Living with a mental health disorder isn't easy. It can carry the weight of stigma, making you feel different. For people who face racial and ethnic discrimination, experts say the added "otherness" of mental illnesses may prove one hurdle too many in reaching the help they need.
"They might not want to share that they are having a problem with members of their family or community, for fear of being discriminated against or treated differently," said Alice Villatoro, an assistant professor in the public health program at Santa Clara University in California. "They are already treated as an 'other' as a minority, and don't want to add to that."
Fear of discrimination and stigma is just one of the many complex barriers contributing to disparities in who gets mental health care, a gap that research shows widens as severity of mental illnesses grows. It can carry long-term consequences. A recent scientific statement from the American Heart Association analyzed a large body of research showing a strong link between mental and physical well-being and the impact of psychological stress on heart and brain health.
While the rates of mental health disorders, conditions ranging from mild to moderate depression and anxiety to more severe and pervasive conditions such as schizophrenia, are similar across races and ethnicities, research shows white adults are nearly twice as likely to receive mental health services as Black or Hispanic adults.
When they do receive care, research shows they are treated differently than their white peers. Black adults are less likely to be offered medication or behavioral therapy and are more likely to be incarcerated than any other racial or ethnic group as a result of a mental illness, according to the American Psychiatric Association. Black, Hispanic, Asian, American Indian and Alaskan Native adults with serious mental illnesses also are more likely to be overdiagnosed with conditions such as schizophrenia and to be involuntarily hospitalized when they seek care.
The treatment disparities start long before adulthood. Black and Hispanic teenagers and other young people of color with behavioral health issues are more likely to end up in the juvenile justice system than white adolescents, who are more likely to be referred to a mental health care professional.
These experiences further fuel the distrust that originated with America's "complicated history around race," said Tené T. Lewis, an associate professor at Emory University's Rollins School of Public Health in Atlanta. "There is a legacy of mistreatment, and people don't want to expose themselves to that."
Concerns about how they might be treated by a counselor, psychologist or psychiatrist – if that person comes from a different race, ethnicity or culture – can prevent people from seeking professional help, Lewis said. The vast majority of mental health providers – over 80% – are white.
Black people in mental distress instead may seek support from friends, family or their church, rather than be vulnerable in therapy, she said.
To break down these barriers, mental health providers must acknowledge the impact of the nation's painful history of discrimination, and the implicit biases we all have with people who are different from us, Lewis said.
"Discrimination is often a major source of mental anguish for people of color," she said. "If you say this can't be true, you immediately undermine this person's existence. If you don't believe that there's a problem, you can't treat it."
Sharing the same racial and ethnic background can be critical for some people, Villatoro said. For instance, some health care networks offer Spanish-speaking counselors, but "just knowing how to speak Spanish is not the same as sharing someone's culture and what the expectations are in that community."
In Hispanic communities, "social connectedness is vital to well-being, and family is intertwined with this," she said. If "your provider does not understand this, it can be challenging to try to work on your mental health."
Biases show up in other ways. Some are structural, said Benjamin Lê Cook, director of the Health Equity Research Lab at Cambridge Health Alliance in Boston and associate professor in the Harvard Medical School Department of Psychiatry.
The health care system is poorly designed for people who work jobs where it's difficult to take time off to schedule or attend appointments, said Cook. "They may have multiple jobs, live further away, need day care or lack transportation. If they are uninsured or underinsured, they have to pay more out of pocket."
His center works collaboratively with researchers, health care professionals and community members to identify and develop strategies for reducing inequities in the health care system. "This is where we spend a lot of our time, trying to fix this," Cook said.
For example, his team is exploring a system that allows community members to lead support groups outside of the mental health care system to bridge some of the gaps. These certified peers also could guide people in need of greater care through the health system so they would feel better supported.
Another strategy is to integrate mental health screenings and referrals into primary care.
"Screening really matters," said Adam Biener, an assistant professor of economics at Lafayette College in Easton, Pennsylvania. His research has shown that while people from racial and ethnic communities may shy away from mental health and preventive care, they are more likely to see a doctor when they are physically ill.
But "nobody is talking about mental health when they see a (primary care) doctor," Biener said.
When referrals to mental health professionals do happen, doctors should ensure the list is diverse and that they ask patients about their preferences, Lewis said.
"We can do this in cardiology clinics," she said, especially since heart patients have a high risk for depression, which can increase their risk of death.
Still, Villatoro said, it's important for providers – regardless of background – to acknowledge the wide range of identities people have and how they affect mental health.
"We need to look beyond just talking about major ethnic groups and be more nuanced, take on an intersectional approach," she said. For example, a Hispanic woman whose identity corresponds with her birth sex would face different challenges and likely require different coping strategies than a Black woman who is transgender.
"Our identities influence what we do and experience in life," Villatoro said. "Context is everything. And your path to good mental health could be very different from my path."
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