Review Article, Int J Ment Health Psychiatry Vol: 5 Issue: 2
Delving into Disparities: An Examination of American Mental Health
*Corresponding Author : Marianna Ringel, MD
Bailey Psychiatric Associates, P.A., Houston, Texas, California, USA
E-mail: [email protected]
Received: October 05, 2019 Accepted: October 23, 2019 Published: October 30, 2019
Citation: Ringel M, Mohayed M, Bailey TA, Bailey RK (2019) Delving into Disparities: An Examination of American Mental Health. Int J Ment Health Psychiatry 5:2.
Access to quality mental health care is not equally enjoyed by all Americans. There are a multitude of factors that have created this disparity. Factors such as cost of care are easy to intuit. However, there are many other contributors to disparity. These contributors can be subtle. Often, they are only demystified through careful examination of social, economic, and legal elements. This article seeks to demystify some of the various causes of mental health disparities in the U.S. This will be done be through a multifaceted inspection. Variations in the rates of care will be illuminated. Particular focus will be given to minority populations who typically underutilize mental health services. Cultural views inform how individuals view psychiatric illness. Indeed, dismissive attitudes often form in a cultural context. This, along with stigma, may prevent minority populations from seeking care. Furthermore, society (as a whole) perception of psychiatric illness has ramifications as well. Laws regarding mental health often reflect the public zeitgeist. Therefore, this article will emphasize key legislation as well. By doing so, this article will add fundamental perspective to this complex, dynamic, and often neglected disparity.
Keywords: Mental Health Care; Disparities; Policies
America grows strength from its cultural diversity. But the full potential of our diverse, multicultural society cannot be achieved until all Americans, including minorities, gain equal access to quality health care that meets their needs.
Most scholars recognize the Centers for Disease Control and Prevention (CDC) definition of mental health disparities as the most uniform definition. The CDC defines disparities as “Preventable differences in the burden of disease, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations” .
Why do Mental Health Care Disparities matter? Nearly one in five Americans will have a mental health issue in any given year. Only a little over one in three people with a mental health problem will get help . Various reports documented the lack of access and the poor standard of mental health care among minorities—patients are less likely to receive mental health service. There are a number of factors that may limit African American’s access to mental health care. Some psychosocial obstacles may be lack of finances, transportation, or access. An additional factor may be a mistrust of the provider and/or a racial-ethnic mismatch between provider and patient . Additionally, it may include the clinician’s lack of expertise in cultural issues, bias, or the inability to speak the patient’s language, as well as the patient’s fear and mistrust. Some authors see disparities as an outcome from failed health care provider/patient relationship and lack of caring within society.
To provide the most effective mental health care to all those who enter the mental health service delivery system, it is crucial that researchers and clinicians stay informed of the most up-to-date mental health conditions and mental health needs of diverse populations in their respective communities. Moreover, it is very important to recognize and spread culturally competent intervention and prevention measures most suitable to specific ethnic and cultural groups so that mental health inequalities in diverse populations may be reduced, if not eliminated.
Mental Health Care Disparities
Number of consumers
Number of consumers receiving Mental Health Services increased from 6.1 million to 6.8 million between 2007 and 2010. The majority of patients (6.5 million out of 6.8 million) received care from community providers (2010). State hospitals steadily provided care for 170000 patients annually from 2007 to 2009 with a drop to 160000 in 2010 .
Treatment rates were variable, being maximal in non-Hispanic white males (21.8%) and at a minimum in non-Hispanic Asian females (4.8%) between 2009 and 2011. Between 2007 and 2009, the average cost per adult (ages 18-26) for the mental health service was about $2000. Among this population, the average treatment cost of mental health problems was more expensive for young adults (ages 18-21), estimated at $2300 per year than for those ages 22-26, estimated at $1800. Nearly 30% of individuals with severe mental illnesses who received community mental health services after prolonged stays in a state hospital achieved full recovery in psychiatric status and social function. Another third improved remarkably in both areas .
Among the reasons for not receiving mental health care, according to Substance Abuse and Mental Health Service Administration (SAMHSA) National Survey (2013), the cost of care took first place. 48.3% of respondents could not afford treatment. Interestingly, 26.5% thought they could handle the problem without seeking care. 24.6% of adults did not know where to go for services. Only 9.2% of respondents believed treatment would not help them. Coverage of care was recognized as an issue by 8.9% adults .
African-Americans are disproportionately exposed to social and environmental conditions, which adversely affect their mental health. Three of those conditions are poverty, low level of education, and community violence. Only 12% of African Americans received adequate treatment for depression compared to 22% of Latino and 33% of White population [6,7].
Gender and level of income
Roughly 25% of females (aged 18 and older) who are at 100% or less of federal poverty level, struggle with depression, and 22.4% with anxiety. These numbers drop at 400% and above poverty level to 7.8% and 9.2% respectively . Only one in three men (33%) with daily feelings of depression and anxiety, received treatment for those feelings, and just one-quarter (25.7%) had an appointment a with mental health specialist within the previous year. Black and Hispanic males (36%) were less likely than their white counterparts (43%) to have used either of these mental health treatments. Approximately 51% of non-Hispanic White and 30.5% of non-Hispanic Black men, whose income were less than 200% of Federal Poverty Level (FPL), with feelings of depression and anxiety were able to get help. The numbers are decreased to 41% and 19.7% respectively at income level at or above 200% FPL .
20% of the youth in the U.S. could be potentially diagnosed with mental health illness. 30% exhibit signs of depression . The suicide rate among five racial and ethnic populations (non-Hispanic White, African American, Hispanic, Asian/Pacific Islander, American Indian/ Alaska Native (AI/AN)) for both male and female between age 18-24 is 12.8 deaths per 100000 population. The highest rate was observed in the AI/AN population, particularly in males with 34.3 deaths per 100000 individuals . Less than 35% of AI/AN adolescent will seek professional help during self-inflicted fatalities . Less than half of children with severe mental health conditions receive adequate treatment . Trends show that African American and Latino children and adolescents receive markedly less outpatient mental health and substance abuse treatment than their non-minority contemporaries .
Lesbian, GAY, Bisexual, and Transgender (LGBT)
LGBT youth are predisposed to more health concerns than heterosexual youth. Recent studies revealed that there are many cases of HIV diagnoses among gays below 25 years of age who come from racial and ethnic minority communities. This study concluded that risk factors for mental health challenges and involvement in drug and substance abuse are more evident among LGBT youth than their heterosexual counterparts. The National Institute of Health (NIH) posits that these risk factors include victimization, violence, harassment and homelessness. This makes young adults in LGBTcommunities vulnerable .
Cost and benefit analysis
Serious mental illnesses cost the U.S. an estimated $193.2 billion in lost earnings per year. In 2006, 186000 young adults received social security disability benefits due to their mental illness severity. They were found to be unable to engage in substantial gainful employment. Of the six million people served by state mental health authorities across the nation, only 21% are employed . The State Mental Health Agency (SMHA) Revenues and Expenditures Study (2010) clearly showed that from FY 2001, SMHA-controlled expenditures have failed to keep pace with population growth and inflation in 30 states .
Dr. Stephen Poulin with colleagues at the University of Pennsylvania conducted a study that identified 2703 persons meet the federal criteria for chronic homelessness (one year of continuous homelessness or four episodes of homelessness within three years). They assessed cost data for these people for outreach and community housing and shelter services, mental health inpatient and outpatient care, and jail cost. They found that a subgroup of 20% of these individuals accounted for 60% of the costs of the total group. Among the 20% of the high-users, 81% had a diagnosis of schizophrenia or major affective disorders .
Effective nationwide school-based substance abuse prevention programming can offer states savings within two years ranging from $36 million to $199 million in juvenile justice, $383 million to $2.1 billion in education, and $68 million to $360 million in health services. Supported employment plans that help people with the most serious psychiatric illnesses, place over 50% of their clients into paid employment . Furthermore, only 1/10th of individuals with substance use disorders seek treatment. In 2/3rds of individuals who do not seek care, cost in the cited as the primary deterrent. Nationally, nearly 1/3rd of individuals who seek substance use disorder treatment rely on Medicaid. In Baltimore, MD, proactive approaches have taken to aid those with substance use disorders. For example, recipients can Purchase 2 doses of Naloxone, a narcotic overdose medication, for $1. The market price for this drug is ($100-$4500) . When accounting for the total cost of addiction, for every dollar spent on treatment, society saves 12 dollars .
Health Care Policies
Many provisions of the Patient Protection and Affordable Care Act (ACA) were implemented in fiscal year 2013-2014. Numerous state legislative sessions are actively working to expand Medicaid under this law. During the initial first six months enrollment period in October 2013, in all states under the ACA, an estimated 2.65 million people with mental illness qualified for subsidies to buy private health insurance in the Health Insurance Marketplaces.
The ACA requirement for all Qualified Health Plans to provide mental health benefits in compliance with federal mental health parity law benefits an estimated 62 million Americans, prompting mental health parity legislation in a number of states. After years of struggling to meet the rising need with decreasing resources, public mental health systems are pushed to the limit. Today, rebuilding state mental health budgets is necessary to monitor and improve mental health service delivery .
The implementation of the ACA in 2013 affected the lives of many people diagnosed with severe mental illnesses (SMI). The rate of uninsured patients with SMI dropped from 28.1% to 19.5% in 2012-2015, according to the National Health Interview Survey report. The number of adult Americans who required but could not afford, treatment for SMI decreased in the same amount of time . Indeed, after implantation of the ACA, access to care increased for most Americans. However, there was no evidence of reduction in racialethnic disparities in mental health treatment access .
Today, under the current administration, there is a potential for revision or repeal of the ACA, which would have a devastating impact on healthcare gains for previously uninsured Americans. If this comes to fruition, millions of Americans will lose their health insurance, including those populations heavily dependent on Medicaid, who have benefitted from the Medicaid expansions provided by the passage of the ACA. Repealing the ACA will further widen the already-daunting gap in mental health treatment between majority groups and minorities perhaps to such an extent that bridging the gap may seem futile. Preexisting boundaries to treatment for mental health disorders, substance abuse disorders, etc. will be further worsened by repeal or revision of the ACA .
Integrated Care and Early Intervention
The Integrated Behavioral Health Care (IBHC) model of collaborative care focuses on new methods that minimize disparities in other care models while reducing barriers to service utilization even further by changing the style in which care is delivered. Particularly, session frequency, duration, and procedures for patient referrals move rapidly at this stage. Mental health professionals are available to see patients immediately at the moment mental health needs are recognized . The CRASH Course (Considering Culture, showing Respect, Assessing/Affirming differences, showing Sensitive/Self Awareness, and to do it all with Humility) in cultural competency training was developed at Morehouse School of Medicine, Atlanta, GA. The course aims to help medical professionals care for an increasingly diverse patient population, while minimizing culturally dysfunctional behaviors and providing a specific and measurable skill set instrumental to demonstrating cultural competence. Step one involves the acknowledgement of the importance of culture for a patient population. For instance, determining how a patient understands and expresses his or her depression will direct diagnosis and treatment. It is commonly understood that African Americans often exhibit somatic symptoms in their depression. Simple, open-ended questions, such as “Tell me about your family background” can help practitioners to learn about the patient. One should never presume regarding individuals based on a group membership, which is why each patient must be assessed for their unique cultural history. For example, individuals from Eastern Europe are often labeled broadly as Slavic. However, the Slavic languages are divided into three groups, East, West, and South, which together constitute more than twenty languages. The CRASH Course and IBCH model serve as guides for professionals, enabling them to provide culturally competent care .
After the Newtown tragedy, the National Alliance on Mental Illness (NAMI) advocated for polices targeting early identification and intervention. More specifically they trained personnel for schools, involved, ore of the family and the public, and increased access to care with mental services in schools. Several states took a proactive approach in passing legislation focused on prevention of possible incidents such as the Sandy Hook shooting. The State of Nebraska enacted LB 556, which helped develop behavioral health screening and provide education and training on children’s behavioral health. Bill AB 386 was passed in Nevada to establish a pilot program for the administration of mental health screenings to students enrolled in elected secondary schools. Minnesota enacted HF 359, requiring that case management services continue to be available to youth living with mental illness after the age of 18 .
Mental Illness and Violence Prevention
Violence among adolescents and young adults can be avoided. The reduction of mental health disparities is achievable with evidencebased methods. In practice, violence reduction has been limited due to absence of prevention programs addressing public risk factors. The CDC-supported investigation has showed three positive communitylevel responses. A violence reduction program in Los-Angeles, CA, Business Improvement Districts (BIDs), is linked to a 12% reduction in burglaries and to an 8% overall crime reduction. The Alcohol Policy program was invented in Richmond, VA. It resulted in a significantly decreased rate of interventions for violent injuries in young adults aged 15-24, from 19.6 to 0.0 per 1000 cases. In Baltimore, MD, the Safe Streets program implementation has helped to decrease rates of homicide and non-fatal shootings. Community-based programs are a crucial piece of a comprehensive approach that is aimed at widely reducing violence . Many state legislations, reflects federal mental illness prohibitions, but states have also created a variety of additional policies. Florida prohibits citizens from possessing firearms if they have been initially admitted unwillingly to a mental institution, even if they eventually agree to stay in the hospital voluntarily. Connecticut and Indiana both have regulations that allow law enforcement to remove firearms from manifestly dangerous individuals (who may or may not have not mental disorder). Thus far, the effectiveness of such policies has not been studied. There are numerous lapses in what we know about gun violence, mental illness, and the effectiveness of policies to minimize the risk of gun violence and suicide. Recently, President Obama issued a Presidential Memorandum directing the CDC to initiate such a research study . The New York Secure Ammunition and Firearms Enforcement (SAFE) Act of 2013 (S 2230) was the first part of legislation passed in 2013 to expand clinician duty to report mental health cases in order to constrict firearms purchases. This is highly debatable due to its all-encompassing nature of mandated policies. The SAFE Act set a model for the same bills in other states, which focused on raising requirements to disclose mental health information to the National Instant Criminal Background Check System (NICS). Under the SAFE Act, clinicians providing mental health services must report threats of violence to law enforcement officials .
Stigma Reduction and Seeking Help
Mental health stigma continues to be prevalent with three out of four people with mental illness reporting they have experienced stigma. Such stigma perpetuates prejudice and discriminatory behavior towards individuals with mental illness . Culture determines the recognition, expression, and social acceptance of mental illness. For example, in many Latino cultures, psychiatric illness is stigmatized, particularly if the person is labeled as loco and requires medications to control his symptoms . The insight from the California Well Being Survey offers policymakers and advocates information that can be used to improve access and utilization of mental health services among Latinos [34,35]. A significant finding of this survey was that community organizations, services, and supports must adopt peer-to-peer approaches in order to be effective in improving mental health treatment for underserved Latinos. Peer support and mentoring programs have the common goal of reducing stigma, building trust, maintaining open communication, developing relationships, and increasing accessibility to treatment .
Interestingly, African Americans are typically unwilling to seek treatment for mental illness. Compared to other demographics in the US, they are more likely to be spiritually engaged . More Black churches are forming partnerships with mental health providers and requiring their ministers to obtain training in counseling. Zion, a Baptist Church in the District of Colombia, frequently has mental health care professionals give talks on topics such as depression and anxiety disorders. More churches in Washington are adopting this model and requiring clergy to be trained in mental health counseling and be competent and capable in referring individuals to mental health clinicians .
Recently, two states passed bills addressing language and practices that have the effect of stigmatizing people living with mental illness. State of Tennessee (SB 1376) changed the wording of their policy to line up with American with Disabilities Act (ADA) standards. West Virginia (HB 2463) finally eliminated the law, which allowed sterilization of people identified as mentally incompetent [39,40].
Most states offer psychiatric inpatient beds in a combination of private and public hospital settings. Such a multi-tiered system can make it challenging to track the availability of inpatient psychiatric beds. In some states, there is an inadequate inpatient capacity to meet the demand. These factors result in long wait times, emergency room boarding, or the unnecessary involvement of the justice system to manage acute crisis psychiatric cases. In Virginia, HB 2118 was passed, which improved the state’s inpatient psychiatric bed tracking system. HB 2118 requires that all private and public inpatient and crisis stabilization facilities to report on bed availability, at least once a day. HF 449, in Iowa, directs the Department of Human Services (DHS) to develop and implement an inpatient psychiatric bed tracking system. The bill requires court clerks to use the system to find openings and arrange placements. DHS would have the ability to certify and recognize crisis stabilization programs operating in psychiatric medical institutions and provide children with mental and substance abuse treatment. It allocates $200000 in FY 2016 .
It is important to understand the profile of a mentally ill prisoner. Females comprise only 10% of the incarcerated population. However, female inmates have a greater burden of disease than their male counterparts. Posttraumatic stress disorder (PTSD) is particularly common among incarcerated women. Conversely, men are reported to have higher rates of antisocial personality disorder. Caucasians are more likely to report mental illness than blacks or Hispanics . African Americans are incarcerated in state prisons at 5.1 times the rate of Caucasians . Experts argue that authorities ignore or treat displays of pathology by African Americans, in particular, as criminal behavior instead of properly recognizing the mental illness component. This may be due to the stereotype that African Americans are more likely to engage in crime and violence. The misjudgment of African American is not limited to law enforcement officials. Psychiatrists themselves can have a skewed evaluation of minority patients. This was illustrated in the study “Clinical Prediction of Assaultive Behavior among Male Psychiatric Patients at a Maximum-Security Forensic Facility (1999)”. Psychiatrists at a New York forensic psychiatric hospital were asked to predict the patients more likely to show violent behavior during a three-month period. They over estimated violence among minority patients. Despite these predictions, the violence rate did not vary according to ethnicity . It is not surprising that that bias may influence harsher sentencing and incarceration rates. In the study, Mass Imprisonment and the Life Course.
Race and Class Inequality in U.S. Incarceration data showed that 22.4% of black men had been imprisoned by the time they reached the age of 30. Conversely, only 3.2% of white men had been imprisoned by that same age .
As a result of authorities misinterpreting African American behavior, there is less likelihood they will receive appropriate treatment or have accessibility to treatment in the community or criminal justice system . The socioeconomic disparities between the incarcerated and nonincarcerated population are alarming, however, the mental health disparities in incarcerated populations are the most dramatic. Over half of state inmates and up to 90% of jail detainees suffer from drug dependence, compared to 2% in the general population . Years of a lack of coordination between the justice system, communities, and health agencies exacerbate the issues of disparities even more. Establishing an information sharing system between the justice system and health agencies can result in early identification of behavioral issues that require treatment. In Los Angeles County, CA, everyday substantial resources are directed at caring for over 3500 county jail inmates with chronic mental health illness, many of whom would be better served through community health systems. In September 2014, Los Angeles County implemented the Third District Diversion and Alternative Sentencing Program. The program drove down the prison populations by about 25% while reducing crime rates. This year a few states applied alternative sentencing specifically to inmates with mental health or substance use disorders. In California, SB 219 specifies that female inmates in state prisons cannot be excluded from voluntary alternative custody, solely on the basis of a psychiatric condition . In King County, WA, both the Jail Health Services (JHS) and release planners focus on meeting the needs of vulnerable individuals, such as those with mental illness, substance use disorders, and pregnant women, upon their release. Planners work with individuals and enroll them into Medicaid, if eligible, and help set up their benefits, make medical appointments, coordinate mental health or substance abuse treatment, and arrange other social services . Elsewhere, in Harris County, Texas, a new inmate policy came to effect in 2013. The policy seeks to protect and guarantee LGBT inmates equal treatment. For example, the policy allows transgender people to choose their preferred gender and not biological sex as the basis of their provision of housing .
Throughout the US, many states have created and implemented programs in their juvenile justice system to address mental health in young offenders. Arizona, California, Colorado, and New Hampshire are among the states that have established courtroom procedures to request mental health assessments and screenings for juveniles involved in delinquency proceedings. Other government entities have initiated special courts in order to properly attend to the needs of youth with mental health issues .
There is a nationwide shortage of mental health professionals which further prevent children and adults from receiving appropriate mental health care, particularly in underserved communities. Increasing workforce diversity is crucial to achieving health equality. Studies have demonstrated that health care providers of color are more likely to practice in underserved communities, with larger racial and ethnic minority populations that may be uninsured or underinsured.
Presently, SAMHA’s Minority Fellowship Program and the Health Resources and Service Administration (HRSA) Graduate Psychology Education Program are the only federal programs addressing diversity in the mental health care workforce. They are funded at about $4 million and $2 million, respectively . Minnesota Hospital Association (MHA) recently supported the decision of Minnesota Legislature to fund loan forgiveness and residency grant programs. These programs were designed to extend diversity in the state’s health care workforce, including psychiatrists, psychiatric nurses, psychologists, and licensed clinical social workers. In the next four years, $10.6 million is planned to be invested in loan forgiveness, with a preference for candidates with documented diverse cultural competence. Additionally, a $200000 grant program that encourages state licensure of foreign trained health care professionals, including mental health professionals, is planned . In 2015, the MHA successfully advocated for the Minnesota Telemedicine Act. It will provide coverage and payment parity for services that fall under Minnesota’s Medicaid and Minnesota Care Programs. Services, such as therapy and assessments, delivered through telemedicine by mental health professionals will be covered services for non-self-insured insurance plans. Telemedicine offers that advantage of providing services in rural and underserved areas, where there is also the greatest storage in workforce.
Discussion and Recommendations
Government agencies within States should ensure that people living with mental illness are enrolled in the most appropriate type of coverage for their health and mental health care needs.
Comply with mental health parity. The ACA requires mental health as an essential health benefit on par with medical/surgical benefits for all Qualified Health Plans and Medicaid Alternative Benefit Plans. The States should expand Medicaid and include all mental health care benefits that are available in traditional Medicaid. Mentally ill patients should be exempt from cost-sharing requirements. The governmental agencies should require health plan transparency regarding mental health benefits, medical necessity criteria for mental health, substance use and primary care, out-of-pocket costs, provider networks for mental health and substance use and consumer protections.
Increase the mental health workforce capacity. With millions of Americans gaining health insurance coverage in 2014, there is likely to be an acute shortage of mental health workers available. Mental health facilities nationwide should ensure active recruitment and training of mental health professionals skilled in effective, culturally competent interventions for children and adults. The government should address mental health workforce shortages and enhance existing capacity by increasing telehealth and appropriate use of peer specialists and allied professions.
It should be required to enable primary care clinicians to recognize mental health conditions and provide routine mental health care.
It is absolutely necessary to identify mental illness and intervene early. It is essential to ensure that children, youths and adults living with mental illness have the opportunity to thrive and reach their full potential. Mental health screening should be routine in primary care. The States should fully comply with Medicaid requirements for Early Periodic Screening Diagnosis and Treatment (EPSDT). Those who screen positive should be promptly linked with a more comprehensive evaluation and an array of effective services for children, youths and young adults as indicated.
Increase integrated care
Integrated mental health, addiction and primary care for children and adults with multiple chronic conditions improves overall health and reduces costs, prevents duplication and gaps in care. It makes more efficient use of service providers. The States should ensure 24/7 psychiatric response services with mobile crisis response teams or crisis response specialists, crisis stabilization units and respite services.
This article has highlighted the disparity in mental health care observed in the United States. Cost of care is often cited by many individuals as an influential limiter to their healthcare. In many instances, proactive approaches that address the need for psychiatric services may reduce the overall cost to society. Furthermore, credence needs to be given to importance of mental health care. It is true; there is a need for greater awareness among those seeking care. However, much of the responsibility falls upon lawmakers. Those in legislative roles formulate laws that can help ameliorate or exacerbate mental health disparities. Indeed, it has been shown that both federal and state law vastly impact access and quality of care. Well known federal programs such as Medicare and Medicare serve to cover some of the cost of care. Politicians have often to seek to reduce Medicaid; a service heavily depended on by those with psychiatric illness. Conversely, many at the state level have begun to appreciate the need for quality mental health care. This is seen in community initiative aimed at reducing crime and preemptively supporting at-risk youth. Additional, measures have been taken to incentivize those in mental health professions to provide care for underserved communities. Minorities, glut the nation’s prisons. Likely reformation of the penal system is needed. In doing so, mental health should be considered. Delving into this topic has revealed that more mental health services are needed. With increased resources, providers and advocates can provide greater assurance, options, and hope to individuals. In turn, this will ward off some of the stigma that still lingers regarding the often misunderstood and underappreciated issue of mental health.
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