Matt Freed, Post-Gazette Earl Hill is the new mental health director for Hill House.. Click photo for larger image.

For about nine months, Earl Hill has directed mental health care at the Hill House, where the 30-year-old program is a satellite of UPMC's Western Psychiatric Institute and Clinic.

His position puts Hill on the front line of mental health wellness for black Americans and he knows that depression, anxiety, psychosis and suicide are as real as heart attacks or diabetes. Unfortunately, only one-third of Americans get the mental health care they need and for black Americans the gaps in mental health treatment and services are wider than ever.

The Hill District, where many of Hill's 1,500 clients come from, is a microcosm of the mental health challenges for African Americans. More than 90 percent of those clients are women, survivors of foster care, prison and poverty, all stressful situations that can cause mental disorders. If that's not bad enough, costs and cultural stigma keep more blacks from seeking mental health treatment.

Hill, 60, came of age in the 1960s, before he, a self-admitted "angry black man" went on to earn degrees in psychology from Heidelberg College and Sonoma State University and settled into a career in mental health counseling. Today, Hill reflects on these challenges.

Q. Does mental illness present itself differently across cultures?

A. Oh, you betcha.

In fact diagnoses are different across cultures. For example, African Americans are diagnosed with depression less often than whites, but are diagnosed with schizophrenia much more often. Many times, how people present is misinterpreted.

For example, religious preoccupation is usually a marker for schizophrenia, but in black Americans the actuality is that a person is really praying.

Also, blacks tend to access treatment later, so mental illnesses are usually more progressed. And, psychologists don't take into consideration all the trauma of poverty and violence that blacks must deal with. So, post-traumatic stress, sleep disorder and phobias are often overlooked.

Q. Are there community conditions that push people toward mental illness, and how much of those are related to developing substance abuse?

A. I say mental illness is a combination of bio-psycho-social conditions. Some is genetic predisposition, where drug and alcohol addiction runs in a family. I think the environment plays a role.

What came first doesn't make us any difference. We have to treat both. One trend now is to look at mental illness from a recovery perspective. It helps give a sense of hope. You're not necessarily recovered, but recovering and they understand that it's a process.

Q. The Hill District can be so stereotyped for violence, drug dealing and crime. Do you sometimes feel as if you're fighting a losing battle?

A. No, I say a small hole will sink a great ship and if you patch small leaks, you'll keep it afloat.

Little things will make a big impact. If we help one family and one person, we're throwing the pebble in the pond and it will have rippling effect to help someone else.

Q. What role do black clergy have in combatting mental illness?

A. The spiritual-cultural connection is strong. Our patients may not attend church, but all know a church where they can go. They know a church to call on for a wedding or funeral.

We'd like to see more messages from the pulpit saying "go and be treated." You just can't pray the illness away.

It's not enough, but it is happening. Some are doing mental health days and awareness and stuff like that. But we still have to educate and we have a long way to go.

Q. One huge taboo to blacks seeking health care is distrust of the health system. Outside of costs, what are other barriers?

A. For people with alcohol addiction, they don't take medicines because it means you can't drink.

Blacks shy away from treatment, fearful it will make them appear weak and not spiritual enough.

We treat it as a secret and don't want anyone to know. Even in my family growing up, I heard, "nobody from the outside has know what's going on." This attitude works against black because it keeps them from seeking treatment so they stay sick longer.

There is a lack of trust in going outside of community looking for help and most feel more comfortable with someone the same race.

Q. Do these taboos weigh more heavily on black men, ages 15-19, who statistics tell us are at least 150 percent more likely than their white peers to commit suicide?

A. I think, yes.

There are traditionally three ways to access treatment.

Family and friends is most prevalent, and most healthy because there's usually support. School and jobs are another way. But large numbers of black men are not in school or they don't have jobs. The least popular way to access is mental health treatment is through the courts or jail.

Unfortunately for black men, many get treatment through the jails. What happens is they don't talk a lot about their problem, because it's a sign of weakness, so there's little intervention. Because they don't talk a lot about what's going in, black men can internalize a lot of those feelings, which can manifest in depression, violence, anxiety. Again, by the time they get to the courts or jail the situation is most critical.