The Lybbaverse / under-served-communities  

How the border crosses psychiatric care


Alejandra Postlethwaite, M.D. and UCSD assistant clinical professor, offers psychiatric care to Mexican American families in under-served communities in San Diego County and Calexico. A first- generation immigrant herself, she feels passionately about serving those that need her guidance - in her words, "to make change where it's viewed as impossible." She addresses the many challenges of the patients she serves, not to mention the constraint of the 15-minute limit she has to spend with them. 

Dr. Postlethwaite treats mostly children and families who are on Medi-Cal, at or below 133% of the Federal Poverty Level. At La Maestra, a Federally Designated Underserved Community Health Clinic, she works with children, adolescents, and adults who are either on Medi-Cal, indigent (meaning they have no health insurance), or on the government’s new Low Income Health Plan (LIHP). 

Approximately 90% of the patients she treats are minorities. Most of them are Latino children and adults - the children she treats are usually first- or second-generation Mexican Americans, and the adults are usually immigrants or first-generation Mexican Americans. Most either came to this county or grew up in this country in poverty.

How does the lack of resources cause or compound mental illness?

I believe the lack of resources could both be the cause of a mental illness or subsequently worsen an already existing mental illness.

If a person is genetically predisposed to developing a mental health disorder and is faced with the adversity and stresses of poverty, this can definitely trigger and be seen as the primary cause of a mental disorder. But it really depends on what type and severity of mental illness we are looking at. 

Do strong cultural and familial ties provide a supportive network for patients (or not)?

When it comes to Latino patients, most of them have important family ties to their homeland. However, they either migrated from their county or are the sons or daughters of immigrant parents who come to this county, where they find minimal to no family or supportive ties. They are faced with the unexpected expenses of the American way of life that most of the time cannot be met with one working parent.

This can then put pressure on the family unit, either pushing both parents into a harsh workforce with inadequate pay and childcare, or creating marital discord and/or anxiety that, if not adequately managed, is then transferred to the children, who can be remarkably resilient or experience emotional disturbances as a result (acting out behaviors, drug use, and/or academic failure).

Marital problems due to financial distress can also trigger divorce or parental separation. Single-parent households are prone to additional stressors of their own, worsening existing emotional problems in the family unit and individuals.

The more acculturated Latinos become to the American way of life, the worse their mental health becomes, as does their health in general, and the more prone they are to substance abuse and dependence. They are one of the only minority groups in the USA that exhibits this behavior. 

The reason is unknown, however one can speculate that in Latino countries, community and collectivism are important concepts and ways of life. In the United States, individualism, self-development and independence are encouraged and celebrated. It might be that the backbone of our Latino culture has "the familial" ingrained so strongly that even if a Latino is born in the U.S., acculturating to the U.S. might be perceived as acculturating “out” of their family unit, causing guilt and internal conflict, leading to internalizing disorder as depression and anxiety.

How does negotiating a dual cultural role add to this?

I can speak to the challenges that the dual cultural role brings to the Latino community in the U.S. It brings different types of challenges when looking at Latinos parenting first-generation Latino American children in the US. In many ways the U.S. is more liberal when compared to Latino countries.

Children in the U.S. are taught to be tolerant of differences in others from preschool on. Having a same-gender couples as classmates in high school or a friend whose parents are gay is not as uncommon as it is in most cities in Latin American. This is very likely due to the strong and most common religious preference in Latin America, Catholicism.

A immigrant Latino parent could experience culture shock and find it disturbing if their American child expresses behaviors that are viewed as age-appropriate in the U.S. but are unaccepted or not talked about in Mexico - for example, premarital sex or sexual experimentation. This could create significant turmoil in the family, and the child might feel misunderstood and/or lonely even if their family unit is considered strong or close-knit.

Mental illness continues to be somewhat of a taboo in Latin American cultures. It's not discussed openly, and if a child has a mental illness, it's viewed as a result of poor parenting rather than a medical condition. That said, many Latino children in the U.S. are not brought in for an assessment or treatment due to the stigma of mental illness in their communities.

Tell us about your work in Calexico and San Diego, and how they compare.

One of the major differences that I see when I compare Calexico to San Diego is that in Calexico I treat mostly first-generation Mexican American children - all were either citizens or permanent residents. This was due to working for a county system that serves Medi-Cal patients and county public health systems not accepting indigent patients. Since I've worked for La Maestra, I see all types of patients - some with Medi-Cal, but as stated above, many who are indigent or on Low Income Health plans.

A big difference, as well, is that the parents of the children or the adults in San Diego tend to be less dependent on welfare and other governmental programs. Most of the parents of the children I treat work or have recently been laid off and are looking for work. However, in Calexico most of the parents of the children I treat have governmental aid. I think this is because Calexico is significantly less expensive than San Diego, and families can live a comfortable life on welfare and food stamps when compared to San Diego.

How is the outreach conducted, and how are you able to spread the word about the services? Is finding funding difficult?

In one of the public mental health clinics where I work (Rady's Children’s Hospital), the outreach is conducted at the schools. The clinic has therapists who see children in schools, and if needed, refer me to them for an evaluation. All of this is done with prior parental consent. A therapist, even if they are based on school grounds, cannot meet with a student if his or her parent does not sign a consent form.

The outreach at La Maestra, the inner city clinic mentioned, is done by the other doctors and/or clinicians working here, or by the centralized Medi-Cal access hotline that has our information available for those searching for help.

Is most of your time spent managing medications? 

Most of my time is spent providing psychoeducation and medications. Unfortunately the way the public and managed health care system is set up now, psychiatrists are hired to provide only medication management to patients and have patient flows like most family practitioners, meaning 15-minute appointments.

It's hard to provide adequate psychotherapeutic intervention in 15 minutes. During that time, one needs to assess the response to medication, side effects, review laboratory results and active symptomatology, and lastly, document all of this, usually on non-user-friendly electronic health record systems.

Therapy is usually deferred to social workers, psychologists, or family therapists. However, if a patient has an urgent need for a psychotherapeutic intervention that does not involve medications I take the time needed to intervene. 

Why are mental health services especially crucial for under-served communities?

One, because a large number of the population that lives in under-served communities is low-income or lives in poverty, and as explained above, poverty and/or financial stress is a risk factor for developing or worsening mental illness.

Second, under-served communities are usually “medically under-served” as well, meaning their patient-to-doctor ratio is extremely high because doctors avoid working in underserved communities for various reasons - mostly because  the patient population tends to have significant co-morbid medical and/or mental health conditions. Hence, they are difficult to treat, their prognosis is not great, the number of patients and workloads are higher than in non-under-served areas, and the ability to refer out for more specialized care or tests can be extremely difficult to impossible, so doctors are left to do a lot, for many patients, with minimal resources.

Nevertheless, I am passionate about working within under-served communities because even though it can be hard, the rewards are significantly higher when one makes change in a place where change is viewed as impossible by most.