CHAPTER 3

Mental Health Care for African Americans

Availability, Accessibility, and Utilization of Mental Health Services

Availability of Mental Health Services

The overrepresentation of African Americans in high-need populations implies great reliance on the programs and providers—public hospitals, community health centers, and local health departments—comprising the health care and mental health safety net (Lewin & Altman, 2000). State and local mental health authorities figure most prominently in the treatment of mental illness among African Americans. They may provide care either directly through the administration of mental health pro-grams, or by contracting with not-for-profit providers or for-profit firms. The number, type, and distribution of safety net providers, as well as arrangements made for the provision of care, greatly influence the treatment options available to the most vulnerable populations of African Americans and others. Fortunately, the safety net includes programs and practitioners that specialize in treating African Americans. Several studies suggest that these care providers are especially adept at recruiting and retaining African Americans in outpatient treatment (Yeh et al., 1994; Snowden et al., 1995; Takeuchi et al., 1995).

The supply of African American clinicians is important. Studies of medical care reveal that African American physicians are five times more likely than white physicians to treat African American patients (Komaromy et al., 1996; Moy & Bartman, 1995) and that African American patients rate their physicians' styles of interaction as more participatory when they see African American physicians (Cooper-Patrick et al., 1999). Mental Health United States reported that, among clinically trained mental health professionals, only 2 percent of psychiatrists, 2 percent of psychologists, and 4 percent of social workers said they were African American (Holzer et al., 1998). African Americans seeking help-who would prefer an African American provider will have difficulty finding such a provider in these prominent mental health specialties.

The availability of mental health services also depends on where one lives. As discussed earlier, a relatively high proportion of African Americans live in the rural South. Evidence indicates that mental health professionals are concentrated in urban areas and are less likely to be found in the most rural counties of the United States (Holzer et al., 1998). Furthermore, African Americans living in urban areas are often concentrated in poor communities; urban practitioners who do not accept Medicaid or offer services to high-need clientele are not available to them.

Accessibility of Mental Health Services

Lack of health insurance is a barrier to seeking mental health care. Nearly one-fourth of African Americans are uninsured (Brown et al., 2000), a percentage 1.5 times greater than the white rate. In the United States, health insurance is typically provided as an employment benefit. Because African Americans are more often employed in marginal jobs, the rate of employer-based coverage among employed African Americans is substantially lower than the rate among employed whites (53% versus 73%; Hall et al., 1999).

Although insurance coverage is one of the most important determinants for deciding to seek treatment among both African Americans and whites, it is clear that insurance alone, at least when provided by private sector plans, fails to eliminate disparities in access between African Americans and whites (Scheffler & Miller, 1989; Snowden & Thomas, 2000). Provision of insurance benefits with more generous mental health coverage does not increase treatment seeking as much among African Americans as among whites (Padgett et al., 1995). Overcoming financial barriers is an important step in eliminating disparities in care; however, according to evidence currently available, it is not in itself sufficient.

Medicaid, a major public health insurance program subsidizing treatment for the poor, covers nearly 21 per-cent of African Americans. Medicaid payments are among the principal sources of financing for the services of safety net providers on which many African Americans depend. Medicaid-funded providers have been more successful than others in reducing disparities in access to mental health treatment (Snowden & Thomas, 2000).

African American attitudes toward mental illness are another barrier to seeking mental health care. Mental illness retains considerable stigma, and seeking treatment is not always encouraged. One study found that the proportion of African Americans who feared mental health treatment was 2.5 times greater than the proportion of whites (Sussman et al., 1987). Another study of parents of children meeting criteria for AD/HD discovered that African American parents were less likely than white parents to describe their child's difficulties using specific medical labels and more likely to expect a shorter term course (Bussing et al., 1998). Yet another study indicated that older African Americans were less knowledgeable about depression than elderly whites (Zylstra & Steitz, 1999).

Practitioners and administrators have sometimes failed to take into account African American preferences in formats and styles of receiving assistance. African Americans are affected especially by the amount of time spent with their providers, by a sense of trust, and by whether the provider is an African American (Keith, 2000). Among focus group participants, African Americans were more likely than whites to describe stigma and spirituality as affecting their willingness to seek help (Cooper-Patrick et al., 1997).

Utilization of Mental Health Services

Community Studies

Adults

Both the ECA and NCS investigated the use of mental health services by African Americans. Although only about 1 person in 3 of all respondents needing care received it, African Americans were distinguished by even lower levels of use (Robins & Regier, 1991). After eliminating the impact of sociodemographic differences and differences in need, the percentage of African Americans receiving treatment from any source was only about half that of whites (Swartz et al., 1998). Most African Americans who received care relied on the safety net public sector programs.

The more recent NCS also examined how many per-sons used mental health services. Results indicated that only 16 percent of African Americans with a diagnosable mood disorder saw a mental health specialist, and fewer than one-third consulted a health care provider of any kind. Table 3-2 shows that most African Americans suffering from mood and anxiety disorders did not receive care. The NCS also compared the use of mental health services by various ethnic groups and concluded that African Americans received less care than did white Americans.

Disparities between African Americans and whites also exist after initial barriers have been overcome. After entering care, African Americans are more likely than whites to terminate prematurely (Sue et al., 1994). They are also more likely to receive emergency care (Hu et al., 1991). These differences may come about because African Americans are relatively often coerced or other-wise legally obligated to have treatment (Akutsu et al., 1996; Takeuchi & Cheung, 1998).

Table 3-2 gives data from the National Comorbidity Survey on the use of mental health services by African Americans. The data illustrate that among people with mood or anxiety disorders who seek any form of treatment, only half seek help from a mental health specialist.

Besides using fewer mental health services than do white Americans, African Americans appear to choose different care providers. The National Ambulatory Medical Care Survey, which asked U.S. physicians about their patients, found that African Americans with mental health concerns were appreciably more likely to see their primary care physician than to see a psychiatrist (Pingitore et al., in press). Whites with mental health concerns, on the other hand, were only slightly more likely to see their primary care physician than to see a psychiatrist. Another study that included only private sector providers reported similar findings (Cooper-Patrick et al., 1994).

Research cited above documents a pervasive under-representation of African Americans in outpatient treatment. At the same time, it may be that African Americans have become willing to seek mental health care as much as, if not more than, other Americans. In a follow-up study at the Baltimore site of the ECA, Cooper-Patrick and colleagues (1999) discovered that all groups studied had increased their rates of mental health help-seeking. The increase among African Americans was such that the disparity between blacks and whites had been eliminated.

Notable differences between African Americans and white Americans have been documented in the use of inpatient psychiatric care. African Americans are significantly more likely than whites to be hospitalized in specialized psychiatric hospitals and beds (Snowden & Cheung, 1990; Breaux & Ryujin, 1999, Snowden, 1999b). Underlying the difference are a number of factors, such as delays in treatment seeking and a high African American rate of repeat admission. One study of clients discharged from State mental hospitals found that African Americans were substantially more likely than others to be hospitalized again during the ensuing year (Leginski et al., 1990). Researchers have not yet evaluated the impact of managed care rationing on hospitalization rates.

Children and Youth

African American and white American children receive outpatient mental health treatment at differing rates. Using the National Medical Expenditure Survey, a large, community survey, Cunningham and Freiman (1996) discovered that African American children were less likely than white children to have made a mental health outpatient visit. The difference could not be attributed to underlying socioeconomic, family-related, or regional differences between the groups. Among children who received outpatient mental health treatment, African Americans and whites had similar rates of receiving care from a mental health specialist.

A handful of smaller studies support this finding. One of them considered mental health care provided by specialists, by physicians and nurses, and in the schools (Zahner & Daskalakis, 1997). African American children and youth were less likely than whites to receive treatment, and their underrepresentation varied little, no matter which source of treatment was used. Other school-based studies have reported similar findings (Cuffe et al., 1995; Costello et al., 1997).

Perhaps because of lack of health insurance, few African American children are in psychiatric inpatient care (Chabra et al., 1999), but there are many black children in residential treatment centers (RTCs) for emotion-ally disturbed youth (Firestone, 1990). RTCs provide residential psychiatric treatment similar to that available in hospitals, but they are more likely to be funded from public sources.

In many cases, it is not parents, but child welfare authorities who initiate treatment for African American children. The child welfare system is a principal gate-keeper for African American mental health care (Halfon et al., 1992; Takayama et al., 1994). For this reason, several studies focusing on metropolitan areas have found an overrepresentation of African American children and youth in public mental health services (Bui & Takeuchi, 1992; McCabe et al., 1999). However, access via the child welfare system often does not result in beneficial treatment.

Older Adults

Little evidence is available documenting the use of mental health services by older black adults. However, one study found that these adults, like their younger counter-parts, often do not obtain care (Black et al., 1997). In fact, this study reported that 58 percent of older African American adults with mental disorders were not receiving care. Another study indicated that older blacks in long-term care were less likely to use available community services than were older whites in long-term care (Mui & Burnette, 1994).

Complementary Therapies

African Americans are thought to make extensive use of alternative treatments for health and mental health problems. This preference is deemed to reflect African American cultural traditions developed partly when African Americans were systematically excluded from mainstream health care institutions (Smith Fahie, 1998).

Box 3-3: Complementary treatments are not always beneficial

Joan (age 50)
A 50-year-old African American woman, "Joan," was hospitalized following a suicide attempt. She cried and was nearly mute, reporting only her inability to sleep and having heard voices commanding her to kill herself. Her medical records indicated a previous admission for psychotic depression. Joan recovered after she took antidepressant medication.

In response to questioning, Joan indicated that she had been successfully treated before, but that she had discontinued psychiatric medication after responding to a letter from an itinerant minister. He had administered holy oil in exchange for payment and informed her to stop taking medication because she had been cured.

After relating this story, Joan was supported in her religious belief and in seeking spiritual uplift from one of many legitimate religious institutions in her community. She was warned, however, against opportunists and charlatans (Bell, 1997).

However, there is scant empirical data on the use of complementary therapies among African Americans suffering from mental health or other health problems (Koss-Chioino, 2000). Preliminary community- and clinic-based studies have found that complementary therapies are used to treat anxiety and depression (Elder et al., 1997; Davidson et al., 1998) and to treat health problems that occur in conjunction with mental health problems (Druss & Rosenheck, 2000). One nationally representative survey indicated that African Americans held more favorable views toward use of home remedies than did whites (Snowden et al., 1997).

It is important to realize that alternative therapies are popular in general: As many as 40 percent of Americans use them to complement standard medical care (Eisenberg et al., 1998). Nevertheless, research from rural Mississippi and from public housing in Los Angeles suggests that African Americans may turn to alternative therapies more than do whites (Becerra & Inlehart, 1995; Frate et al., 1995; Smith Fahie, 1998).