CHAPTER 1

Introduction

America draws strength from its cultural diversity. The contributions of racial and ethnic minorities have suffused all areas of contemporary life. Diversity has made our Nation a more vibrant and open society, ablaze in ideas, perspectives, and innovations. But the full potential of our diverse, multicultural society cannot be realized until all Americans, including racial and ethnic minorities, gain access to quality health care that meets their needs.

This Supplement to Mental Health: A Report of the Surgeon General (U.S. Department of Health and Human Services [DHHS], 1999) documents the existence of striking disparities for minorities in mental health services and the underlying knowledge base. Racial and ethnic minorities have less access to mental health services than do whites.¹ They are less likely to receive needed care. When they receive care, it is more likely to be poor in quality.

These disparities have powerful significance for minority groups and for society as a whole. A major finding of this Supplement is that racial and ethnic minorities bear a greater burden from unmet mental health needs and thus suffer a greater loss to their overall health and productivity. This conclusion draws on prominent international and national findings. One is that mental disorders are highly disabling across all populations.² According to a landmark study by the World Health Organization, the World Bank, and Harvard University, mental disorders are so disabling that, in established market economies like the United States, they rank second only to cardiovascular disease in their impact on disability (Murray & Lopez, 1996). Another important finding comes from the largest disability study ever conducted in the United States It found that one-third of disabled³ adults (ages 18–55) living in the community⁴ reported having a mental disorder contributing to their disability (Druss et al., 2000).

While neither of these studies addressed the disability burden for minorities relative to whites, key findings from this Supplement do: Most minority groups are less likely than whites to use services, and they receive poorer quality mental health care, despite having similar community rates of mental disorders. Similar prevalence, combined with lower utilization and poorer quality of care, means that minority communities have a higher proportion of individuals with unmet mental health needs. Further, minorities are overrepresented among the Nation’s vulnerable, high-need⁵ groups, such as homeless and incarcerated persons. These subpopulations have higher rates of mental disorders than do people living in the community (Koegel et al., 1988; Vernez et al., 1988; Breakey et al., 1989; Teplin, 1990). Taken together, the evidence suggests that the disability burden from unmet mental health needs is disproportionately high for racial and ethnic minorities relative to whites.

The greater disability burden to minorities is of grave concern to public health, and it has very real con-sequences. Ethnic and racial minorities do not yet completely share in the hope afforded by remarkable scientific advances in understanding and treating mental disorders. Because of preventable disparities in mental health services, a disproportionate number of minorities are not fully benefiting from, or contributing to, the opportunities and prosperity of our society.

More is known about the existence of disparities in mental health services — and their significance — than the reasons behind them. The most likely explanations, identified in Mental Health: A Report of the Surgeon General, are expanded upon throughout this Supplement. They trace to a mix of barriers deterring minorities from seeking treatment or operating to reduce its quality once they reach treatment.

The foremost barriers include the cost of care, societal stigma, and the fragmented organization of services. Additional barriers include clinicians’ lack of awareness of cultural issues, bias, or inability to speak the client’s language, and the client’s fear and mistrust of treatment. More broadly, disparities also stem from minorities’ historical and present day struggles with racism and discrimination, which affect their mental health and contribute to their lower economic, social, and political status.

The cumulative weight and interplay of all of these barriers, not any single one alone, is likely responsible for mental health disparities. Furthermore, these barriers operate to discernibly different degrees for different individuals and groups, depending on life circumstances, age, gender, sexual orientation, or spiritual beliefs. What becomes amply clear from this report is that there are no uniform racial or ethnic groups, white or nonwhite. Rather, each is highly heterogeneous, including a diverse mix of immigrants, refugees, and multigenerational Americans, with vastly different histories, languages, spiritual practices, demographic pat-terns, and cultures.

² Disability is measured in terms of lost years of healthy life from either disability or premature death.

³ Disability is self-reported and defined as having a level of functional impairment sufficient to restrict major life activities.

⁴ Most epidemiological studies using disorder-based definitions of mental illness are conducted in community household surveys. They fail to include nonhousehold members, such as persons without homes or per-sons residing in institutions such as residential treatment centers, jails, shelters, and hospitals.

⁵ This Supplement defines vulnerable, high-need groups as any population subgroup (such as children or adults who are homeless, incarcerated, or in foster care) which has (1) a higher risk for mental illness, (2) a higher need for mental health services, or (3) a higher risk for not receiving mental health services.