Understanding Barriers to Minority Mental Health Care

Spikes in violence and an uptick in school and mass shootings continue to propel discussion of the unmet demands of the American mental health system. A 2016 CDC report revealed suicide rates in the United States jumped a startling 24 percent from 1999 to 2014, with a marked increase in deaths from those as young as 10 to as old as 74. A question repeatedly asked by both health experts and policy pundits is: If resources are not sufficient for the general population, how do underserved groups address their psychiatric needs?

Perspective of scale is key to understanding the extent of the issue. One in six Americans suffer from a diagnosable, treatable mental health condition. However, minority groups — African Americans, Hispanics, Asian Americans and Native Americans — are more likely to experience the risk factors that can cause such disorders. In one study, African Americans were found to have significantly higher rates of schizophrenia compared to whites. In contrast to their white counterparts, African Americans were also more likely to report their depression as being extremely severe and disabling. Meanwhile, Native Americans and Alaska Natives have a higher tendency to experience feelings of nervousness and restlessness when compared to non-Hispanic white people.

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Social and Environmental Factors That Affect Mental Health

Deep dives into the forces that drive disparities in minority care often point to barriers to medical access. Access can be limited by lack of insurance coverage; more than half of uninsured U.S. residents are people of color. People with limited resources also experience logistical barriers, such as taking time off of work, securing child care, or finding transportation to and from appointments. Linguistic and cultural differences — particularly for immigrant populations — can result in breakdowns in communication that lead to poorer health outcomes.

Lack of qualified, available professionals to evaluate, diagnose and treat mental health conditions is another factor fueling uneven coverage. Even in areas with high densities of mental health professionals, minority groups report high rates of poor mental health. Although New Hampshire is deemed a state with almost 95 percent of its mental health care needs met, 39 percent of the state’s Native Americans and Alaska Natives self-report their mental health status as “not good.”

Why is this happening?

In high-risk areas, those who choose to seek treatment often receive inferior care because there tends to be little diversity among mental health providers and decreased understanding about the different mental health needs across minority groups. Even when language translation services are provided, lack of diversity breeds cultural insensitivities that lead to negative health outcomes, such as higher treatment dropout rates. Studies have shown that minorities are less satisfied with the quality of care they receive since they feel that providers simply do not understand their needs.

“We are teaching our students about the central importance of social determinants of health, with racism being a key determinant, in the health of individuals and families.”

Provider discrimination also affects the quality of care that minority populations receive. Though all discrimination is harmful, an examination of the effects of racism — the most commonly studied and cited form of discrimination — reveals implications for the mental health of individuals in minority groups.

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Although provider discrimination and cultural microaggressions can be subtle, the implications are great. Two studies have documented how physicians were less likely to identify the severity of depression among minority patients versus white patients. Often, a clinician with the false assumption that mental health needs are less prevalent among minorities may be less likely to recommend treatment in comparison to a white patient with similar symptoms. These studies show us that racism is not just a civil rights issue, but also a public health concern.

Social determinants of health (SDOH) also have a major influence on health outcomes. According to the Office of Disease Prevention and Health Promotion, SDOH are “conditions in one’s environment — where people are born, live, work, learn, play, and worship — that have a huge impact on how healthy certain individuals and communities are or are not.” In diverse populations, these determinants underscore the current rates of suicides and mental health disorders reported in the United States.

Most notably, lack of income triggers depression, anxiety and post-traumatic stress disorder (PTSD), and minorities statistically are more likely to straddle the poverty line throughout their lives. They are also less likely to get help. A 2016 study found minorities received significantly fewer mental health care services than whites. The following graphic displays the self-reported barriers to pursuing care, as indicated by adults in the United States who had an unmet need for services between 2008 and 2012.

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Implications for Medical Providers

Closing the gap in minority mental health will not happen overnight. It will require a widespread and collective effort to account for all underserved populations and tailor interventions to satisfy their unique challenges. Primary care providers can start to break down barriers by educating themselves — as well as their colleagues and communities — on the ethnic and cultural gaps among patient populations.

Providers should consider their own values and how these perceptions may influence their interactions with patients from other cultures. Listening to minority patients’ needs and helping them to feel safe and understood can empower them to get the mental health treatment they deserve and to live productive and fulfilling lives.

Primary care providers, including family nurse practitioners, are integral to ensuring all patients receive comprehensive care, and they serve as a key resource for those most vulnerable to the negative health effects resulting from discrimination.

“We are teaching our students about the central importance of social determinants of health, with racism being a key determinant, in the health of individuals and families,” said Ellen Olshansky, professor and chair of University of Southern California’s Suzanne Dworak-Peck School of Social Work Department of Nursing.

Communities at highest risk for discrimination are the same communities that are perpetually marginalized by the negative impact of SDOH. In a 2013 Atlantic article titled, “How Racism Is Bad for Our Bodies,” writer Jason Silverstein points out that the cyclical effect of discrimination on health is what is referred to as “embodied inequality,” which creates poor health outcomes that are often passed down through generations. This results in a vicious cycle where the sickest and poorest among us are more likely to remain sick and poor.

Strategic Actions

What specific steps can be taken to reduce the disparities in mental health care for minorities? Health care professionals and policymakers can play a key role in curbing discrimination by supporting legislation and policies that address these issues, such as the U.S. Department of Health and Human Services (HHS) Action Plan to Reduce Racial and Ethnic Health Disparities. The U.S. Office of Minority Health provides a summary of this action plan and serves as a “one-stop source for minority health literature, research and referrals for consumers, community organizations and health professionals.” By using available resources and appropriate support networks, victims of discrimination can find the support they need to exercise their rights and end the various forms of discrimination they may be vulnerable to.

Providing access to necessary resources and additional support for these patients is critical. Here are some starting points:

Education and awareness: Despite progress in recent years, there is still a stigma associated with mental illness. Embarrassment can be lessened by helping people in at-risk communities understand that mental health is an essential part of well-being — just like a healthy diet, sleep and exercise. Initiatives such as Mental Health First Aid, endorsed by Michelle Obama, are helping people to better understand and respond to signs of mental illness.

Policy changes: Universal mental health care coverage would dramatically improve access for minorities. Quality improvement efforts include screening, cultural sensitivity training and language-appropriate treatment and educational materials. At the federal level, policies would assist in training a diverse workforce to adequately meet America’s mental health needs.

Advocacy and outreach: Public health advocates have proven effective in reducing barriers to care for at-risk communities. For instance, the Substance Abuse and Mental Health Services Administration created the Office of Behavioral Health Equity (OBHE), which aims to eliminate disparities in mental and/or substance abuse disorders across all populations. OBHE’s outreach strategies include helping underserved racial and ethnic groups within communities understand the importance of maintaining good emotional health.

Integrating behavioral health with primary care: In minority communities where specialists are not plentiful, identifying a mental health practitioner can be a challenge. However, integrating mental health care with primary care could reduce disparities in access to care and could increase the odds of identifying a patient’s mental illness.

Additionally, it is essential that health care professionals work to better recognize the effects of discrimination by taking SDOH into consideration as part of their approach to care, understanding which populations may be at greater risk for discrimination, screening for negative mental health outcomes that may be a direct result, and ensuring that discrimination is not occurring within their own practice settings.

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Citation for this content: Nursing@USC, the online FNP program from the University of Southern California