How Would You Tackle Mental Health Disparities?

Targeted and collaborative efforts are needed at individual and systemic levels to address underlying causes of mental health disparities.

The definition of mental health disparity varies depending on the focus and purpose of different agencies. Essentially, mental health disparities refer to gaps in the health status, health outcome, quality of treatment, or access to care among various populations.

The National Institute of Mental Health (NIMH) defines significant disparity in the overall rate of mental illness incidence or prevalence, morbidity, mortality, or survival rates in a health disparity population as compared with the health status of the general population. NIMH defines health disparity populations to include: American Indians/Alaska Natives, Asian Americans, Blacks/African Americans, Hispanics/Latinos, Native Hawaiians and other Pacific Islanders, sexual and gender minorities, socioeconomically disadvantaged populations, and underserved rural populations.1 Alternatively, the National Conference of State Legislatures refer to behavioral health disparities in terms of differences in outcomes and access to services related to mental health and substance use, which are experienced by groups based on their social, ethnic, and economic status.2

Factors That Influence Mental Health Disparities

The field of medicine and public health are increasingly recognizing how external factors can impact individuals’ health, and not solely attributing mental health disorders to the fault of the individual. Social determinants of health, or those “conditions in which people are born, grow, live, work, and age, which are shaped by the distribution of money, power, and resources” are underlying drivers that exacerbate gaps in health status and care access.Underlying social and economic inequalities such as economic instability, neighborhood environment, food security, educational-level, and structural racism/discrimination systemically impact health. These factors serve as important framework to consider when planning health interventions.3

For mental health specifically, cultural stigma surrounding mental health care, lack of access to high-quality mental health care services, and various factors can contribute to poor mental health outcomes.4 For example, rates of suicide and death rates from suicide remain significantly higher among American Indian/Alaska Native populations from late adolescence through adulthood.5 Moreover, suicidal thoughts and behaviors increased markedly among Black and Asian youths.5 In terms of substance use disorder, although there is a dramatic rise in opioid-related deaths, especially among Blacks and Hispanics, fewer Latinos and African Americans receive needed treatment for mental health and substance abuse care.6,7 While racial/ethnic minorities are more likely to have more severe and persistent courses of disorders, minorities in the United States are more likely than whites to delay or fail to seek mental health treatment and to have less access to mental health services. They are also less likely to receive needed care and more likely to receive poor-quality care when treated.6 Asian Americans, for instance, are the least likely to access mental health care compared to other racial-ethnic groups.8 Furthermore, providers’ own implicit biases may also influence diagnosis and treatment quality among certain groups.9

Promoting Equity

Mental health parity laws try to ensure that mental health conditions and substance use disorders will be provided the same level of insurance coverage. The Mental Health Parity and Addiction Equity Act (MHPAEA) in 2008 required insurance coverage for mental health/substance use disorder conditions to be no more restrictive than insurance coverage for other medical conditions. In 2020, Congress required insurers and health plans to show that they are complying with such provisions.10 Benefit plans that must be covered equally include services like inpatient and outpatient care both in-network and out-of-network, intensive outpatient services, partial hospitalizations, copays, prescription drugs, and criteria used to approve or deny care.11 However, it can be difficult to measure and determine how effectively these policies are being implemented on the grounds to ensure equal access to care.

How to Address Mental Health Disparities

Focused, targeted efforts are needed at personal, community, and national levels to address mental health disparities and promote equity. The first question to consider is, which population would I like to focus my efforts on (eg, a particular minority group, women, children/youth, or rural populations)? The second question to clarify is, what is my desired outcome (such as a target to reduce suicide rates, enhance health-seeking behavior, or increase access to addiction services)? The third question to evaluate is, what is the evidence for effectiveness, feasibility, and sustainability of such interventions? How can I continue to evaluate its impact?

Following are some ideas for creating personal and systematic changes to promote health equity.

Individual-Level Changes

-Assess patients’ cultural beliefs, attitudes, and stigma related to mental health in clinical interactions.

-Provide culturally appropriate interventions such as suicide hotlines targeted for specific populations (such as for the LGBTQ community, veterans, youth, or Asian Americans), or assistance in finding local resources for safe gun storage.

-Advocate for changes in your health care organization—eg, ask for support staff to help with prior authorizations, promote availability of addiction services, advocate for appropriate interpreters and staff members, and create workgroups to examine data on health disparities, outcomes, and access.

-Understand your own potential biases. You can take free 5-minute Implicit Association Test that may reveal certain implicit biases at https://implicit.harvard.edu/.

Systemic-Level Changes

-Addressing mental health disparities through research: Although it is important to examine the incidence or prevalence of disease burden among various populations (such as how many individuals are impacted by serious mental illness or suicide attempts), research efforts must also move beyond incidence or prevalence data. Further research should acknowledge the underlying structural and cultural factors that contribute to mental health disparities and seek for ways to address them.

NIMH encourages researchers to examine underlying causes of mental health disparities as well as to explore ways to test novel approaches to reduce disparities.12 Interventions that address social determinants of health seem to have effective impact on improving mental health. For example, providing universal school meal programs in several states were associated with improvement in psychosocial outcomes, including reductions in hyperactivity, anxiety, depression symptoms as well as academic outcomes and school attendance.13 Encouraging savings accounts demonstrated improved socioeconomic outcomes and mental health outcomes for those from low- and moderate-income backgrounds.13 There is also evidence that these saving accounts can also reduce mothers’ depression symptoms around 3 years after intervention.13 Expansion of green (eg, parks, fields, and gardens) and blue (eg, oceans and lakes) spaces in neighborhood seems to be associated with mental health well-being and decreased feelings of depression and worthlessness amongst residents compared to control sites.13 Continual research that focuses on addressing social determinants of health is needed to examine the effectiveness of public health interventions on mental health.

-Alliance building: Partnerships are needed between mental health providers, physicians, educators, community leaders, and government agencies to create targeted, effective interventions. Such efforts may focus on destigmatizing mental health, improving insurance coverage access, providing culturally and linguistically appropriate mental health services, or addressing other barriers to care. Promoting connectedness among members of a community, building alliances with local communities, and improving culturally appropriate access to care can help reduce some factors that contribute to disparity. For example, the Centers for Disease Control and Prevention (CDC) works with local partners/states to reduce suicide disparities: They teach community members how to identify and refer individuals at risk of suicide, work on reducing access to lethal means by promoting safe storage of firearms, and provide social-emotional learning programs to promote coping and problem-solving skills in youth activities in schools.14 Such efforts require coordination and alliance building at community and national levels. Collaborative networks, such as National Network to Eliminate Disparities in Behavioral Health (NNED), is one way to share information amongst health care works and community-based organizations.

-Policy advocacy: Get involved with local or national mental health policy advocacy organizations,15 contact your local representative or Congress person, and stay informed.

Concluding Thoughts

Although the general media and research narrative focus on disparities, much attention should also be paid to emphasize each groups’ strengths and resiliencies and current efforts to promote equity. Carefully considered, targeted, and collaborative efforts are needed at individual and systemic levels to address underlying causes of mental health disparities. Only when we commit to creating individual changes will we be able to create changes at a larger scale together.

Dr He is a practicing adult psychiatrist with special interests in health disparities and public health. She completed her residency training at George Washington University Hospital and received her Master of Public Health from Yale School of Public Health.

References

1. Overview. National Institute on Minority Health and Health Disparities. Updated May 5, 2021. Accessed June 29, 2022. https://www.nimhd.nih.gov/about/overview/

2. Behavioral health disparities. National Conference of State Legislatures. December 20, 2017. Accessed June 29, 2022. https://www.ncsl.org/research/health/behavioral-health-disparities636355423.aspx#:~:text=Behavioral%20health%20disparities%20refer%20to,%2C%20ethnic%2C%20and%20economic%20status

3. Ndugga N, Artiga S. Disparities in health and health care: 5 key questions and answers. KFF. May 11, 2021. Accessed June 29, 2022. https://www.kff.org/racial-equity-and-health-policy/issue-brief/disparities-in-health-and-health-care-5-key-question-and-answers/

4. Mental health disparities: diverse populations. American Psychiatric Association. Accessed June 29, 2022. https://www.psychiatry.org/psychiatrists/cultural-competency/education/mental-health-facts#:~:text=Racial%2Fethnic%2C%20gender%2C%20and,of%20awareness%20about%20mental%20health

5. Barksdale C, Pérez-Stable E, Gordon J. Innovative directions to advance mental health disparities research. Am J Psychiatry. 2022;179(6):397-401.

6. McGuire TG, Miranda J. New evidence regarding racial and ethnic disparities in mental health: policy implications. Health Aff (Millwood). 2008;27(2):393-403.

7. Behavioral health equity data. Substance Abuse and Mental Health Services Administration. Accessed June 29, 2022. https://www.samhsa.gov/behavioral-health-equity/obhe-data#:~:text=Some%20measures%20include%20data%20presented,their%20male%20counterparts%20(3.9%25)

8. Yang K, Rodgers C, Lee E, Lê Cook B. Disparities in mental health care utilization and perceived need among asian Americans: 2012–2016. Psychiatr Serv. 2020;71(1):21-27.

9. FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics. 2017;18(1):19.

10. The Mental Health Parity and Addiction Equity Act (MHPAEA). Centers for Medicare & Medicaid Services. Accessed June 29, 2022. https://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/mhpaea_factsheet

11. What is mental health parity? National Alliance on Mental Illness. Accessed June 29, 2022. https://www.nami.org/Your-Journey/Individuals-with-Mental-Illness/Understanding-Health-Insurance/What-is-Mental-Health-Parity

12. NIMH’s approach to mental health disparities research. National Institute of Mental Health. Accessed June 29, 2022. https://www.nimh.nih.gov/about/organization/od/odwd/nimhs-approach-to-mental-health-disparities-research#addressing-mental-health-disparities-through-research

13. Alegría M, Zhen-Duan J, O’Malley I, DiMarzio K. A new agenda for optimizing investments in community mental health and reducing disparities. Am J Psychiatry. 2022;179(6):402-416.

14. Disparities in suicide. Center for Disease Control and Prevention. Accessed June 29, 2022. https://www.cdc.gov/suicide/facts/disparities-in-suicide.html

15. Mental health policy and advocacy organizations. National Center on Domestic Violence, Trauma & Mental Health. Accessed June 29, 2022. http://www.nationalcenterdvtraumamh.org/resources/mental-health-policy-and-advocacy-organizations/