1987). Expressed emotion and schizophrenia outcome among Mexican American families.Journal of Nervous and Mental Disease,175,143–151.

Kessler, R. C., Aguilar-Gaxiola, S., Alegria, M., Andrade, L., Bijl R., Caraveo-Anduaga, J., et al. (2000). The International Con- sortium of Psychiatric Epidemiology.Psychiatrie,1,15–20.

Koss-Chioino, J. D., & Vargas, L. A. (1999).Working with Latino youth. San Francisco: Jossey-Bass.

Ku, L., & Matani, S. (2001). Left out: Immigrants’ access to health care and insurance.Health Affairs,20,247–256.

Leigh, W. A., Lillie-Blanton, M., Martinez, R. M., & Collins, K. S.

(1999). Managed care in three states: Experiences of low income African Americans and Hispanics. Inquiry, 36, 318–

331.

Lewin-Epstein, N. (1991). Determinants of regular source of health care in Black, Mexican, and Puerto Rican, and non-Hispanic White populations.Medical Care,29,543–557.

Link, B. G., Phelan, J. C., Bresnahan, M., Stueve, A., & Pescosolido, B. A. (1999). Public conceptions of mental illness: Labels, causes, dangerousness, and social distance.American Journal of Public Health,89,1328–1333.

Loewenstein, D. A., Arguelles, T., Aguelles, S., & Linn-Fuentes, P. (1994). Potential cultural bias in neuropsychological assessment of the older adult.Journal of Clinical and Experimental Neuropsychology,16,623–629.

Lopez, S. (1981). Mexican Americans usage of mental health facili- ties: Underutilization reconsidered. In A. Baron (Ed.),Explo- rations in chicano psychology. New York: Praeger.

Lopez, S. (1988). The empirical basis of ethnocultural and linguistic bias in mental health evaluations of Hispanic patients.Ameri- can Psychologist,43,1095–1097.

Lopez, S. R., Kopelowicz, A., & Canive, J. M. (in press). Strate- gies in developing culturally congruent family interventions for schizophrenia: The case of Hispanics in Madrid and Los Angeles. In H. P. Lefley & D. L. Johnson (Eds.),Family inter- ventions in mental illness: International perspectives. Westport, CT: Greenwood.

Lopez, S., & Hernandez, P. (1987). When culture is considered in the evaluation and treatment of Hispanic patients.Psychotherapy, 24,120–126.

Lopez, S. R. (1997). Cultural competence in psychotherapy: A guide for clinicians and their supervisors. In C. E. Watkins, Jr. (Ed.),Handbook of psychotherapy supervision. New York:

Wiley.

Lopez, S. R., & Taussig, I. M. (1991). Cognitive–intellectual functioning of impaired and non-impaired Spanish-speaking elderly: Implications for culturally sensitive assessment.

Psychological Assessment: Journal of Consulting and Clinical Psychology,3,448–454.

Markides, K. S., Martin, H. W., & Sizemore, M. (1980). Psycholog- ical distress among elderly Mexican Americans and Anglos.

Ethnicity,7,298–309.

McFarlane, W. R., Lukens, E., Link, B., Dushay, R., Deakins, S. A., Newmark, M., et al. (1995). Multiple-family groups and psy- choeducation in the treatment of schizophrenia.Archives of General Psychiatry,52,679–687.

Miranda, J., Hohmann, A. A., Attkisson, C. C., & Larson, D. B., (Eds.). (1994).Mental disorders in primary care. San Francisco:

Jossey-Bass.

Moscicki, E. K., Rae, D. S., Regier, D. A., & Locke, B. Z. (1987).

The Hispanic Health and Nutrition Examination Survey: De- pression among Mexican Americans, Cuban Americans, and Puerto Rican. In M. Gaiviria & J. D. Arana (Eds.).Health and behavior: Research agenda for Hispanics. (Simon Bolivar Res.

Monogr. Series, No. 1), Chicago: University of Illinois Press.

National Center for Education Statistics. (1999).Dropout rates in the United States: 1998(NCES 2000–022). Washington, DC:

U.S. Department of Education.

National Science and Technology Council. (2000). Ensuring a strong U.S. scientific, technical, and engineering workforce in the 21st century. Washington, DC: Office of Science and Technology.

Newburger, E. C., & Curry, A. (2000).Educational attainment in the United States: Population characteristics(Current Population Reports P20–P528). Washington, DC: U.S. Census Bureau.

Padilla, A. M., & Ruiz, R. A. (1973).Latino mental health: A review of the literature.(DHEW Pub. No. (HSM) 78-9143). Rockville, MD: National Institute of Mental Health.

Pescosolido, B. A., & Boyer, C. A. (1999). How do people come to use mental health services? In A. V. Hortwitz & T. L. Scheid (Eds.),A Handbook for the study of mental health: Social con- text theories, and systems. New York: Cambridge University Press.

Regier, D. A., Goldberg, I. D., & Taube, C. A. (1978). The de facto US mental health services system.Archives of General Psychi- atry,35,685–693.

Roberts, R. E., & Chen, Y. (1995). Depressive symptoms and suicidal ideation among Mexican-Origin and Anglo Adolescents.

Journal of the American Academy of Child and Adolescent Psychiatry,34,81–90.

Roberts, R. E., Roberts, C., & Chen, Y. R. (1997). Ethnocultural differences in prevalence of adolescent depression.American Journal of Community Psychology,25,95–110.

Roberts, R. E., & Sobhan, M. (1992). Symptoms of depression in adolescence: A comparison of Anglo, African, and Hispanic Americans.Journal of Youth and Adolescence,21,639–651.

Rogler, L. H. (1996). Research on mental health services for Hispanics: Targets of convergence. Cultural Diversity and Mental Health,3,145–156.

Rogler, L. H., Malgady, R. G., & Rodriguez, O. (1989).Hispanics and mental health: A framework for research.Malabar, FL:

Krieger.

Ruiz, P. (1985). Cultural barriers to effective medical care among Hispanic-American patients.Annual Review of Medicine,36, 63–71.

Ruiz, P. (1997). Issues in the psychiatric care of Hispanics.Psychi- atric Services,48,539–540.

Sabin, J. E. (2000). Managed care and health care reform: Comedy, tragedy, and lessons.Psychiatric Services,51,1392–1396.

Salgado de Snyder, V. N., de Jesus Diaz-Perez, M., Maldonado, M., & Bautista, E. M. (1998). Pathways to mental health services among inhabitants of a Mexican village.Health and Social Work,23,249–261.

(12)

Schreter, R. K. (2000). Economic grand rounds: Trends in managed care, 2000 edition.Psychiatric Services,51,1993–1498.

Shaffer, D., Gould, M. S., Brasic, J., Ambrosini, P., Bird, H. R., &

Aluwahlia, S. (1983). A children’s global assessment scale (CGAS).Archives of General Psychiatry,40,1228–1231.

Sue, D. W., & Sue, D. (1999).Counseling the culturally different:

Theory and practice(3rd ed.). New York: Wiley.

Sue, S., Fujino, D. C., Hu, L., & Takeuchi, D. T. (1991). Community mental health services for ethnic minority groups: A test of the cultural responsiveness hypothesis.Journal of Consulting and Clinical Psychology,59,533–540.

Sue, S., & Zane, N. (1987). The role of culture and cultural techniques in psychotherapy: A critique and reformulation.

American Psychologist,47,37–45.

Swanson, J., Holzer, C. E., & Ganju, V. K. (1993). Hispanic Americans and the state mental health hospitals in Texas: Eth- nic parity as a latent function of a fiscal incentive policy.Social Science and Medicine,37,917–926.

Telles, C., & Karno, M. (Eds.). (1994).Latino mental health. Los Angeles, CA: UCLA Neuropsychiatric Institute.

U.S. Census Bureau. (1998).Current Population Survey, March 1997. Washington, DC: Author.

U.S. Census Bureau. (2000). Census brief: Coming from the Americas: A profile of the nation’s Latin American foreign- born(CENBR/00-3). Washington, DC: Author.

U.S. Census Bureau. (2001).Overview of race and Hispanic origin.

Census 2000 Brief. Washington, DC: Author.

U.S. Department of Commerce. Retrieved from, http://www.

census.gov/prod/2000pubs/cenbr003/pdf. Accessed 10-22-01, Issued Sept. 2000.

Vega, W. A., & Alegria, M. (2001). Latino mental health and treatment in the United States. In M. Aguirre-Molina, C. Molina, &

R. Zambrana (Eds.),Health Issues in the Latino Community.

San Francisco: Jossey-Bassey.

Vega, W. A., Kolody, B., & Aguilar-Gaxiola, S. (2001). Help seeking for mental health problems among Mexican immigrants and Mexican Americans.Journal of Immigrant Health,3,133–140.

Vega, W. A., Kolody, B., Aguilar-Gaxiola, S., Alderete, E., Catalano, R., & Caraveo-Anduaga, J. B. (1998). Lifetime prevalence

of DSM-III-R psychiatric disorders among urban and rural Mexican Americans in California.Archives of General Psy- chiatry,55,771–778.

Vega, W. A., Kolody, B., Aguilar-Gaxiola, S., & Catalano, R. (1999).

Gaps in services utilization by Mexican Americans with mental health problems.American Journal of Psychiatry,156,928–

934.

Vega, W. A., Khoury, E. L., Zimmerman, R. S., Gil, A. G., &

Warheit, G. J. (1995). Cultural conflicts and problem behaviors of Latino adolescents in home and school environments.

Journal of Community Psychology,23,167–179.

Vega, W. A., & Rumbaut, R. (1991). Ethnic minorities and mental health.Annual Review of Sociology,17,351–383.

Velasquez, R. J., Ayala, G. X., & Mendoza, S. A. (1998).Psychodiag- nostic assessment of U.S. Latinos: MMPI, MMPI-2, MMPI-A results. Lansing, MI: Julian Samora Research Institute, Michi- gan State University.

Wallace, S. P., Campbell, K., & Lew-Ting, C. (1994). Structural barriers to the use of formal in-home services by elderly Latinos.

Journals of Gerontology,49,253–263.

Warheit, G., Vega, W., & Buhl, J. (1983). Mental Health Needs As- sessment Approaches: Case for Applied Epidemiology.Pre- vention in Human Services,2,9–34.

Wells, K. B., Hough, R. L., Golding, J. M., Burnam, M. A., &

Karno, M. (1987). Which Mexican Americans under utilize health services? American Journal of Psychiatry,144,918–

922.

Western Interstate Commission of Higher Education. (1996).Cul- tural competence standards in managed mental health care for Latino populations(Publication No. 3B85). Boulder, CO:

Author. Retrieved from, http://www.wiche.edu/MentalHealth/

CCStandards/index.htm

Williams, S., & Kohout, J. L. (1999).A survey of licensed practition- ers of psychology: Activities, roles, and services. Washington, DC: American Psychological Association.

Woodward, A. M., Dwinelle, A. D., & Arons, B. S. (1992). Barriers to mental health care for Hispanic Americans: A literature review and discussion.Journal of Mental Health Administration, 19,224–236.