KAUAI, HAWAII – It’s been nearly 12 years since former U.S. Surgeon General David Satcher released a report spotlighting the impact of mental illnesses on racial and ethic minority groups in the United States.
Today, that report "still rings true in terms of its findings of the striking ethnic, racial, and linguistic disparities in mental health care, with members of diverse groups being less likely to receive services and to have a poorer quality of care once they enter the door for psychiatric care," Dr. Annelle B. Primm said at the annual meeting of the American College of Psychiatrists.
Dr. Annelle B. Primm
"To compound matters, they are underrepresented in mental health research, making it more difficult for us to be certain that we’re providing these populations the best care. Taken together, these disparities impose a great disability burden."
In 2011, minority births exceeded white births, she said, and 50% of 3- and 4-year-olds were white and 50% were nonwhite. "Our country is becoming more and more diverse to the point where we may need to start referring to these populations as an emerging majority," said Dr. Primm, director of minority and national affairs at the American Psychiatric Association (APA). "What this means is that in our mental health care settings, there are going to be even greater cross-cultural interactions. This is something that we in the psychiatry community need to be prepared for."
Patient-level factors, system-level factors, and individual practitioner factors contribute to the existing disparities, said Dr. Primm, who is also the APA’s deputy medical director. Data from the Agency for Healthcare Research and Quality’s (AHRQ’s) National Healthcare Disparities Report, which was published in 2011, show that blacks and Hispanics who had major depressive episodes within the last 12 months were less likely to receive treatment during that time, compared with whites.
"There are also some differences with respect to education level, with people with any college education being more likely to receive treatment, compared with those who are either high school graduates or had less than a high school education," Dr. Primm said.
The AHRQ also notes disparities in substance abuse treatment. For example, among people aged 12 and older who need treatment for illicit drug use or an alcohol problem, blacks are more likely to receive treatment, compared with their white or American Indian counterparts. Yet, blacks are less likely to complete treatment, compared with the other cohorts.
The rate of uninsured also is a barrier to mental health care. Data from the 2010 U.S. Census estimate that about 20% of the nonelderly population are uninsured. Of those uninsured, 46% are white, 31% are Hispanic, 16% are black, and 5% are Asian American. "We can expect an influx of these populations with health care reform and Medicaid expansion," Dr. Primm said.
Another access challenge is the shortage of behavioral health providers in some geographic areas, major cutbacks in public mental health services, and a lack of mental health workforce diversity. "If we look at the diversity of the psychiatry workforce, in almost all groups, there is a mismatch between the population percentage and the percentage of the psychiatric workforce," she said.
Despite current challenges that mental health care clinicians face in providing services to underserved patient populations, Dr. Primm emphasized that significant efforts are underway to bring meaningful change. Whatever shape pending health care reform ultimately takes, she predicted, it will contribute to improving access to mental health services by special populations. For example, mental health parity "will be helpful in terms of access to mental health services for diverse groups," she said. "Expanding health coverage through the employer mandate, health exchanges, Medicaid expansion, and allowance of coverage for people with preexisting conditions will also be [important]."
She said she envisions improved access through other pathways as well, such as community health centers, the Indian Health Care Improvement Act, and the Health Resources and Services Administration’s National Health Service Corps, "which pays for medical school and other health professional training for those who are prepared to ‘give back’ after they finish their training," Dr. Primm said.
Other trends underway aimed at eliminating disparities in the provision of mental health services include the involvement of peer support specialists – which has been proposed by recovery-oriented models of care. This trend "also stems from the saying ‘nothing about us without us,’ where people with mental illness who have been successful in managing their illness become a part of the team to help patients who are struggling, to identify with their recovery success," Dr. Primm explained. "We also need to see that community health workers and mental health navigators can serve as cultural brokers, particularly if they reflect the culture of the patient population served.