M E N T A L H E A L T H
New Evidence Regarding Raeial
And Ethnie Disparities In
Mental Health: Poliey
Reduction of social inequities is not necessary to achieve parity in
mental health status, but it is vital to better mental health care.
by Thomas G. McGuire and Jeanne Miranda
ABSTRACT: Minorities have, in generai, equai or better mental health than white Ameri-
cans, yet they suffer from disparities in mental heaith care. This paper reviews the evidence
for mentai heaith and mentai heaith care disparities, comparing them to patterns in heaith.
Strategies for addressing disparities in heaith care, such as improving access to and quaiity
of care, should aiso work to eliminate mental health care disparities. In addition, a diverse
mentai health workforce, as weii as provider and patient education, are important to elimi-
nating mentai heaith care disparities, [Health Affairs 27, no. 2 (2008): 393-403; 10,1377/
ing disparities. We orient our discussion around two questions relevant for public
policy to reduce disparities: First, to what degree do policies need to be tailored to
mental health care, or can general health care policies be counted on to reduce
mental health care disparities? And second, to what degree do policies that pro-
mote improved quality of mental health care also reduce disparities?
NTIL RECENTLY, LITTLE WAS KNOWN about disparities in mental
health status and mental health care use by well-defined ethnic groups.
Newly available knowledge should inform public policies aimed at reduc-
New Findings On Mental Heaith Disparities
Startling new findings make clear that disparities in mental health exhibit a de-
cidedly different pattern from disparities in other kinds of health. In general, Afri-
can Americans have poorer health and health outcomes than whites have,' His-
panic Americans have advantages compared with white Americans at younger and
older ages but are disadvantaged during their middle years. Only Asian Ameri-
Tom McGuire is a professor of health economics in the Department of Health Care Policy at Harvard Medical
School in Boston, Massachusetts. Jeanne Miranda (email@example.com) is aprofessorin the Department of
Psychiatry and Biobehavioral Sciences at the University of California, Los Angeles.
H E A L T H A F F A I R S - Volume 27, Number 2 3 9 3
DOI 10.1377/hlthaff.27.2.393 C20O8 Project HOPE-Thc People-to-People Health Foundation, Inc.
S P E C I F I C D I S P A R I T I E S
cans, with the exception of Hawaiian natives, hold overall advantages in health.
• Prevalence of mental disorders among minorities. Recent studies were de-
signed to determine whether minorities also have poorer mental health than do
white Americans. Eour studies funded by the National Institute of Mental Health
(NIMH) Consortium on Psychiatric Epidemiology Studies (CPES) fielded common
questions and unified sampling weights to permit comparisons across white, black
(African American and Caribbean descent), Hispanic (Puerto Rican, Cuban, Mexi-
can, and other descent), and Asian (Chinese, Eihpino, Vietnamese, and other de-
scent) ethnic groups.^ Given the higher rates of poverty and poor health among U.S.
minorities compared with whites and the fact that poverty and poor health are posi-
tively related to mental disorders, one would anticipate that ethnic minorities, par-
ticularly African Americans and Latinos, would also report higher rates of mental
disorders. However, with the exception of Puerto Ricans, all of the subgroups of mi-
norities reported lower rates of lifetime mental disorders than white Americans re-
ported. Similar advantages existed for the presence of a mental disorder in the past
year, although Latino and black rates were relatively close to that of whites.^ Al-
though not part of these studies, mental disorders have also been studied in two
American Indian reservation populations.'' Compared with a nationally representa-
tive sample of the U.S. population, Americans Indians were found to be at lower risk
for major depression.
• Exceptions to prevaience findings. Exceptions exist to the lower or equal
overall prevalence of mental disorders among minorities. American Indians are at
heightened risk for posttraumatic stress disorder (PTSD) and alcohol dependence.^
Compared with whites, blacks may have higher levels of schizophrenia, a low-preva-
lence but serious condition. The results of three major community prevalence stud-
ies indicate a higher incidence of schizophrenia among African Americans than
among whites, but the studies contained too few cases for stable estimates.^ In a pro-
spective birth-cohort study, African Americans were found to have much-elevated
rates of schizophrenia compared with whites.'' Eurthermore, blacks with schizo-
phrenia are overrepresented in state psychiatric hospitals.^ Although much evi-
dence exists to suggest that clinicians overdiagnose schizophrenia and underdiag-
nose mood disorders in African Americans, clinical errors alone are unlikely to
account for the differences.' More-effective screening may mitigate overdiagnosis of
African Americans and perhaps provide data to clarify group differences in rates.^°
• Subtle disparities in mentai iieaith status. More subtle disparities in men-
tal health status have also been noted. Specifically, Hispanics and blacks report a
lower risk of having a psychiatric disorder compared with their white counterparts,
but those who become iH tend to have more persistent disorders." Similarly, black
Americans are less likely to have major depression during their lifetimes than their
white counterparts hving in similar areas, but the rates of major depression in the
past year are similar across groups, indicating more-persistent illness. Eurthermore,
relative to whites, blacks are more likely to rate their depression as very severe and
394 March/April 2008
M E N T A L H E A L T H
• Symptom levels. Although rates of disorders are not higher among minorities
than among white Americans, the number of psychological symptoms among mi-
norities does tend to be greater.'^ Higher symptom levels may be important because
poorer functioning has been related to symptoms that do not reach criteria for a di-
agnosis.''' For example, maternal depressive symptoms have been related to poorer
mental health and functioning in offspring.'^ Higher rates of symptoms among mi-
nority women suggest that there may be disparities in the need for care that are not
reflected in diagnoses.
Ethnicity and language can affect behavior and symptom expression, leading to
caution in giving too strong an interpretation to the general finding of lower rates
of mental disorders among minorities.'^ Frederic Huang and colleagues studied
the relationship between severity of depression as measured by the Patient Health
Questionnaire (PHQ) and self-reported disability days, clinic visits, and symp-
tom-related difficulties.''' Latinos reported a lower correlation of severity with dis-
ability than blacks or non-Hispanic whites reported, after adjustment for age, sex,
education, and language. The researchers could not distinguish whether this find-
ing was the result of Latinos' reporting elevated symptoms from a given disability,
as has been found by some other researchers, or whether Latinos were better able
to tolerate depression without having it cause disability. Margarita Alegria and
Thomas McGuire used data from the National Comorbidity Survey and found
some major differences in the relation of key symptoms to psychiatric disorders
across groups.'^ Race and ethnicity affected symptom/disease relationships in al-
cohol abuse and depression. A person's ethnicity/race/culture may affect what he
or she reports, what the clinician asks the patient to report, and how the clinician
interprets the information provided. This apphes both to patient-clinician inter-
action and to a person's response to survey questions.
Racial/Ethnic Disparities in Mentai Heaith Care
• Definitions. Despite a large hterature on the topic of health care disparities, no
consensus exists on how to measure disparities. Here we rely on the definition em-
ployed by the Institute of Medicine (IOM) in its Unequal Treatment report: a disparity
is a difference in health care quality not due to differences in health care needs or
preferences of the patient." As such, disparities can be rooted in inequahties in ac-
cess to good providers, differences in insurance coverage, or discrimination by
health professionals in the clinical encounter.
The IOM definition is distinct from that applied by the Agency for Healthcare
Research and Quality (AHRQ) in its annual l^ational Healthcare Disparities Report,
where any difference between populations is a disparity, with no adjustment for
underlying need for care. The IOM definition is also distinct from much of the re-
search hterature that adjusts disparity estimates for socioeconomic and geo-
graphic variables, thus disregarding disparities associated with lack of insurance
HEALTH AFFAIRS - Volume 27, Number 2 395
S P E C I F I C D I S P A R I T I E S
coverage, geographic access to providers, education, or income, which are consid-
ered disparities within the IOM concept.^" We believe, consistent with the IOM
approach, that social circumstances, such as lack of insurance, constitute dispari-
ties if they lead to poorer-quality or less care when care is needed.
• Evidence on access, use, and spending. Most research comparing mental
health care across groups finds evidence of disparities in access and use. As docu-
mented in the U.S. surgeon general's report on mental health and its supplement, ra-
cial and ethnic minorities have less access to mental health services than whites
have, are less likely to receive needed care, and are more likely to receive poor-quality
care when treated.^' Also, minorities are more likely than whites to delay or fail to
seek mental health treatment.^^ After entering care, minority patients are less likely
than whites to receive the best available treatments for depression and anxiety." Af-
rican Americans are more likely than whites to terminate treatment prematurely.^''
Among adults with a diagnosis-based need for mental health or substance abuse
care, 37.6 percent of whites, but only 22.4 percent of Latinos and 25.0 percent of Af-
rican Americans, receive it.^^
McGuire and colleagues implemented the IOM definition of disparities in out-
patient mental health care and found that overall spending for blacks and Latinos
on outpatient mental health care is about 60 percent and 75 percent of spending
rates for whites, respectively, after taking into account need for care.^^
• Trends In mental health care disparities. Some studies have begun to track
trends in mental health care disparities. Three use the IOM definition of disparities.
Using a national data set (the Medical Expenditure Panel Survey, or MEPS), black-
white and Hispanic-white disparities in rates of any mental health care use wors-
ened from 2000-01 to 2003-04.^'' Using another nationally representative sample of
those with access to services (the National Ambulatory Medical Care Survey, or
NAMCS), no evidence was found for progress against disparities in depression and
anxiety care in primary care settings over the past decade.^^ In a national sample of
Enghsh-speaking people, overall rates of treatment for psychiatric disorders in-
creased between 1990 and 2003, but in both years blacks were only 50 percent as
likely to receive psychiatric treatment as whites were for diseases of similar sever-
Mechanisms Contributing To Disparities
Mechanisms behind disparities in health and mental health care show some dif-
ferences. A broad distinction, introduced by the IOM, is between disparities due
to discriminatory behavior of providers (that is, treating otherwise similar pa-
tients differently according to race/ethnicity) and disparities due to access, insur-
ance, and other factors associated with the operation of the health care system.^"
• Providers' bias and stereotyping. Discrimination by providers is often the
first potential source of disparities that comes to mind. Discrimination by race/eth-
nicity is a complex behavior that can stem from a number of sources, some malevo-
396 M a r c h / A p r i l 2008
M E N T A L H E A L T H
lent, some not.^' A provider harboring a bias against a certain group may exert less
effort on behalf of a member of that group, leading to discrimination.^^ Discrimina-
tion can also stem from the negative stereotypes a provider might hold. For example,
if a doctor believes that "blacks are less likely than whites to comply with treat-
ment," the doctor might prescribe differently based on race for otherwise similar pa-
tients. Many white Americans harbor negative stereotypes about blacks." Michelle
van Ryn and Jane Burke argue that "physicians may be especially vulnerable to the
use of stereotypes in forming impressions of patients since time pressure, brief en-
counters, and the need to manage very complex tasks are common characteristics of
• Providers' "statistical discrimination." It is also important to recognize,
however, that the behavior of discrimination can result from application of clinical
decision rules that in themselves seem to be neutral and even "efficient" but have dif-
ferent effects by race. Clinicians make decisions about what test to run or treat-
ments to recommend in the face of considerable uncertainty about the underlying
"true" condition of the patient, and their decision rules reflect that reahty The same
symptom report—chest pain, for instance—may be logically interpreted as meaning
different things for a young woman than for an older man. The doctor may "discrimi-
nate" by recommending that the young woman try an over-the-counter gastro-
intestinal medication and that the older man get an electrocardiogram (EKG). This
kind of discrimination, stemming from the doctor's rational response to uncertainty,
is termed "statistical" discrimination.^^ Statistical discrimination shares with ste-
reotyping the feature that actions are based on behefs about group characteristics
but are distinct, at least in principle, because the stereotypical belief is negative and
exaggerated, whereas the clinical generalization is based on fact.
The concept of statistical discrimination is a potential link between features of
disparities in mental health care as compared to other health care. The prevalence
of mental disorders is generally lower among minorities, so that a clinician's statis-
tical "prior" that a patient is ill when encountering a minority patient should be
that this patient is less likely to be ill in comparison to an otherwise similar white
patient. If so, a more serious indication of symptoms would be necessary to cause a
clinician to revise the prior enough to justify recommending treatment. In health,
where minorities may on average be worse off than whites, application of popula-
tion priors will tend to favor rates of treatment for minorities. Furthermore, in ad-
dition to a prior probability, the clinical decision-making literature refers to the
"signal," or symptom report, coming from the patient. If communication is gener-
ally worse when the patient and doctor come from different ethnic, racial, or lan-
guage groups, the resultant "noisier" signal will be rationally given less weight by
the doctor.^* Minorities will be worse off on two counts, then, in connection with
statistical discrimination. Their lower priors and noisier signals lead to lower
probability of treatment for a patient with a given level of health care need. If sta-
tistical discrimination of this kind feeds into treatment decisions, disparities aris-
H E A L T H A F F A I R S - V o l u m e 27. N u m b e r 2 3 9 7
S P E C I F I C D I S P A R I T I E S
''Appeal to exceptionalism does not seem necessary to reduce
mental health care disparities."
ing within the clinical encounter are more important in mental health than in gen-
eral health. In the case of mental disorders, where population prevalence is
generally lower for minorities and where communication/understanding may be
worse, this type of provider discrimination leads to lower rates of treatment for
• Provider and geographic differences. In the health care area, the second set
of factors, provider- or geographic-level differences, are major sources of dispari-
ties,^'' Provider A may provide low-quality care to all patients, and Provider B, high-
quality care to all patients, and if minorities are more likely to be seen by Provider A,
these across-provider differences will account for some disparities. Geographic-
level factors can work similarly, to the extent that minorities are more likely than
whites to live in areas characterized by low-quality care,
• Health insurance differences. As in general health care, mental health care
disparities associated with access in general, and lack of insurance, are significant in
minority communities.^^ Inadequate access in poor, rural communities may be shared
by everyone hving there, but since minorities are more likely to live in poor communi-
ties, this form of access problem can contribute to mental health disparities,
issues For Poiicy Consideration
• "Exceptional" versus generai remedies. Discussion of mental health policy
often centers on the issue of mental health "exceptionaHsm": Is mental health differ-
ent from the rest of health care in some way that justifies special pohcy? In mental
health economics, for example, higher demand response for mental health services
once supported arguments for less insurance coverage. Similarly, the inadequacy of
case-mix adjustments for hospital care to capture expected resource use argued
against use of diagnosis-related group (DRG)-based payment for hospital care of
patients with mental iUnesses,^^
Appeal to exceptionalism does not seem necessary to reduce mental health care
disparities. The major recommendations for eliminating health care disparities
from the IOM's Unequal Treatment report appear applicable to mental health care.
Specifically, the report recommends that health care systems take steps to im-
prove access to care, ensuring that they do not disproportionately burden or re-
strict minority patients' access, and take further steps when necessary, such as
providing interpreter services. Further, the report recommends that economic in-
centives be considered for improving patient-provider communication and trust
as well as for rewarding appropriate screening, preventive, and evidence-based
clinical care. If followed, these general policies would likely improve disparities,
• Greater diversity in the mental heaith workforce. Increasing the proportion
398 March/April 2008
M E N T A L H E A L T H
of racial minority providers is considered an important factor for improving health
disparities. This is even more important for mental health care, where ethnic minori-
ties are even more poorly represented than in health care in general, and where di-
versity may make more of a difference in addressing minority patients' concerns
about trust. African Americans and Latinos constituted 13 percent and 14 percent,
respectively, of the U.S. population in 2005, but African Americans constituted only
3 percent of psychiatrists and 2 percent of psychologists. Latinos were just slightly
better represented at 5 percent and 3 percent, respectively""^ A more diverse work-
force would likely provide not only more culturally appropriate treatment, but also
language skills to match those of patients. A federal commitment to the outreach
and educational support necessary to build a truly diverse mental health workforce
is a critical policy recommendation for decreasing disparities in mental health care.
• Cuituraliy appropriate education for providers. A promising direction in
mental health care picks up on our hypothesis about the relative importance of un-
derstanding the circumstances and symptom reports from minority patients. Men-
tal health care is different from some of the rest of health care in its heavier rehance
on understanding and communication to determine patients' needs.'" Culturally ap-
propriate education for providers is important, as is education for patients to better
understand disease and disease management. Eor example, ethnic minority women
are less likely than their similarly poor white counterparts to perceive a need for de-
pression care.''^ Clearly, routine screening for depression in health care settings, edu-
cating providers about ethnic minority patients, and educating patients about men-
tal illness and interventions could all help reduce disparities.
• impact of quality improvement on disparities. Although quality improve-
ment strategies and steps to reduce racial/ethnic disparities do not need to be seen
as alternatives, an issue of relative emphasis exists: should quality improvement ef-
forts be focused on low quahty, or should care for minorities get special attention?
One argument is that the overall gaps in quahty are so large that they dwarf differ-
ences among groups. Katherine Baicker and Amitabh Chandra argue that "policies
should focus on getting the rates right, rather than solely on racial differences.'"*^
Low-quality health care and racial/ethnic health care disparities are indicators
of failure to attain social and health care objectives, in the first case for all patients
and in the second case for a subgroup of patients. According to the IOM, equity is
one of the six domains of health care quality Both low quality and disparities can
be seen as manifestations of the same underlying issue. However, recent empirical
research suggests that the quality of health care and disparities in health care are
not invariably related. In Medicare, health plan outcomes and the magnitude of
disparities are not related.'*'* Steven Asch and colleagues found no racial dispari-
ties in care among a population of patients with access to care in twelve communi-
ties, despite the average low quality of care for patients in this study'*^
Should health care providers pursue one set of interventions that will address
both quality and disparities or two sets of interventions—one set addressing
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S P E C I E I C D I S P A R I T I E S
''Improving the quality of medical care is likely to benefit minority
patients who have access to care."
quality and a second set addressing disparities? Two studies have looked at inter-
ventions designed to improve the quality of mental health care and minority out-
comes. In a large trial of quality improvement for depression in older patients, a
collaborative care intervention improved care significantly more than care as
usual for African American, Hispanic, and white patients similarly"** A similar
study of two quality improvement interventions for depression (psychotherapy
and medications) in large managed care settings found that clinical outcomes at
one year were greater for Latinos and African Americans than they were for white
patients.'*'' Five years later, the interventions were found to improve disparities
markedly by improving health outcomes and unmet need for care among Latinos
and African Americans relative to whites.''^
Taken together, these studies suggest that improving the quality of medical care
in general is likely to benefit minority patients who have access to care. General
improvement may also help decrease disparities. In the one study showing such an
effect, efforts were made to make the quality improvement interventions appro-
priate for ethnic minorities. Specifically, experts in mental health interventions
for minorities participated in designing all of the quality improvement materials
in English and Spanish. Videotaped educational materials for patients included
African American and Hispanic providers and patients. Furthermore, information
on cultural beliefs and ways of overcoming barriers to care for Latino and African
American patients were included in all training. Finally, the psychotherapy inter-
vention had been developed for use specifically with low-income and minority pa-
tients. Overall, quahty improvement interventions have the potential to decrease
levels found in ethnic minorities than in whites.^^ The absence of disparity in men-
tal health is remarkable and not easy to interpret, but we can at least say that re-
duction of social inequahties is not necessary for achieving parity in mental health
status. Improving access to and quahty of care would likely improve the mental
health of ethnic Americans. The question then becomes. Does evidence-based care,
developed largely for white, middle-class Americans, appear to be equally effective
for ethnic minorities? A recent review of the hterature suggests that it is, but this
question is in need of much more research attention in the near future.^°
N SUM, OUR REVIEW OE THE EVIDENCE leads US to conclude that eliminat-
ing social disparities is essential for reducing general health disparities; in
mental health, this would likely contribute to reducing the higher symptom
400 March/April 2008
M E N T A L H E A L T H
The authors are grateful to the John D. and Catherine T MacArthur Foundation for support of this research. In
addition, Tom McGuire's research was supported by Grant no. P50 MH073469from the National Institute of
Mental Health (NIMH) and Grant no. P20 MD000537from the National Center on Minority Health and Health
Disparities (NCMHD). Jeanne Miranda's research was supported by the Resource Centers for Minority Aging
Research/Center for Health Improvement of Minority Elderly (RCMAR/CHIME), funded by the National
Institute on Aging (Grant no. 3P03AG021684); the UCLA/Drew Project EXPORT, funded by the NCMHD
(Grant no. 1P20MD00148-01); and the UCL4-RAND Center for Research on Quality in Managed Care, funded
hy the NIMH (Grant no. MH068639-01).
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37 K. Baicker and A. Chandra, "Medicare Spending, the Physician Workforce, and Beneficiaties' Quality of
Care," Health Affairs 23 (2004); wl84-wl97 (published online 7 Aptil 2004; 10.1377/hlthaff.w4.184).
38. M. Alegria et al., "Health Insurance Coverage for Vuhierable Populations; Contrasting Asian Ameticans
and Latinos in the United States," Inquiry 43, no. 3 (2006); 231-254.
39. R.G. Frank and T.G. McGuire, "Savings from a Medicaid Carve-Out for Mental Health and Substance
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402 March/April 2008
M E N T A L H E A L T H
41. Furthermore, some research addresses special protocols for racial minorities in psychopharmacology. See
W,B. Lawson, "Clinical Issues in the Pharmacotherapy of African Americans," Psychopharmacolo^ Bulletin
32, no, 2 (1996): 275-281.
42. E. Nadeem et al., "Does Stigma Keep Poor Young Immigrant and U.S.-Born Black and Ladna Women from
Seeking Mental Health Care?" Psychiatric Services 58, no. 12 (2007); 1547-1554.
43. Baicker and Chandra, "Medicare Spending."
44. A.N. Trivedi et al,, "Trends in the Quality of Care and Racial Disparities in Medicare Managed Care," New
England journal of Medicine 353, no. 7 (2005): 692-700.
45. S.M. Asch et al., "Who Is at Greatest Risk for Receiving Poor-Quality Health Care?" New England journal of
Medicine 354, no. 11 (2006): 1147-1156.
46. P.A. Arean et al., "Improving Depression Care for Older, Minority Patients in Primary Care " Medical Care
43, no. 4 (2005): 381-390.
47 J. Miranda et al., "Improving Care for Minorities: Can Quality Improvement Interventions Improve Care
and Outcomes for Depressed Minorities? Results of a Randomized, Controlled Trial," Health Services Re-
search 38, no. 2 (2003): 613-630.
48. K. Wells et al., "Five-Year Impact of Quality Improvement for Depression: Results of a Group-Level Ran-
domized Controlled Trial," Archives of General Psychiatry 61, no. 4 (2004): 378-386.
49. For discussion of this idea, see M. Alegria, D. Perez, and S. Williams, "The Role of Public Pohcies in Reduc-
ing Disparities in Mental Health Status for People of Color," Health Affairs 22, no. 5 (2003): 51-64.
50. J. Miranda et al., "State of the Science on Psychosocial Interventions for Ethnic Minorities," Annual Review of
Clinical Psychology 1 (2005): 113-142.
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