Racial/Ethnic Differences in Attitudes Toward Seeking Professional Mental Health Services

Article (PDF Available)inAmerican Journal of Public Health 91(5):805-7 · May 2001with42 Reads
DOI: 10.2105/AJPH.91.5.805 · Source: PubMed
Abstract
This study examined racial/ethnic differences in attitudes toward seeking mental health services. Data from the National Comorbidity Survey, which administered a structured diagnostic interview to a representative sample of the US population (N = 8098), were analyzed. Multiple logistic regression was used, and data were stratified by need for mental health services. African Americans with depression were more likely than Whites with depression to "definitely go" (odds ratio [OR] = 1.8, P < .001) seek mental health services. African Americans with severe psychiatric disorders were less likely to be "somewhat embarrassed if friends knew they sought care" (OR = 0.3, P < .001) than were their White counterparts. African Americans reported more positive attitudes toward seeking mental health services than did Whites.
ABSTRACT
American Journal of Public Health 805
Racial/Ethnic Differences in Attitudes
Toward Seeking Professional Mental
Health Services
Chamberlain C. Diala, PhD, MPH, Carles Muntaner, MD, PhD,
Christine Walrath, PhD, Kim Nickerson, PhD, Thomas LaVeist, PhD,
and Phil Leaf, PhD
ABSTRACT
Objectives. This study examined
racial/ethnic differences in attitudes to-
ward seeking mental health services.
Methods. Data from the National
Comorbidity Survey, which adminis-
tered a structured diagnostic interview to
a representative sample of the US pop-
ulation (N = 8098), were analyzed. Mul-
tiple logistic regression was used, and
data were stratified by need for mental
health services.
Results. African Americans with
depression were more likely than
Whites with depression to “definitely
go” (odds ratio [OR] = 1.8, P < .001)
seek mental health services. African
Americans with severe psychiatric dis-
orders were less likely to be “somewhat
embarrassed if friends knew they sought
care” (OR = 0.3, P < .001) than were
their White counterparts.
Conclusions. African Americans
reported more positive attitudes toward
seeking mental health services than did
Whites. (Am J Public Health. 2001;91:
805–807)
Chamberlain C. Diala, Christine Walrath, Kim Nick-
erson, and Phil Leaf are with the Department of Men-
tal Hygiene, Johns Hopkins University, Baltimore,
Md. Carles Muntaner is with the Department of Be-
havioral and Community Health, University of Mary-
land–Baltimore, Baltimore, Md. Chamberlain C.
Diala and Thomas LaVeist are with the Department
of Health Policy and Management, Johns Hopkins
University, Baltimore, Md.
Requests for reprints should be sent to Cham-
berlain C. Diala, PhD, MPH, Johns Hopkins Uni-
versity, Center for Communication Programs, 111
Market Pl, Room 3059, Baltimore, MD 21202
(e-mail: diala@maxinter.net).
This brief was accepted July 29, 2000.
Several factors influence a person’s atti-
tudes toward seeking health care.
1
For African
Americans, provider bias in the diagnosis and
treatment of mental disorders
2–5
may affect
their tendency to seek care. Furthermore, Af-
rican Americans may have a higher preva-
lence of mental illness because they tend to be
poorer than Whites.
6,7
Along with economic
barriers, African Americans may have prior
negative attitudes
7
toward seeking care, which
may explain their mistrust of White providers
8
and subsequent lower use of mental health
services, particularly at times of need.
Previous studies of African Americans’
attitudes toward seeking mental health serv-
ices have been limited to a specific sex
9
or
occupation.
10
In addition to sample compo-
sition, another limitation of past studies has
been the failure to consider that attitudes to-
ward seeking care depend on clinical status
11
(i.e., the link between need and service). The
goal of the current study was to determine
whether African Americans have more nega-
tive attitudes toward seeking mental health
services than do Whites in a representative
sample of the US population, after adjustment
for socioeconomic position and need for
services.
Methods
We analyzed the National Comorbidity
Survey,
12
the only survey to have administered
a structured psychiatric diagnostic interview
to a national probability sample in the United
States. The National Comorbidity Survey sam-
ple was based on a stratified, multistaged area
probability sample of persons aged 15 to 54
years.The Institute for Social Research at the
University of Michigan in Ann Arbor admin-
istered the survey between 1990 and 1992. A
total of 8098 respondents participated, with a
response rate of 82.4%.
12
A modified version
of the Composite International Diagnostic In-
terview,
13
a diagnostic interview designed for
nonclinicians, was used to generate diagnoses
based on Diagnostic and Statistical Manual of
Mental Disorders, RevisedThird Edition, and
International Classification of Diseases, 10th
Revision.
The National Comorbidity Survey was
administered in 2 parts. Part 1 (N = 8098) in-
cluded the core diagnostic interview, a brief
risk factor battery, and an inventory of socio-
demographic data. Part 2 (N=5877) included
a more detailed risk factor battery and sec-
ondary diagnoses and was the basis of this
study. Three adjustment weights were con-
structed to account for systematic nonre-
sponse and different probabilities of selection
between and within households and to ap-
proximate the age, sex, and income distribu-
tion of the US population.
We used the National Comorbidity Sur-
vey 12-month prevalence of major depres-
sion, “any disorder,” and a category of “se-
vere disorders” to stratify by need for services
in our analysis. Severe disorders included psy-
choses, required hospitalization, or severe role
impairment.
13
The dependent variables for
this analysis were attitudes toward seeking
professional care in the 12 months preceding
data collection, and the independent variable
was respondent self-identified race/ethnicity
(African American or White). Race/ethnicity
was defined as a social stratification vari-
able—that is, as an indicator of economic, po-
litical, and cultural discrimination for minor-
ity groups.
14
Thus, self-reported race/ethnicity
is a surrogate for exposures to economic, po-
litical, and cultural discrimination among Af-
rican Americans.
Respondents’ attitudes toward seeking
mental health services were assessed with
the following question: “People differ a lot
in their feelings about seeking professional
help for emotional problems. If you had a se-
rious emotional problem, would you—defi-
nitely go, probably go, probably not go, or
definitely not go?” Respondents’ behavioral
May 2001, Vol. 91, No. 5
May 2001, Vol. 91, No. 5806 American Journal of Public Health
TABLE 1—Racial/Ethnic Differences in Attitudes Toward Seeking Professional Mental Health Care in the General Population
and Among Respondents With Major Depression: National Comorbidity Survey, 1990–1992
General Population Respondents With Major Depression
(n = 5877) (n = 427)
OR 95% CI P OR 95% CI P
Seek professional help for emotional problems
Definitely go
African Americans 1.5 (1.3, 1.8) <.001 1.8 (1.1, 3.1) <.001
Whites 1.0 1.0
Probably not go
African Americans 0.5 (0.3, 0.6) <.001 0.9 (0.8, 1.2) NS
Whites 1.0 1.0
Level of comfort talking with a professional
Very comfortable
African Americans 1.2 (1.0, 1.4) <.05 1.1 (0.9, 1.3) NS
Whites 1.0 1.0
Somewhat comfortable
African Americans 1.3 (1.1, 1.5) <.01 1.2 (0.8, 1.4) NS
Whites 1.0 1.0
Not very comfortable
African Americans 0.4 (0.3, 0.5) <.001 0.8 (0.7, 1.2) NS
Whites 1.0 1.0
Not at all comfortable
African Americans 2.1 (1.7, 2.4) <.001 1.4 (0.9, 1.8) NS
Whites 1.0 1.0
Level of embarrassment if friends knew about
professional help
Somewhat embarrassed
African Americans 0.4 (0.3, 0.5) <.001 0.4 (0.2, 0.9) <.01
Whites 1.0 1.0
Note. Results from multiple logistic regression analyses of the survey were adjusted for age, sex, education, and income. Whites are the
reference category. OR= odds ratio; CI= confidence interval; NS = not statistically significant at P < .05.
disposition toward seeking care was mea-
sured with the following question: “How
comfortable would you feel talking about per-
sonal problems with a professional?—very
comfortable, somewhat comfortable, not very
comfortable, not at all comfortable.” Re-
spondents’ emotions were measured with the
following question: “How embarrassed would
you be if your friends knew you were getting
professional help for an emotional prob-
lem?—very embarrassed, somewhat embar-
rassed, not very embarrassed, not at all em-
barrassed.” Preliminary analyses established
that these indicator variables measured dif-
ferent aspects of respondents’ attitudes.
We included 4 potential confounders of
the association between race/ethnicity and at-
titudes as covariates in logistic regression
analyses (i.e., age, sex, income, and educa-
tion) for the general population, major de-
pression, any disorder, and severe mental dis-
order subsamples separately. As in previous
National Comorbidity Survey studies, these
variables were not so highly correlated as to
create a multicollinearity problem.
15
Dummy-
coded indicators were used for each covariate
in the multiple logistic regression models for
each subsample. The 3 attitude questions were
operationalized as dichotomous variables (e.g.,
definitely go vs other, very comfortable vs
other, very embarrassed vs other). We used
SUDAAN
16
to account for possible survey de-
sign effects due to clustered sampling. We pre-
sent odds ratios (ORs), their associated con-
fidence limits, and P values.
Results
Attitudes in the General Population and
Among Persons With Major Depression
The prevalence of depression among Af-
rican Americans (9.3%) and Whites (9.8%)
was similar. However, African Americans re-
ported more positive attitudes toward seek-
ing care than did their White counterparts,
both in the general population and among
those with depression (Table 1). For exam-
ple, among general respondents and among
those with depression, African Americans re-
ported a greater predisposition than Whites
to “definitely go” seek care if they had seri-
ous emotional problems (OR= 1.5, P < .001,
and OR = 1.8, P< .05, respectively). African
Americans in the general population reported
more positive behavioral dispositions than did
Whites because they felt “very comfortable”
(OR =1.2, P<.05) and “somewhat comfort-
able” (OR= 1.3, P < .01) talking about per-
sonal problems with professionals. African
Americans in the general population reported
fewer negative behavioral attitudes toward
seeking care than did Whites (“would proba-
bly not go,” OR = 0.5, P< .001, and “not very
comfortable,” OR = 0.4, P < .001). Further-
more, African Americans in the general pop-
ulation and those with depression reported
less negative emotions if friends knew they
were getting professional help than did Whites
(“somewhat embarrassed,” OR= 0.4, P<.001,
and OR =0.4, P< .01, respectively).
Attitudes of Respondents With Any
Disorder and Severe Disorders
Among those in greater need of care, Af-
rican Americans also reported more positive
attitudes toward seeking care than did Whites
(Table 2). African Americans with any or se-
vere psychiatric disorders were more likely
than Whites to seek care if they had serious
emotional problems (“would definitely go,
OR=1.5, P< .001, and OR =1.8, P <.001, re-
spectively). In both categories of need, Afri-
can Americans were less embarrassed than
were Whites if their friends knew they sought
care (“not at all embarrassed, OR= 1.9, P<
.001, and OR = 1.5, P <.04, respectively).
May 2001, Vol. 91, No. 5 American Journal of Public Health 807
TABLE 2—Racial/Ethnic Differences in Attitudes Toward Seeking Professional Mental Health Care Among Respondents With
Any Psychiatric Disorder or Severe Psychiatric Disorders: National Comorbidity Survey, 1990–1992
Any Psychiatric Disorder (n = 1892) Severe Disorders (n = 855)
OR 95% CI P OR 95% CI P
Seek professional help for emotional problems
Definitely go
African Americans 1.5 (1.1, 2.0) <.001 1.8 (1.1, 2.9) <.001
Whites 1.0 1.0
Probably not go
African Americans 0.4 (0.2, 0.6) <.001 0.4 (0.2, 0.8) <.01
Whites 1.0 1.0
Level of embarrassment if friends knew about
professional help
Not at all embarrassed
African Americans 1.9 (1.4, 2.5) <.001 1.5 (1.1, 2.4) <.04
Whites 1.0 1.0
Somewhat embarrassed
African Americans 0.4 (0.3, 0.6) <.001 0.3 (0.2, 0.7) <.01
Whites 1.0 1.0
Note. Results from multiple logistic regression analyses of the survey were adjusted for age, sex, education, and income. Whites are the
reference category. OR= odds ratio; CI= confidence interval; NS = not statistically significant at P < .05.
Discussion
Results of this study show that African
Americans in the general population and those
in need of care have more positive attitudes to-
ward seeking mental health care than do
Whites. Previous studies assumed that prior
negative attitudes
7
among African Americans
and mistrust
8
of White providers accounted
for lower use of services at times of need. In
contrast, our results suggest that African
Americans have comparable and, in most in-
stances, more favorable attitudes toward seek-
ing care for their mental illness than do their
White counterparts.
Contributors
C. C. Diala and C. Muntaner planned the study, ana-
lyzed the data, and wrote the paper. C. Walrath and
K. Nickerson assisted with study design and data
analysis. T. LaVeist and P. Leaf supervised study de-
sign and data analysis and also edited the paper.
References
1. Andersen RM. Revisiting the behavioral model
and access to medical care: does it matter?
J Health Soc Behav. 1995;36:1–10.
2. Flaskerud JH, Hu L-T. Racial/ethnic identity and
amount and type of psychiatric treatment. Am J
Psychiatry. 1992;149:379–384.
3. Adebimpe V, Cohen E. Schizophrenia and af-
fective disorder in black and white patients: a
methodologic note. J Natl Med Assoc. 1989;81:
761–765.
4. Worthington C. An examination of factors in-
fluencing the diagnosis and treatment of black
patients in the mental health system. Arch Psy-
chiatr Nurs. 1992;6:195–204.
5. Mutchler JE, Burr JA. Racial differences in
health and health care service utilization in later
life: the effect of socioeconomic status. J Health
Soc Behav. 1991;32:342–356.
6. Bruce ML, Takeuchi DT, Leaf PJ. Poverty and
psychiatric status: longitudinal evidence from
the New Haven Epidemiologic Catchment Area
study. Arch Gen Psychiatry. 1991;48:470–474.
7. Mouton C, Harris S, Rovi S, Solorzano P, John-
son M. Barriers to black women’s participation
in cancer clinical trials. J Natl Med Assoc. 1997;
89:721–727.
8. Nickerson K, Helms J, Terrell F. Cultural mis-
trust, opinions about mental illness, and Black
students’ attitudes toward seeking psychologi-
cal help from White counselors. J Consult Clin
Psychol. 1994;41:378–385.
9. Leaf P, Bruce M, Tischler G, Holzer C. The re-
lationship between demographic factors and at-
titudes toward mental health specialist services.
J Community Psychol. 1988;15:275–284.
10. Hall L, Tucker C. Relationships between eth-
nicity, conceptions of mental illness, and atti-
tudes associated with seeking psychological
help. Psychol Rep. 1985;57:907–916.
11. Leaf P, Livingston M, Tischler G, Weissman M,
Holzer C, Myers J. Contact with health profes-
sionals for the treatment of psychiatric and emo-
tional problems. Med Care. 1985;23:
1322–1337.
12. Kessler R, McGonagle K, Zhao S, et al. Life-
time and 12-month prevalence of DSM-III-R
psychiatric disorders in the United States: re-
sults from the National Comorbidity Survey.
Arch Gen Psychiatry. 1994;51:8–19.
13. Robins LN, Wing J, Wittchen HU, et al. The
Composite International Diagnostic Interview:
an epidemiological instrument suitable for use in
conjunction with different diagnostic systems
and in different cultures. Arch Gen Psychiatry.
1988;45:1069–1077.
14. Muntaner C. Invited commentary: social mech-
anisms, race, and social epidemiology. Am J Epi-
demiol. 1999;150:121–126.
15. Blazer DG, Kessler RC, McGonagle KA,
Swartz MS. The prevalence and distribution of
major depression in a national community sam-
ple: the National Comorbidity Survey. Am J Psy-
chiatry. 1994;151:979–986.
16. Shah B, Barnwell B, Bieler G. SUDAAN User’s
Manual: Software for Analysis of Correlated
Data, Release 7.0. Research Triangle Park, NC:
Research Triangle Institute; 1996.
    • "They were less likely to come from other inpatient settings than White Americans. These findings showing numerous paths to inpatient services are consistent with studies suggesting that African Americans are more likely to use inpatient than outpatient care (Chow, Jaffee, & Snowden, 2003; Snowden & Cheung, 1990) and with a study showing that African Americans display positive attitudes toward seeking mental health services (Dalia et al., 2001). It is noteworthy that, contrary to previous research (Chow et al., 2003 ), distinctions were not observed between groups in their referral rates from criminal justice sources. "
    [Show abstract] [Hide abstract] ABSTRACT: This study investigated inequities in access, diagnosis, and treatment for African Americans and Hispanic Americans receiving treatment in northeast, public sector, inpatient mental health settings as part of a Department of Mental Health and Addiction Services Health Disparities Initiative. Data from 1,484 adults were obtained through a random extract of patients admitted to state inpatient facilities between 2002 and 2005. After controlling for demographic variables and symptom severity, logistic and linear regression showed that Hispanic Americans were significantly more likely to enter inpatient care through crisis/emergency sources and were significantly less likely to self-refer or come to inpatient care through other sources (e.g., family, outpatient). After admission, Hispanic Americans were more likely to be diagnosed with other psychotic disorders (e.g., schizoaffective disorder, delusional disorder), were less likely to receive an Axis II diagnosis at discharge, and had a shorter length of stay than non-Hispanic White Americans. African Americans were more likely than other groups to be diagnosed with schizophrenia, drug-related, and Cluster B diagnoses (discharge only), and they were less likely to be diagnosed with mood disorders and other nonpsychotic disorders. Although African Americans were more likely than other groups to come to inpatient units from numerous routes, including self-referral and referral from other sources (e.g., family, outpatient), they were more likely to terminate treatment against medical advice and displayed shorter length of stay despite receiving ratings of greater symptom severity at discharge. These findings highlight the need for policies, programs, and system interventions designed to eliminate disparities and improve the quality and cultural responsiveness of behavioral health services. (PsycINFO Database Record (c) 2015 APA, all rights reserved).
    Article · May 2015
    • "Ou da lógica de doença mental para a lógica de saúde mental (Renault, 2008). De modo análogo, o Sofrimento Social é uma abordagem de inclusão, quer tomemos como simples exemplos um ponto de vista racial e étnico (Diala et al., 2001), quer sob o exemplo das minorias deficientes excluídas do trabalho ou, enfim, sob a égide mesmo da noção do binômio inclusão/exclusão tratada dentro da ideia de sofrimento social, que tem o poder de abarcar todos esses exemplos mais pontuais da exclusão (e inclusão) social (Renault, 2008). A abordagem do Sofrimento Social, portanto, traz em seu nome o termo " sofrimento " , no esforço de observar, analisar e compreender o distúrbio inscrito na dimensão social e a repercutir na dimensão individual da vivência psíquica – que não se reduz, necessariamente, a uma patologia individual já manifesta no corpo físico. "
    [Show abstract] [Hide abstract] ABSTRACT: Este trabalho objetiva esclarecer as relações entre sofrimento individual e sofrimento coletivo (Sofrimento Social), no contexto dos atuais sistemas de produção. Há, na ciência, um espaço entre o coletivo e o patológico individual no âmbito da saúde coletiva e saúde pública. Investigou-se a relação entre Sofrimento Social e Sofrimento Psíquico no trabalho, no cenário teórico atual da área de Saúde Mental e Trabalho. O texto central tomado para análise é de Emmanuel Renault (2008). O método de pesquisa adotado foi uma revisão analítica, sistemática e crítica de conceitos, teorias e abordagens sobre aspectos sociais e psíquicos da relação entre sofrimento e trabalho. Os resultados confirmam que isso é uma séria e urgente questão e indicam que o sofrimento social opera em duas dimensões simultaneamente interligadas: coletiva (social) e individual (intrapsíquica). A revisão de como o Sofrimento Social agride a saúde coletiva e individual está baseada em fundamentos teóricos aprofundados.
    Full-text · Article · Apr 2015
    • "Given that help-seeking attitudes are multifaceted, there has been increased focus on understanding (a) individuals' stigma concerns associated with seeking professional psychological services, (b) individuals' comfort with acknowledging personal psychological problems, and (c) individuals' willingness to seek help from professionals , as they may each play a unique role in psychological distress. Fear of stigma may be a particularly salient concern among African American women (Diala et al., 2001;Nadeem et al., 2007). Given African American women's double minority status, the stigma associated with seeking professional psychological services may create an additional unwanted burden. "
    [Show abstract] [Hide abstract] ABSTRACT: The Strong Black Woman (SBW) race-gender schema prompts African American women to use self-reliance and self-silence as coping strategies in response to stressors. Utilizing the coping strategies associated with the SBW race-gender schema could trigger anxiety and depression symptoms that may intensify when coupled with negative attitudes toward professional psychological help. The present study investigated whether African American women's endorsement of the SBW race-gender schema predicted increased symptoms of anxiety and depression and whether attitudes toward professional psychological help-seeking intensified psychological distress. Data were collected from 95 participants ranging in age from 18 to 65. Hierarchical regression analysis demonstrated significant main effects for the SBW race-gender schema and greater anxiety and depression, respectively. Greater indifference to stigma, 1 dimension of help-seeking attitudes, predicted lower levels of anxiety. African American women's attitudes toward professional help-seeking did not moderate the associations between endorsement of the SBW race-gender schema and anxiety or depression, respectively. Finally, endorsement of the SBW race-gender schema was inversely and significantly associated with 2 facets of help-seeking attitudes: (a) psychological openness and (b) help-seeking propensity. Taken together, these findings provide empirical support for the role of cultural factors, like the SBW race-gender schema, in African American women's experience of psychological distress and potential underutilization of mental health services. Future research directions are discussed. (PsycINFO Database Record (c) 2015 APA, all rights reserved).
    Article · Jan 2015
Show more