Mental Health Disparities
- Rhonda Wells-Wilbon, Rhonda Wells-WilbonSchool of Social Work, Morgan State University
- Rhea Porter,
- Taylor Geyton
- and Anthony Estreet
Millions of Americans are affected by a mental illness or disorder each year. Given the prevalence, it is unfortunate that significant disparities exist within mental health care. Some of the most common reasons mental health disparities exist include stigma, previous negative experiences, limited mental health literacy, lack of culturally aware providers and services, language access, and lack of financial resources. Additionally, members of racial and ethnic, gender, and sexual orientation minority groups, who already encounter higher levels of bias, experience poorer mental health outcomes due to disparities than their counterparts. Grounded in the values and ethics of the profession, it is no surprise that social workers play a vital role in reducing mental health disparities.
Mental health is a topic that has gained more national attention in the 21st century. This attention is often triggered by a crisis that has negative consequences such as a school shooting, serial killer, workplace shooting, or the suicide of a public figure. However, the challenge of mental health is a much bigger problem, often experienced away from public attention and concern.
According to the National Institute of Mental Health (2019), one in five U.S. adults live with a mental illness (i.e., 44.7 million in 2016). Parks et al. (2006) reported that mental illnesses, including depression, are the third largest cause of hospitalization for adults aged 18–44, and those who suffer with serious mental health have a lifespan that is about 25 years lower than those who do not. An additional concern that receives little attention is mental health disparities. Within this group of already marginalized people are subgroups of people that face even greater challenges. This entry will not only identify those groups that are often marginalized, but also focus primarily on the most common reasons disparities exist, including stigma, inadequate mental health literacy, fear of consequences, lack of culturally competent providers and services, lack of training among providers, desire for self-sufficiency, lack of financial resources, and previous negative experiences. This is a broad overview of some of the most common mental health disparities.
Mental Health Prevalence
In 2016, globally, approximately 1.1 billion people were estimated to live with a form of mental illness (Ritchie & Roser, 2018). The most prevalent diagnoses globally in 2018 were depression, affecting approximately 300 million people; bipolar disorder, with approximately 60 million people diagnosed; schizophrenia and other psychoses, affecting around 23 million people worldwide; and dementia, with approximately 50 million people living with the disorder (World Health Organization, 2018).
The Centers for Disease Control (2018) estimated that approximately 50% of all Americans will experience a mental illness or disorder during their lifetime. Furthermore, among adults, mental illness is the third leading cause of hospitalization, and individuals with serious mental illness live an average of 25 years less than others (Centers for Disease Control, 2018).
Most Common Disparities
In the Unequal Treatment report, the Institute of Medicine (IOM) defines disparity as a difference in health care quality not due to differences in health care needs or preferences of the patient (Smedley et al., 2003). By definition, disparities can be rooted in inequalities in access to good providers, differences in insurance coverage, or discrimination by health professionals in the clinical encounter (McGuire & Miranda, 2008). Other most common reasons mental health disparities exist include stigma, sociohistorical experiences, previous negative experiences, desire for self-sufficiency, limited mental health literacy, lack of culturally competent providers and services, language barriers, lack of financial resources, location of services, and use of alternative resources. Additionally, limited English proficiency, inadequate health literacy, geographic inaccessibility, and lack of medical insurance are all more common among immigrants, minority populations, individuals of low socioeconomic status, and people in rural areas (Sanchez et al., 2016); these are the groups that are identified as most likely to experience disparities.
Racial and ethnic minorities with mental illnesses who are also economically disadvantaged are less likely than Whites to receive mental health services (Willging et al., 2008; Wilson, 2009). Only 30% of African Americans and 27% of Hispanics with any past-year mental illness used mental health services, compared with 46% of Whites between 2008 and 2012 (Substance Abuse and Mental Health Services Administration, 2015). Minorities are also more likely than Whites to drop out of mental health treatments prematurely (Kreyenbuhl et al., 2009; Wang, 2007). Stigma within racial and ethnic minority communities continues to reduce the utilization of mental health services; for example, African Americans often prefer primary care clinics to receive needed treatment for mental disorders due to the stigma associated with the use of specialized mental health services (Whitley & Lawson, 2010).
African Americans have a lack of trust in doctors and treatment due to past experiences and a history of injustices experienced by African Americans in the healthcare system (Campbell & Long, 2014). Culturally incompetent providers and services, as well as displeasing experiences, validate the disparity in mental health care for African Americans; African Americans often report feeling culturally misunderstood and dissatisfied with treatment in general (Smith, 2015). The lack of cultural competence by health care providers may contribute to underdiagnosis and/or misdiagnosis of mental illness of racial and ethnic minorities (American Psychiatric Association, 2017a).
Populations Most Likely to Experience Mental Health Disparities
While one in eight men, compared with one in five women, suffer from a form of mental illness, men are actually underdiagnosed and less likely to be diagnosed with common mental health disorders, such as anxiety, depression, phobia, and obsessive-compulsive disorders (Peate, 2010). More than one in ten men will experience a major depressive episode in their lifetime (Parker & Brotchie, 2010). One of the challenges to serving men is a lack of understanding within the mental health profession on common signs and symptoms of their mental illness, which can differ from that of women (National Institute of Mental Health, 2017). Furthermore, it is estimated that more than half of men with diagnosable psychiatric disorders will receive no mental health counseling or even assistance from friends and family (Addis & Mahalik, 2003). Thus, a significant number of men will continue to suffer from psychiatric disorders without needed resources from mental health professionals.
Many men are reluctant to seek help for psychological problems due to biological, psychological, and sociological factors (Smith et al., 2006). Shafer and Wendt (2015) noted that men are often socialized into certain “masculine” views that deter them from seeking help. Men often hold the belief that depression should be dealt with alone. Factors that encourage men to deal with depression alone are a belief that it is a self-limiting disorder, that the use of substances are an effective way to deal with it, and that depression is due to personal weakness (Jorm et al., 2006).
Finally, men frequently report feeling that helping professionals are not equipped to improve their mental health, and they see poor mental health as a state of being common to men that cannot be improved (Shafer & Wendt, 2015). Other barriers that discourage men from help-seeking include the belief that the experience of depression is normative, the state of happiness is not a natural masculine trait, and control is needed in all situations—namely, never exposing weaknesses, looking good to others, and hiding emotional pain (Rochen et al., 2010).
Each year 20% of women in the United States are projected to experience a mental illness (American Psychiatric Association, 2017d). The most common mental health diagnosis among women in 2017 was depression (American Psychiatric Association, 2017d). Women are twice as likely as men to experience depression in their lifetime (National Institutes of Health, 2008). Women are also twice as likely to experience post-traumatic stress disorder (PTSD) and related symptoms, and anxiety according to the Diagnostic and Statistical Manual, updated in 2013 (American Psychiatric Association, 2013). The rate of suicide attempts among women in 2016 was higher than the rate of attempts by men; however, women were four times less likely than men to die from suicide (U.S. Census Bureau, 2016a, 2016b). The majority of individuals diagnosed with eating disorders are also women. In 2016, of individuals diagnosed with anorexia nervosa or bulimia nervosa 85–95% were women. Of those diagnosed with a binge eating disorder 65% were women (Smith et al., 2018).
The disparate rates at which women experience these disorders is influenced through women’s lived experiences. In 2017, women’s annual earnings were 82% of the annual earnings of men (Bureau of Labor Statistics, 2018). Women are more likely than men to experience poverty and the stressors of financial constraints as a result. Socioeconomic status has also been indicated as a pertinent stressor and a potential factor in women’s rates of mental illness (American Psychiatric Association, 2017d). The often low social economic status of many women, particularly single mothers, is also associated with low service utilization and participation due to resource limitations.
According to the American Psychiatric Association (2017d), women are more likely to seek treatment from their primary care doctor rather than a mental health professional. Physicians have been noted to diagnose women with depression more frequently than they do men in spite of identical presentation of symptoms and scores on depression inventories (American Psychiatric Association, 2017d).
It is not surprising that women experience greater instances of intimate partner violence which has been linked to adverse mental health outcomes (Beydoun et al., 2017). Like other oppressed and/or disadvantaged populations, women also experience stigma associated with their life experiences and choices.
The National Institutes of Mental Health (2019) reported that 75% of all lifetime cases of mental illness begins by the age of 24. Of the adults with any mental illness, young adults have the highest prevalence and the lowest rate of mental health service utilization. Approximately 22.1% of young adults were diagnosed with any mental illness in 2016, and only 35.1% of those diagnosed utilized services (National Institute of Mental Health, 2017). Of the young adults aged 18–25, 5.9% also have the highest prevalence of serious mental illness, and only 51.5% of those affected received treatment (National Institute of Mental Health, 2017).
In 2016, young adults had the highest frequency of suicidal ideation, planning, and attempts across all adult age groups. An estimated 8.8% of young adults had serious thoughts of suicide, while 2.9% of young adults created plans for suicide. Finally, 1.8% of young adults, over 600,000, attempted suicide (Substance Abuse and Mental Health Services Administration, 2017). In 2017, the Centers for Disease Control reported suicide as the second leading cause of death among the 15–24-year-olds (US Department of Health and Human Services, 2017).
Substance abuse is a major concern for this population; approximately 5.3 million young adults required treatment for substance use in 2016 (Park-Lee et al., 2017). This is 15.5% of the young adult population. Among those requiring treatment for substance use, 2.5 million young adults required treatment for illicit substance use while 3.8 million young adults required treatment for their alcohol use (Park-Lee et al., 2017).
It has been estimated that 20% of people aged 55 years or older experience some type of mental health challenge; the most common conditions include anxiety, severe cognitive impairment, depression, and bipolar disorder (Centers for Disease Control, 2018). Also, older adults are more likely to experience certain life stressors that may increase their risk of developing a mental health disorder, such as a chronic illness or the death of a loved one (Sorocco & McCallum, 2006). Karel, Gatz, and Smyer (2012) estimated that, by the year 2030, more than 15 million older adults will have a diagnosable mental health disorder.
Research has also found that older adults with mental health disorders are less likely to receive mental health services than other age groups (Bogner et al., 2009; Karlin et al., 2008). Adults over the age of 60 are approximately one-third as likely to consult a mental health specialist compared with adults aged 40–59 years (Bogner et al., 2009). Access to mental health care services for most older adults is inadequate; mental health disorders are often missed, wrongly diagnosed, and poorly treated in older adults due to ageism, stigma related to mental illness, and the lack of geriatric mental health providers (Charney et al., 2003). Barriers that discourage older adults from seeking mental health treatment and contribute to the early termination of services include lack of perceived need for care, lack of knowledge about availability of mental health services, lack of insurance and lack of transportation (Sorkin et al., 2016). The older adults who do pursue treatment for mental health problems often seek care from a physician (Sorocco & McCallum, 2006).
Rates of mental illness among African Americans closely follow national trends (Primm & Lawson, 2010). Opioid use among African Americans was 2 percentage points higher than the national average in 2016, indicating a slightly higher occurrence of use. However, African Americans represented only 12% of deaths by opioid overdose in2017 compared with 78% of non-Hispanic Whites (Kaiser Family Foundation, 2017). Disparities in mental health among African Americans are most prominent in service utilization and availability (Primm & Lawson, 2010). The American Psychiatric Association (2017b) reported that “only one-in-three African Americans who need mental health care receives it” (p. 2). There are multiple factors influencing access to care for African Americans, including low rates of insurance coverage, lack of a regular healthcare provider, difficulty finding resources for treatment, distrust in the healthcare system, and stigma of mental illness (Ganz et al., 2018).
In 2015, 27% of African Americans were living below the poverty line (U.S. Census Bureau, 2016a, 2016b). Additionally, approximately 11% of African Americans were not covered by health insurance in 2015 (U.S. Census Bureau, 2016a, 2016b). Financial statistics alone indicate cost associated with care as a barrier to treatment for African Americans living with mental illness (American Psychiatric Association, 2017b).
There are other systemic historical problems that also add to the challenges for African Americans and mental health. A systematic review of studies of health care providers implicit bias has found that many health care providers appeared to have implicit bias toward positive attitudes when working with Whites and negative attitudes when working with African Americans (Hall et al., 2015). African Americans experienced poorer treatment with regard to patient centeredness, contextual knowledge of the patient, and patient–provider communication (Hall et al., 2015). The tumultuous history of medical professionals’ interactions with African Americans also plays a part in service utilization (American Psychiatric Association, 2017b). It has been reported that African Americans were dissected in medical experimentation and used for autopsy practice in medical institutions during their enslavement, and even after its abolition (Suite et al., 2007). These experiments served as a basis for scientists to dehumanize African Americans and characterize them as beneath, immoral, and primitive beings (Suite et al., 2007). Later, clinical trials would effectively withhold life-saving treatment from Black men and sterilize Black women without their consent (Suite et al., 2007). The mistrust of the medical and mental health systems is a crucial element to understanding the disparate rates at which African Americans seek and receive mental health services.
In addition to discrimination and historically founded mistrust, African Americans are less likely to receive quality care from providers (American Psychiatric Association, 2017b). Often providers fail to remain consistent with professional guidelines when treating African Americans. Additionally, members of this population are often underrepresented in mental health research, leaving a gap in the knowledge base regarding appropriate diagnosis and the best treatment practices (Office of the Surgeon General, Center for Mental Health Services, National Institute of Mental Health, 2001). Moreover, African Americans are less likely to receive evidence-based treatment. This may be a result of the greater likelihood of African Americans to leave treatment early or treatment bias on the side of the providers (Wang et al., 2000).
The American Psychiatric Association (2017b) has identified stigma as a substantial contributing factor to the low rates of African Americans seeking mental health treatment. Stigma, according to Hatzenbuehler, Phelan, & Link (2013), is the ascription of negative labels and stereotypes that isolate, degrade, and discriminate against a person in context from a position of power. In other words, a person who is not affected by the contextual element, in this case a diagnosis, asserts the negative stereotyped label onto a person who is affected, devaluing the person and their experiences (Hatzenbuehler et al., 2013). The experience of stigma and the negative associations it creates with mental illness are major deterrents to seeking treatment.
Finally, a lack of racial diversity among service providers and a lack of culturally competent service providers exacerbate the exclusion of African Americans from mental health treatment (American Psychiatric Association, 2017b). The lack of cultural competence from providers often results in misdiagnosis and inadequate treatment and mistrust of mental health professionals (National Alliance on Mental Illness, n.d.a). These disparities can create poorer health outcomes for African Americans as many may not seek or continue mental health treatment.
The National Latino and Asian American Study (NLAAS) found that Latino individuals are at lower risk than Whites for almost all psychiatric disorders except agoraphobia without panic disorder, 43.2% Whites reported any lifetime disorder, compared to 29.7% of Latinos (Alegría et al., 2008). However, U.S.-born Latinos (18.6%) were at a significantly higher risk than immigrant Latinos (13.4%) for major depressive episode (Alegría et al., 2008).
Hispanics/Latinos may be at lower risk than Whites for mental health disorders according to the NLAAS (Alegría et al., 2008). Nevertheless, Latinos encountered many barriers to accessing mental health services, including concerns about cost of services, lack of insurance, shortage of Spanish-speaking providers, fears of deportation, and lack of transportation (Bridges et al., 2012; Sanchez et al., 2016). Bridges et al. (2012) conducted semi-structured service utilization interviews with 84 adult Hispanic participants; nearly 60% of participants reported a cost barrier, 35% reported a lack of insurance, and 31% reported the lack of Spanish-speaking providers as a primary reason for not seeking help when needed. This study also found high prevalence rates for major depressive disorder, PTSD, and generalized anxiety disorder, which indicates that Hispanics have a need for mental health services.
Cultural responsiveness can also serve as a barrier to service use, meaning providers who speak Spanish and are familiar with the cultural values and traditions of Latino clients are lacking (Bridges et al., 2012). Due to all of these barriers, Latinos are less likely to seek mental health treatment than their White counterparts (National Alliance on Mental Illness, n.d.c). Latinos who do seek mental health care services tend to pursue services from primary care physicians (Bridges et al., 2014). In 2001, The Surgeon General’s report, Mental Health: Culture, Race and Ethnicity reported that only 10% of Latinos contact a mental health specialist about their psychological concerns. Some Latinos conceptualize mental health symptoms as physical problems; therefore, instead of seeking help from a mental health professional, they may see a primary care physician for aches and pains (Bridges et al., 2012).
Asian Americans report lower rates of mental disorders and substance use than other groups (Substance Abuse and Mental Health Services Administration, 2012). The National Latino and Asian American Study (NLAAS) found that the overall lifetime prevalence of any psychiatric disorder among Asian Americans to be 18.1%. This study also found that U.S.-born Asian Americans are more likely to experience lifetime mood disorders, substance use disorders, and any mental disorders compared to Asian immigrants, which may be due to healthier individuals choosing to migrate (Hong et al., 2014).
Research has found significant underutilization of mental health services for Asian Americans; furthermore, underutilization was especially acute among Asian American immigrants (Le Meyer et al., 2009). Asian Americans often delay seeking help until the severity of a mental health problem is high, and when treatment is sought, it tends to be informal, alternative, or medical service providers rather than mental health professionals (Sue et al., 2012). Examining the NLAAS sample, Le Meyer et al. (2009) found that only 28% used specialty mental health services (compared with 54% in the general population), 16% used primary care services, and 11% used alternative services to address their mental health concerns. Also, Asians with limited English proficiency tend not to seek mental health services. Another analysis of the NLAAS data found that Asian Americans with better English language proficiency were more likely to have used mental health services in their lifetime (Kang et al., 2010).
Society often sees Asian Americans as resilient, healthy, and experiencing fewer mental health problems compared to other ethnic groups; this false perception decreases the amount of mental health resources for Asian Americans (Okazaki et al., 2014). Both the high cost of mental health care and the lack of medical insurance coverage are also barriers to mental health care access for Asian Americans (Okazaki et al., 2014). There are also other economic factors that limit the access to mental health services, such as workload, being unable to find child care, and lack of transportation. Cultural factors hinder the delivery of mental health services for Asians as well; for example, some Asian Americans hold a perception of mental illness as a sign of weakness that would bring shame to the family if one were to seek treatment (Chu & Sue, 2011).
Sexual Minorities (LGBT)
In 2016, approximately 9 million adults identified as LGBT (lesbian, gay, bisexual and transgender). Semlyen et al. (2016) stated that LGBT individuals are more than twice as likely as their heterosexual counterparts to have a mental health disorder in their lifetime. Additionally, the incidence of depression, anxiety, and substance use among the LGBT community is 2.5 times higher than the prevalence among cisgender heterosexuals (Kates et al., 2018).
LGBT individuals face numerous challenges and barriers to accessing health services, including the limited amount of health professionals competent in LGBT health, lack of health insurance coverage and personal finances, and poor transportation connections to LGBT-specific health care services (Qureshi et al., 2018). Members of this community often have higher rates of poverty and unemployment due to the absence of protection under federal equal employment acts on the basis of sex and sexual orientation (Mustanski et al., 2016). In spite of these challenges, in 2016, LGBT individuals had higher rates of mental health service utilization than heterosexual men and women (Platt et al., 2017). Still, many LGBT individuals have reported feeling unsafe in medical environments due to previous experiences of discrimination on the basis of sexual orientation or sexual identity. As a result, individuals have forgone or delayed necessary medical procedures and services (Safer et al., 2016).
LGBT individuals report discrimination, harassment, and victimization on the basis of sexual orientation and/or gender identity from childhood into and throughout adulthood. Research shows that sexual minority populations are at greater risk for victimization yielding to cumulative stress and the perpetuation of mental illness and distress (Mustanski et al., 2016). Additionally, lack of family support can cause psychological distress for LGBT individuals. Social and familial support for LGBT individuals is often limited or non-existent (Mustanski et al., 2016). LGBT individuals who lack family support experience higher distress from adolescence to adulthood compared to those who receive support (McConnell et al., 2016).
Rates of suicide among sexual minorities are four times greater than heterosexual rates. The degree of discrimination and harassment that LGBT individuals endure can create feelings of hopelessness and despair. Approximately 4.4% of people identifying as gay or lesbian considered attempting suicide in 2016 compared to 2.3% of people identifying as heterosexual (American Psychiatric Association, 2017c). Lesbians are also more likely to consume large amounts of alcohol (Substance Abuse and Mental Health Services, 2016). People who identify as bisexual had a higher rate of suicide consideration with 7.7% of bisexuals considering attempting suicide (American Psychiatric Association, 2017c). More than tripling the rate of bisexuals, 30.8% of transgender people considered attempting suicide in 2016 (American Psychiatric Association, 2017c). Alcohol and drugs are a temporary and harmful coping resource in response to the negative feelings and experiences caused by LGBT-based victimization, which can lead to suicidal ideation and behaviors (Mereish et al., 2014).
Nearly 15% of men and 30% of women who enter the criminal justice system have a serious mental health condition (National Alliance on Mental Illness, n.d.b). Mental health disorders may exist before entering the criminal justice system, but can be further exacerbated by the stress of imprisonment. However, mental health disorders may also develop through imprisonment itself, as a result of prevailing negative conditions (World Health Organization, 2005). The effects of incarceration on mental health are immediate, impacting those currently incarcerated, as well as those previously incarcerated (Turney et al., 2012). While this is a major issue within this population, a large number of inmates with serious mental illness problems fail to receive the necessary treatment while incarcerated (Lurigio & Swartz, 2006).
Research has indicated that the prison system is not using evidence-based screenings, training staff to manage serious mental illness, providing adequate access to services and medications for jailed individuals, or entering into collaborations with community providers (Schyette et al., 2009). Schyette et al. (2009) found in one state, out of the 80 prisons studied, only 12 (15%) reported having mental health staff who provided care within the prison system, either as employees or through contracts with a private provider. The lack of adequate treatment inside prisons is a disservice to the offenders as they will reenter the community improperly treated, which places them at risk for reoffending (Kesten et al., 2012).
Examples of Successful Interventions and Programs
Many organizations have started initiatives to decrease mental health disparities. The National Association of Social Work (NASW) and the American Counseling Association (ACA) advocated for mental health treatment coverage. The ACA advocated by identifying prevention, early intervention, and treatment of mental and/or substance use disorders as a vital health benefit (Smith, 2015). To ensure equal coverage of treatment for mental illness and addiction, the Mental Health Parity and Addiction Equity Act (MHPAEA) was enacted in 2008.
Because stigma is one the main barriers to mental health, various organizations have made tackling stigma one of their primary focuses. The Substance Abuse and Mental Health Service Administration (SAMHSA) is one organization that has committed to reducing stigma. SAMHSA publishes a quarterly memorandum that reports advances in stigma research and highlights successful stigma-reduction programs. Furthermore, six times a year, SAMHSA hosts teleconference trainings to advance knowledge about stigma and stigma reduction and to foster partnerships between consumer groups, businesses, local government agencies, and other organizations interested in combating stigma (Pinto-Foltz & Logsdon, 2009). To assist organizations in fighting stigma, SAMHSA created a free resource tool kit to help others implement initiatives, called the Developing a Stigma Reduction Initiative. The National Alliance on Mental Illness (NAMI) is also working to remove stigma associated with mental health disorders through community education and protests. Stigma Busters is a protest approach used by NAMI to fight stigma which consists in contacting individuals in the media who inaccurately portray mental disorders and demands that they stop inaccurate portrayal. In Our Own Voice is an educational program that was also designed by NAMI to change attitudes, assumptions, and ideas about people with mental health conditions (Pinto-Foltz & Logsdon, 2009).
Several interventions have also been created to reduce mental health disparities for marginalized populations. Integrated behavioral health care (IBHC) is one intervention that has been created to decrease stigma and service utilization barriers. IBHC is a model for mental health care service delivery that seeks to reduce stigma and service utilization barriers by including mental health professionals as part of the primary care team (Bridges et al., 2014). Treatment plans are developed collaboratively between the mental health professional, who made a referral to a behavioral health consultant (BHC), the physician, and with other members of the health care team involved in patient care. Bridges and colleagues (2014) found evidence to suggest that the integration of behavioral health services into primary care clinics may help reduce mental health disparities for Latinos (Bridges et al., 2014). This intervention may also be effective with other racial and ethnic minorities.
The Improving Mood—Promoting Access to Collaborative Care (IMPACT) program is another intervention that provides mental health services through primary care; it follows a collaborative approach to managing depression (Areán et al., 2005). Areán et al. (2005) outlined the IMPACT model, which involves educating primary care providers about evidence-based treatment of late-life depression, such as a depression care manager who works alongside the patient and primary care provider to orientate patients in the management of their depression, providing ongoing mood and medication monitoring based on evidence-based treatment guidelines, and brief psychotherapy; the use of a clinical information tracking system to help the care manager and the primary care provider in making treatment decisions; or ready access to a psychiatrist who offers consultation on complex cases. Collaborative care has been found to be more effective than traditional care for depressed older adults. It has significantly improved rates and outcomes of depression care in older adults (Areán et al., 2005).
The Kate Mills Snider Geriatric Psychiatry Outreach Program (GO Program) seeks to reduce disparities within the older population. Established in 2005, it helps older adults affected by mental illness, who live at home but are unable to get to an outpatient treatment facility, by. providing home-based diagnostic assessments, psychiatric treatment, and case management (Johnston et al., 2010). The GO Program team includes the geriatric psychiatrist who is also the program director, a geriatric nurse practitioner, and a program coordinator. This program has no minimum or maximum number of visits and accepts patients with Medicare or private insurance coverage (Johnston et al., 2010).
Cultural factors often hinder the delivery of mental health services for Asians. To serve this population, Yeung et al. (2010) designed the culturally sensitive collaborative treatment (CSCT) model by adding a cultural component to the collaborative management model. The CSCT includes four components: systematic depression screening; contacting those who screen positive for major depressive disorder to recommend an assessment; culturally sensitive psychiatric assessment via the Engagement Interview Protocol (EIP); and care management. CSCT is said to be feasible and effective in improving recognition and treatment engagement of depressed Chinese Americans (Yeung et al., 2010).
Addressing Common Barriers to Mental Health Treatment Culturally Aware Service Providers
The NASW’s Code of Ethics charged social workers with the responsibility of practicing with cultural awareness (National Association of Social Workers, 2017). In 2015, the NASW revised the standard and indicators of cultural competence to include adherence to the ethics and values of the profession, maintenance of self-awareness, the development of cross-cultural knowledge and skills, culturally appropriate service delivery, advocacy for diversity in the workforce, professional education, language and communication, and leadership to advance cultural competence. Social workers are encouraged to adapt “cultural humility,” a term first introduced by Tervalon and Murray-Garcia (1998), in which the social worker assumes the role of learning about the client’s many identities and experiences, rather than maintaining a position of power of authority within the situation (National Association of Social Workers, 2015). Cultural humility refers to “the ability to maintain an interpersonal stance that is other-oriented (or open to the other) in relation to aspects of cultural identity that are most important to the client” (Hook et al., 2013, p. 2).
Cultural awareness and competence can be achieved through the maintenance of an attitude of openness to and consideration of people’s lived experiences and the tailoring of practice models to individuals (DelVecchio Good & Hannah, 2015; Kohn-Wood & Hooper, 2014). Mental health and mental illness are often associated with cultural experiences, and practitioners should consider the cultural context in which issues arise and exist in order to tailor treatment modalities to the individual (DelVecchio Good & Hannah, 2015). Kohn-Wood and Hooper (2014) further asserted that practitioners should be involved at multiple levels in order to truly embody cultural competence, including providing services in primary care settings, engaging in clinician education, advocating for multidisciplinary teams, being active in policy efforts to increase access for people of color, and openness and support of alternative models of mental health treatment in order to meet the needs of the client.
Along with cultural competence, evidence-based practice is essential in improving the quality and effectiveness of mental health services. However, cultural adaptation is needed when considering the adoption of an evidence-based intervention with people of color (Marsiglia & Booth, 2015). Cultural adaptation is the systematic modification of an evidence-based intervention in which clinicians consider language, culture, and context in a way that is compatible with the cultural patterns, meanings, and values of the client (Bernal & Domenech Rodriguez, 2009). The dualism of cultural competence and evidence-based practices is critical to decreasing mental health disparities among people of color (Whaley & Davis, 2007).
The continued social perception of mental illness as a weakness or fault of character is the primary perpetuator of the shame associated with stigma (Byrne, 2000). Public stigma is the attitudes that others have toward those with mental illness (Rüsch et al., 2005). It is present within social structures and perpetuated in the functioning of those structures as well (Corrigan & Watson, 2002). Research on the perpetuation of stigma within social structures is needed in order to advocate for change on the policy level (Corrigan & Watson, 2002). This research can also assist in the development of interventions to reduce stigma around mental illness.
There is no blanket solution or answer to the dissolution of stigma around mental illness (Corrigan et al., 2014). However, stigma should be addressed through a multilevel and multidimensional approach. Rüsch et al. (2005) suggested that stigma or the internalization and acceptance of public stigma can be challenged through the protest of stigmatizing images and messages within the media, increased education about various mental health issues as well as the specific mental health concerns of the client, and increased contact and exposure to other people living with mental illness. Reducing stigma can ultimately lead to higher treatment rates of mental illness as more individuals will become aware of their own mental illnesses.
Mental Health Literacy
Mental health literacy is defined as “knowledge and beliefs about mental disorders which aid in recognition, management or prevention” (Jorm et al., 1997, p. 182). Furthermore, Mental health literacy is about having the skills to effectively handle mental illness within oneself or others. Jorm (2012) stated that mental health literacy includes knowledge of prevention methods, symptom recognition, available treatment options, self-help strategies, and skills to help others (Jorm, 2012).
Interventions to increase mental health literacy should be age appropriate and delivered in efficient and contextually appropriate settings, such as in schools for children and adolescents (Kutcher et al., 2016). Mental health literacy can also be promoted through media outlets (Chang, 2008). Kelly et al. (2007) identified four intervention domains through which mental health literacy can be increased: whole-of-community interventions; community interventions targeted at young people; school-based interventions; and individual training programs. Community interventions have demonstrated effectiveness in increasing mental health literacy (Kelly et al., 2007). School-based interventions have increased students’ recognition of mental health symptoms, rejection of stigmatizing images, and awareness of service availability (Kelly et al., 2007). Individual training programs to educate people on how to be of assistance to others experiencing mental illness have also showed increases in mental health literacy and enhanced ability to recognize symptoms in others (Kelly et al., 2007).
Lack of Financial Resources
Poverty is linked to poor physical and mental health (Copeland & Snyder, 2011). African Americans are at risk for poverty-related mental illness due to their higher poverty rates and considerable lifetime chance of experiencing poverty (Snowden, 2014). Copeland and Snyder (2011) found that living at or below the poverty line to be a constant risk factor for depression in low-income African American women. Furthermore, economic pressures make it difficult for these women to access needed mental health resources. Obstacles to accessing high-quality mental health care for African Americans and other minority groups include poverty, lack of insurance coverage, and insurance parity (Newhill & Harris, 2007).
In 2017, 11.1% Asian Americans lived at the poverty level (Office of Minority Health, 2019). Asian Americans are often self-employed or employed by small businesses that do not offer health insurance (Cook et al., 2014). However, uninsurance among Asian Americans has decreased since the implementation of the Patient Protection and Affordable Care Act (ACA) in 2010, but disparities in access and utilization still remain (Park et al., 2019). There is also a large number of uninsured immigrant Asian Americans. The rate of Medicaid coverage for most Asian and Pacific Islander immigrants is significantly below that for Whites, which may be due to the belief that enrolling themselves and their children in Medicaid could jeopardize their application for citizenship (Kang et al., 2010).
Policy changes to increase depth and scope of health insurance coverage are needed to improve help-seeking barriers (Bridges et al., 2012). To make mental health services more affordable for socioeconomically disadvantaged individuals, Bridges et al. (2012) proposed providing services on a sliding fee scale and allowing people to make small and regular payments to make mental health services more feasible. Safety net programs, which provide cash and in-kind income supplements either through direct income transfers or by paying for services would be beneficial (Snowden, 2014). These programs may decrease the likelihood of experiencing poverty-related mental illness.
Newhill and Harris (2007) suggested creating a free, 800-number telephone hotline modeled after domestic violence shelter hotlines and available 24 hours a day, seven days a week, to improve help-seeking. Volunteers from the community could cover the hotline, and professionals from the nearest community mental health center could provide volunteer training (Newhill & Harris, 2007). This could also make services affordable and more accessible when needed.
Location of Services
Geographic location plays an important role in the sufficient use of mental health services among racial and ethnic minorities (Kim et al., 2017). Kim et al. (2017) found that Latinos in the South, Blacks and Latinos in the Midwest, and Latinos and Asians in the West had higher unmet need in mental health care than Whites in those parts of the United States. The geographic area in which one lives, such as a rural or urban area, may also be contributing to disparities as some areas have a shortage of specialty mental health professionals and transportation. Solway et al. (2010) found transportation to be a significant problem in accessing mental health care in both rural and urban areas. Mental health services are spread out in rural areas. In urban areas, access to public transportation can be challenging for older adults, especially those with physical disabilities (Solway et al., 2010).
Kim et al. (2017) noted that national-level efforts are needed to improve the access and quality of mental health care, such as increasing the number of mental health care access points to expand the availability of mental health services and strengthening mental health care and related systems and networks through funding. Bringing mental health services to individuals and families in everyday settings, such as schools, workplaces, community centers, neighborhoods, and churches, may address transportation challenges (Bischoff et al., 2017).
Newhill and Harris (2007) suggested developing more community-based support groups and self-help resources along with small personal clinics. These small clinics would be located in the heart of the community and have diverse functions; combining mental health treatment, primary care, drug and alcohol treatment, and help with criminal justice readjustment to the community, all in one place (Newhill & Harris, 2007). Furthermore, these small clinics would offer free child care and transportation assistance. Telemental health and in-home services can also be used to address transportation challenges (Solway et al., 2010). Telemental health has demonstrated effectiveness for diagnosis and assessment in children, adults, older adults, and people of color (Hilty et al., 2013). Additionally, telemental health has demonstrated equal efficacy to mental health services provided in person (Adams et al., 2018).
Integrating mental health into primary care services may also reduce barriers related to location, transportation, and access (Bridges et al., 2012). With this service, primary care physicians will need extensive training in mental health diagnosis and treatment. The Patient-Centered Medical Home Model is one integrated health care that provides a culturally sensitive approach to health care delivery; this model promotes access to care such as “open scheduling” (Holden et al., 2014). Open scheduling provides clients with the opportunity to walk in without a scheduled appointment.
Limited English proficiency (LEP) is associated with lower use of mental health care. Immigrants and refugees in the United States have a higher prevalence of depression compared to the general population and are less likely to receive adequate mental health services and treatment. Furthermore, those with LEP are at an even higher risk of inadequate mental health care (Njeru et al., 2016).
Two racial and ethnic groups in the United States particularly impacted by LEP are Latinos and Asian and Pacific Islanders (Sentell et al., 2007). In 2017, 58.4% of social workers were White (non-Hispanic) (Data USA, n.d.). Miranda et al. (2008) argued that having limited access to racially and ethnically diverse providers influences an individual’s willingness to seek mental health services. Challenges also exist with trained translators due to the lack of assessment tools in languages other than English (Solway et al., 2010).
Patel et al. (2013) examined the awareness, impact, and implications of threshold language policies among a sample of Latino and Vietnamese LEP clients. The single factor that contributed most to LEP individuals’ use of mental health services was access to providers who spoke their native languages; many participants reported worries about using interpreters and a discomfort with their mental health information being filtered through another individual (Patel et al., 2013). Participants also reported feeling a strong cultural and linguistic connection to providers when communication was direct and in their native languages (Patel et al., 2013).
To improve the utilization of mental health services among individuals with limited English proficiency, Bridges et al. (2012) suggested recruiting bilingual students into mental health professions and, once recruited, efforts would be made to retain and support these students. Also, studies have found that religious leaders and folk healers tend to serve as proxy health professionals. Therefore, working closely with community leaders, especially religious leaders, to ensure adequate training in assessment of mental health problems and to form a personal system of referrals may also be beneficial in improving utilization (Bridges et al., 2012).
Sentell et al. (2007) noted that extra effort is needed in primary care settings to explore the mental health needs of patients with LEP. These individuals are more likely to seek assistance for mental health problems from primary care providers; however, language barriers may limit discussion of mental health issues. Additionally, the lack of linguistically appropriate mental health services may make referrals difficult.
From a policy perspective, the efforts to increase access to mental health care should address language barriers. There are policy instruments targeting language barriers that are already in place, such as California’s “threshold language access policy,” which was implemented in 1999. Under this policy, Medi-Cal agencies must provide language assistance programming in a non-English language where a county’s Medical population contains either 3,000 residents or 5% speakers of that language (McClellan et al., 2012).
Implications and Conclusion
Social workers should be at the forefront of addressing prevailing disparities among minority groups by increasing the accessibility of services, decreasing the prevalence of stigma and stigmatizing language, and addressing the systemic barriers to service utilization. At the policy level social workers should work to protect the rights of vulnerable populations, and to eradicate inequity in legislation that impacts the quality of people’s lives. Social workers should demand the implementation and acceptance of inclusive models of care that have included minority populations in data collection and have proven effective. Moreover, social workers should be instrumental in the provision of services and intentional about the quality of services they are providing.
Organizations providing services to minority populations should be intentional about understanding the environmental and social contexts of their target population. This intentionality should go beyond having a general understanding of the culture and strive to be in and among the community members building positive relationships and experiences with service providers and strategically combating stigma. Social Work research should aim to expand upon the existing knowledge base by conducting research that includes minority populations and addresses the needs of the population. Additionally, researchers should take care to highlight and correct inequities and misrepresentations in the knowledge base around mental health treatment.
To decrease these disparities within these communities, more effort is needed to provide outreach at the community level and to bridge the gap between mental health and other medical or alternative health facilities; this may be necessary to effectively reach African Americans, Hispanic/Latino Americans, Asian Americans, men, women, young adults, older adults, and LGBT individuals who are reluctant to seek specialty mental health care. Outreach efforts should include educational material to increase mental health literacy and aid in symptom recognition (Rickwood et al., 2007).
To address the disparities among incarcerated populations, resources within facilities are needed to provide adequate mental health treatment, including medication. Sufficient staffing of qualified mental health personnel will improve the quality and coordination of care for inmates with mental illness. Training for all direct care staff in the use of evidence-based screening tools will help with early symptom recognition and intervention (Schyette et al., 2009).
Implementing key components of patient-centered communication, such as eliciting patient treatment preference and collaborative treatment planning, and providing an understanding of the stigma related to medications are some strategies that will help to increase engagement with all the populations identified (Interian et al., 2011; Hatzenbuehler et al., 2013). Also, having regular mental health screenings for prevalent mental health disorders during primary care visits may decrease the number of adults that are not diagnosed (Sorroco & McCallum, 2006).
According to the World Health Organization (n.d.), gender differences exist in patterns of help-seeking and the use of mental services. Therefore, mental health treatment should reflect these differences. When working with men, masculine norms, such as being action oriented, problem solving, and goal focused, are said to be beneficial in therapeutic settings. In the same way, Shafer and Wendt (2015) encouraged social workers not to automatically label traditional masculine attitudes as negatives as these masculine attitudes will help men in treatment for mental illnesses. It may be helpful for mental health care providers to consider the importance of certain male role norms, including self-reliance, courage, and being the family “breadwinner,” in discussions with male patients (Rochen et al., 2010). Likewise, when working with women, practitioners should be careful not to overpathologize as is noted of physicians (American Psychiatric Association, 2017d). Moreover, practitioners should be willing and able to inquire about women’s histories of violent victimization, bearing the knowledge that women were significantly less likely to volunteer their experience unless they were directly asked (Beydoun et al., 2017).
Social Workers at all levels must be instrumental in the creation of a network of providers, policy advocates, and researchers who hold the interests of these populations in the highest esteem and with the utmost importance. This multileveled network must work to end the stigma around mental illness and to promote mental well-being for all people.
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