propriate language services further limits access and quality treatment to the already limited number of mental health services for those with limited English proficiency (Center for Reducing Health Disparities, 2007; Kung, 2004; Lazear et al., 2008; Scuglik et al., 2007; Wong et al., 2006).

Differential access to insurance and providers does not account for all the disparities in rates of depression treatment, however. A study by Padgett and colleagues found that even in an insured population of federal employees, whites were 1.7 times more likely to visit outpatient mental health providers and make 2.6 more mental health visits per year compared with their African American and Hispanic counterparts (Padgett et al., 1994). Moreover, after accounting for differences at the institutional level, there remain differences in treatment-seeking behaviors between non-Hispanic whites and minority populations. Disparities are likely to be attributable to sociocultural barriers and social determinants of health (World Health Organization, 2008), which operate at the level of both the community and the individual patient.

According to the Surgeon General’s assessment, stigma plays a key role in shaping barriers to treatment that operate at the sociocultural level (U.S. Department of Health and Human Services, 2001), which manifest themselves in underutilization of mental health services, particularly among racial and ethnic minorities. Communities have different norms and beliefs surrounding depression, which include differential definitions of the illness and varying views on appropriateness of treatment options (Cooper et al., 2003; Givens et al., 2007; Scuglik et al., 2007; U.S. Department of Health and Human Services, 2001). These beliefs can be associated with stigmatizing attitudes toward and privacy concerns among those manifesting symptoms of or seeking treatment for depression, thus acting as sources of denial in recognizing symptoms and as barriers to seeking and adhering to treatment (Ayalon and Alvidrez, 2007; Das et al., 2006; Grandbois, 2005; Interian et al., 2007; Nadeem et al., 2007; Sanchez and Gaw, 2007; Scuglik et al., 2007; Van Voorhees et al., 2007). Moreover, in some close-knit communities, where “boundary maintenance” is perceived as a necessity for maintaining community cohesion, those who “leave the community” to seek mental health services may be subjected to severe negativity (Van Voorhees et al., 2007). This problem is further compounded by low levels of mental health literacy found in many communities, especially as it relates to mainstream definitions, availability, and effectiveness of treatments for depression (Ayalon and Alvidrez, 2007; Corrigan et al., 2004; Jorm et al., 2003; Kung, 2004; Thompson, Bazile, and Akbar, 2004). The mental health encounter is unique, requiring a higher level of understanding, empathy, and sensitivity. Racial and ethnic minorities experience issues of trust and linguistic barriers and emphasize a greater need for provider cultural and linguistic sensitivity (Chapa, 2009).



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