CHAPTER 3

Mental Health Care for African Americans

Conclusions

African Americans have made great strides in education, income, and other indicators of social well-being. Their improvement in social standing is marked, attesting to the resilience and adaptive traditions of African American communities in the face of slavery, racism, and discrimination. Contributions have come from diverse African American communities, including immigrants from Africa, the Caribbean, and elsewhere. Nevertheless, significant problems remain:

1.  African Americans living in the community appear to have overall rates of distress symptoms and mental illness similar to those of whites, although some exceptions may exist. One major epidemiological study found that the rates of disorder for whites and blacks were similar after controlling for differences in income, education, and marital status. A later, population-based study found similar rates before accounting for such socioeconomic variables. Furthermore, the distribution of disorders may be different between groups, with African Americans having higher rates of some disorders and lower rates of others.

2.  The mental health of African Americans cannot be evaluated without considering the many African Americans found in high-need populations whose members have high levels of mental illness and are significantly in need of treatment. Proportionally, 3.5 times as many African Americans as white Americans are homeless. None of them are included in community surveys. Other inaccessible populations also compound the problem of making accurate measurements and providing effective services.

The mental health problems of persons in high-need populations are especially likely to occur jointly with substance abuse problems, as well as with HIV infection or AIDS (Lewin & Altman, 2000). Detection, treatment, and rehabilitation become particularly challenging in the presence of multiple and significant impediments to well-being.

3.   African Americans who are distressed or have a mental illness may present their symptoms according to certain idioms of distress. African American symptom presentation can differ from what most clinicians are trained to expect and may lead to diagnostic and treatment planning problems. The impact of culture on idioms of distress deserves more attention from researchers.

4.    African Americans may be more likely than white Americans to use alternative therapies, although differences have not yet been firmly established. When complementary therapies are used, their use may not be communicated to clinicians. A lack of provider knowledge of their use may interfere with delivery of appropriate treatment.

5.   Disparities in access to mental health services are partly attributable to financial barriers. Many of the working poor, among whom African Americans are overrepresented, do not qualify for public coverage and work in jobs that do not provide private coverage. Better access to private insurance is an important step, but is not in itself sufficient. African American reliance on public financing suggests that provisions of the Medicaid program are also important. Publicly financed safety net providers are a critical resource in the provision of care to African American communities.

6.    Disparities in access also come about for reasons other than financial ones. Few mental health specialists are available for those African Americans who prefer an African American provider. Furthermore, African Americans are overrepresented in areas where few providers choose to practice. They may not trust or feel welcomed by the providers who are available. Feelings of mistrust and stigma or perceptions of racism or discrimination may keep them away.

7.    African Americans with mental health needs are unlikely to receive treatment—even less likely than the undertreated mainstream population. If treated, they are likely to have sought help from primary care providers. African Americans frequently lack a usual source of health care as a focal point for treatment. African Americans receiving specialty care tend to leave treatment prematurely. Mental health care occurs relatively frequently in emergency rooms and psychiatric hospitals. These settings and patterns of treatment undermine delivery of high-quality mental health care.

8.    African Americans are more likely to be incorrectly diagnosed than white Americans. They are more likely to be diagnosed as suffering from schizophrenia and less likely to be diagnosed as suffering from an affective disorder. The pattern is longstanding but cannot yet be fully explained.

9.    Whether African Americans and whites benefit from mental health treatment in equal measure is still under investigation. The limited information available suggests African Americans respond favorably for the most part, but few clinical trials have evaluated the response of African Americans to evidence-based treatments. Little research has examined the impact on African Americans of care delivered under usual conditions of community practice. More remains to be learned about when and how treatment must be modified to take into account African American needs and preferences.

Adaptive traditions have sustained African Americans through long periods of hardship imposed by the larger society. Their resilience is an important resource from which much can be learned. African American communities must be engaged, their traditions supported and built upon, and their trust gained in attempts to reduce mental illness and increase mental health. Mutual benefit will accrue to African Americans and to the society at large from a concerted effort to address the mental health needs of African Americans.