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mental health mondays :: separate and not equal

given the ubiquitousness of racial disparities in the united states, there's no reason why we should be surprised that they exist in mental health care. unlike a lot of other areas, the people in power have acknowledged the problem for decades. but the situation isn't getting any better. 


the united states surgeon general documented the differences between white and non-white mental health care back in 2001 so we can assume that it was already a known problem at that point. two years later, a presidential commission said the same damn thing and groups like the national association for mental health seized on this to develop guidelines on how to bridge the ethnic gap. from the turn of the century through 2007, the number of papers and publications talking about the mental health care gap spiked. the issue was viewed as being on par with obesity when it came to urgent problems.

starting in 2004, researchers undertook a massive project that involved the records of nearly a quarter of a million americans. their work continued through 2012 and, when they analysed the results, they found that there had been no improvement at all. things had actually gotten worse for blacks and hispanics. what the hell? how is it possible that the right people have made this a priority, identified what needs to happen and things are still so bad?

as of 2015, 48% of whites who needed mental health care received it. that's a crappy result but for blacks and hispanics it was only 31% and for asians, it was 22%. the numbers are even worse among children. moreover, while the number of whites getting treatment for mental illness increased steadily over that time, the numbers for other ethnic groups have been pretty flat. the growth in the number of prescriptions for psychotropic drugs in that time hasn't happened in minority communities. some may think it's a good thing that cases are being treated without drugs, but the fact is that they aren't being treated at all.

as with many of the issues in the u.s. health care system, affordable insurance is part of the problem. for instance, 11% of african americans have no insurance, compared to 7% of whites. so african americans are more likely to go without treatment because they can't afford it. still, that's a minority of cases. but minorities are also more likely to have lower incomes and poorer insurance plans than whites and are more likely to need help from public options like medicaid. those programs are less likely to offer support for ongoing care; mental disorders require ongoing care. lower incomes also mean less flexibility to do things like visit a doctor during the standard work day.

[side note :: because access to ongoing care is limited, non-whites are more likely to seek emergency care at times of crisis. this leaves their underlying condition untreated, but it also costs the health care system more. what's interesting is that, when given access to the same care, blacks and hispanics seem to respond better to treatment and recover faster than whites. barriers to access are costing all americans billions every year.] 

a major factor, though, seems to be that non-whites, whose daily lives often involve facing racism both covert and overt, just don't feel great about getting care from white psychiatrists. asking for help with a mental disorder isn't like having your blood pressure checked: you need to believe that the person you speak to is going to believe you and that they won't make the social stigma of having a mental disorder worse by making it seem like your problems are your fault. that trust doesn't exist between black patients and white doctors. black patients don't believe that white doctors have their best interests at heart or that they understand their lives enough to make a difference. so even if money is less of an issue, psychiatric treatment isn't appealing. there is a pressing need for more psychiatrists, psychologists and other professionals from minority communities, but that will take time to improve. a shorter term workaround would be to make sure that people from those communities are at least involved in shaping the care that's given and that the people who are there are getting properly trained.

others have posited that all those well-meaning white people made a dangerous assumption when they decided to focus only on access. research on outcomes focuses, of course, on the people who are treated. but there's little evidence to suggest that those results are applicable to everybody, no matter what their cultural background. after all, those who pursue long-term treatment [if we separate those whose conditions are so extreme that they are forced into treatment, which is a whole other can of worms] are those who feel like they are getting some reward from the process. people who feel frustrated or belittled by the care they're receiving don't continue with it. why would they? when they leave the system, that's noted, but there's little attention paid to the why. so the psychiatric establishment continues to act as if it has a one size fits all solution, without a great deal to back that up. [side note :: i want to make it clear that i'm not saying there's evidence that the current path to treating mental illness doesn't work for different ethnic groups. i'm saying there's a lack of evidence that it does. the lack is the important bit. nor am i saying that the nasty white establishment is trying to impose its will on underprivileged groups; many of the arguments i came across pointing out the potential problems in the treatment model came from members of that establishment. but large professions are conservative and progress is slow.]

more adaptable and empowering is the idea of shared decision-making when it comes to all types of disenfranchised groups. no matter how much we want to be objective, we all bring some prejudices to our work and the way to overcome that is to hear about how the world is experienced by people different than us.

before treatment starts, outreach needs to be examined in order to make sure that the right message is being communicated. earlier in this post, i cited a statistic about asians being the least likely group to seek treatment for their mental health. the authors of that study- the one with more than two hundred thousand participants- noted that an increased cultural bias against mental illness might be at work there, but they couldn't say because there was almost no information, let alone proper analysis, on asian americans and mental health. it doesn't matter that you extend a helping hand if the person you're extending it to thinks you're about to slap them. telling someone that they don't need to be ashamed of seeking help for depression when their community is telling them the opposite is shouting at the ground: it doesn't enable it to move any faster. [hat tip to zoviet france.]

even questions of access have a cultural element: it's not just about affordability, as important as that is. access means that you can actually use the services that are provided. long working hours, young children, limited funds for transport, all these are barriers to access that aren't solved by making treatment affordable and they disproportionately affect minorities. [side note :: access may also be tied to another area where institutional racism is obvious: jails. the american prison system has a disproportionately high number of both non-whites and people with mental disorders because prisons are used as a dumping ground people who meet both criteria. minority youth who exhibit signs of mental illness are more often referred to the authorities than a psychiatrist, meaning that they get no treatment and are stigmatized as a criminal. getting the right help early and addressing underlying mental health problems in order to get people who don't belong in prison out, these are part of the overall problem of "access".]

the lack of progress in addressing the health care gap is embarrassing, as it should be. with such a large problem, maybe those with the power to do something simply feel overwhelmed. but to get the process of change kickstarted, it seems like the best way to solve the problem is to bring in more people to help. that means getting diverse communities involved. it may mean trying out a lot of things on a small scale to see what seems promising. even better take a look at what's worked [or failed] in other places. try those things. get feedback. if things don't work, change them or throw them out and try other things. easy for me to say, i realise, but after two decades of having this acknowledged as a major problem and seeing no results, it seems like it's time to throw all the meat on the barbeque. 

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