Lonnie R. Snowden

Racial/Ethnic Disparities in the Use of Mental Health Services in Poverty Areas

OBJECTIVES This study examined racial/ethnic disparities in mental health service access and use at different poverty levels. METHODS We compared demographic and clinical characteristics and service use patterns of Whites, Blacks, Hispanics, and Asians living in low-poverty and high-poverty areas. Logistic regression models were used to assess service use patterns of minority racial/ethnic groups compared with Whites in different poverty areas. RESULTS Residence in a poverty neighborhood moderates the relationship between race/ethnicity and mental health service access and use. Disparities in using emergency and inpatient services and having coercive referrals were more evident in low-poverty than in high-poverty areas. CONCLUSIONS Neighborhood poverty is a key to understanding racial/ethnic disparities in the use of mental health services.

Barriers to effective mental health services for African Americans.

Many African Americans—especially the most marginal—suffer from mental health problems and would benefit from timely access to appropriate forms of care. However, few seek treatment from outpatient providers in the specialty mental health sector and those who do are at risk of dropping out. African Americans visit providers in the general medical sector, although they use another hypothesized alternative to specialty care, voluntary support networks, less than other groups. These help-seeking tendencies may reflect characteristic coping styles and stigma, as well as a lack of resources and opportunities for treatment. More should be learned about differences in need according to location, social standing, and cultural orientation so as to identify treatments and programs that are especially beneficial to African Americans.

Community mental health and ethnic minority populations

National trends in minority utilization of mental health services are reviewed, and recommendations are made for needed research. In relation to their representation in the population, blacks use services more than expected, and Asian American/Pacific Islanders use services less; Hispanics and Native American/Alaska Islander use varies according to type of service. Hospitalization accounts for part of the increase in minority utilization; this trend is problematic. Disruptions in service continue to plague minority clients, possibly stemming from inadequacies in the organization and financing of care, and from cultural incongruity. Much more must be learned about these problems in utilization, as well as about other key issues.

Bias in mental health assessment and intervention: theory and evidence.

A recent surgeon generals report and various studies document racial and ethnic disparities in mental health care, including gaps in access, questionable diagnostic practices, and limited provision of optimum treatments. Bias is a little studied but viable explanation for these disparities. It is important to isolate bias from other barriers to high-quality mental health care and to understand bias at several levels (practitioner, practice network or program, and community). More research is needed that directly evaluates the contribution of particular forms of bias to disparities in the area of mental health care.

Ethnic populations in public mental health: services choice and level of use.

BACKGROUND Barriers to access and use of mental health care by Asians, Blacks, and Hispanic Americans have been a source of concern for many years. Limitations in our knowledge base persist regarding patterns of use in public sector programs of certain services. Using a sample of almost 27,000 persons, this study examined access and level of use by ethnic minority groups of emergency services, inpatient care, individual outpatient visit, and case management. METHODS Data from the management information systems of San Francisco and Santa Clara counties were analyzed for fiscal year 1987/1988. Multivariate models were evaluated at two stages, reflecting whether or not a service had been used, and if used, the level of use. RESULTS Asians and Hispanics used less emergency and inpatient but more outpatient care than did Whites; Blacks used more emergency and less outpatient care. CONCLUSIONS Ethnicity continues to play a role in understanding the utilization of mental health services. Regarding emergency and inpatient care, Asian and Hispanic patterns of use appear relatively favorable, whereas the patterns of Blacks continue to be problematic.

Access to Mental Health Treatment by English Language Proficiency and Race/Ethnicity

BackgroundLimited English proficiency (LEP) may contribute to mental health care disparities, yet empirical data are limited.ObjectiveTo quantify the language barriers to mental health care by race/ethnicity using a direct measure of LEP is the objective of the study.DesignCross-sectional analysis of the 2001 California Health Interview Survey is the study’s design.ParticipantsAdults aged 18 to 64 who provided language data (n = 41,984) were the participants of the study.MeasurementParticipants were categorized into three groups by self-reported English proficiency and language spoken at home: (1) English-speaking only, (2) Bilingual, and (3) Non-English speaking. Mental health treatment was measured by self-reported use of mental health services by those reporting a mental health need.ResultsNon-English speaking individuals had lower odds of receiving needed services (OR: 0.28; 95% CI: 0.17–0.48) than those who only spoke English, when other factors were controlled. The relationship was even more dramatic within racial/ethnic groups: non-English speaking Asian/PIs (OR = 0.15; 95% CI: 0.30–0.81) and non-English speaking Latinos (OR: 0.19; 95% CI: 0.09–0.39) had significantly lower odds of receiving services compared to Asian/PIs and Latinos who spoke only English.ConclusionsLEP is associated with lower use of mental health care. Since LEP is concentrated among Asian/PIs and Latinos, it appears to contribute to racial/ethnic disparities in mental health care. Heightened attention to LEP is warranted in both mental health practice and policy.

Symptoms of depression among blacks and whites.

OBJECTIVES We sought to examine relationships between sociodemographic indicators of risk and depression symptoms within the Black and White populations. METHODS In a national probability sample, differences in sex, age, marital status, religion, social class, employment status, urbanicity, and region were evaluated against a Center for Epidemiological Studies Depression Scale score of 16 or greater. Risk factors were identified within the two populations and compared between them. RESULTS For both races, females were at greater risk for depression than males, and respondents who were formerly married or separated were at greater risk than those who were currently married. Major differences in patterns of risk were also found between the races. Blacks who were 30 to 39 years of age, belonged to non-Western religious groups, and lived in the West were at greater risk than comparable Whites. Blacks who were widowed, members of the middle and lower-middle class, and unemployed were at less risk. CONCLUSIONS Similarities and differences in patterns of risk were evident. The nature of the differences suggests important divergence in sociocultural and economic experience.

African American service use for mental health problems.

The present study examined racial differences in use of mental health services in the specialty mental health and general medical sectors of care. Data came from household and institutional surveys and permitted estimation of services use both in the general population alone and when supplemented with samples of persons confined in jails, prisons, and mental hospitals. In uncontrolled analysis, African Americans in the community presented a mixed pattern of under-, equal-, and overrepresentation in services. Weighting the sample and controlling for sociodemographic differences and diagnoses yielded results indicating that African Americans in the community were consistently less likely than Whites to have sought help. Adding to the analysis persons who were confined eliminated the disparity in the general medical-sector services and reduced the disparity in specialty mental health sector services. Conclusions as to parity and underutilization of mental health services vary with methodological factors linked to adverse social circumstances of African American life.

Frequency and Scope of Mental Health Service Delivery to African Americans in Primary Care

This study examines whether African Americans with mental health complaints visit primary care physicians more than psychiatrists, and whether they demonstrate this preference more than do Whites. It addresses also whether when presenting with mental health concerns, African Americans and Whites receive a comparable range of interventions, including psychotropic medications. National estimates using the National Ambulatory Medical Care Surveys conducted in 1995 and 1996 confirmed the first hypothesis: African American did make more mental health-related office visits to primary care physicians than did psychiatrists and they did so more than Whites. Mental health interventions on behalf of African Americans and Whites proved to be similar, except that African Americans were less likely to be provided a psychotropic medication. Because African Americans are especially likely to receive outpatient mental health services from primary care physicians, the lower quality of mental health care occurring in primary care disproportionately affects African Americans. Fewer African American visits resulted in prescribing psychotropic medications, and this corroborated findings by other researchers. More research is needed to understand this disparity.

Racial differences in informal help seeking for mental health problems

The present study examined the hypothesis of greater African American informal help seeking for mental health problems in a comparison of African Americans and Whites. Controlling for sociodemographic factors, symptom distress, and diagnosis, African Americans were less likely than Whites to report turning for assistance to a friend, family member, or religious figure. Nor did African Americans use informal help as a substitute for professional care; they turned to informal helpers in conjunction with formal helpers, and demonstrated complementarity to a greater extent than Whites. Supportive ties found among African Americans may be advantageous for many purposes, but provide no benefit for the face-to-face discussion of emotional problems.