CHAPTER 3

Mental Health Care for African Americans

Current Status

Geographic Distribution

In spite of the Great Migration to the North, a large African American population remained in the South, and in recent years, a significant return migration has taken place. Today, 53 percent of all blacks live in the South. Another 37 percent live in the Northeast and Midwest, mostly in metropolitan areas. About 10 percent of all blacks live in the West (U.S. Census Bureau, 2001; see Figure 3-1). Nationally, 15 percent live in rural areas, compared to 23 percent of whites and 25 percent of Americans overall (Rural Policy Research Institute, 1997).

Many African Americans still live in segregated neighborhoods (Massey & Denton, 1993), and poor African Americans tend to live among other African Americans who are poor. Poor neighborhoods have few resources, a disadvantage reflected in high unemployment rates, homelessness, crime, and substance abuse (Wilson, 1987). Children and youth in these environments are often exposed to violence, and they are more likely to suffer the loss of a loved one, to be victimized, to attend substandard schools, to suffer from abuse and neglect, and to encounter too few opportunities for safe, organized recreation and other constructive outlets (National Research Council, 1993). Personal vulnerabilities are exacerbated by problems at the community level, beyond the sphere of individual control.

Figure 3-1 illustrates the African American population by region, based on data from Census 2000. It shows that the majority of African Americans live in the South, 19% live in the Midwest, 18% in the Northeast, and 10% in the West.

On the other hand, not all African American communities are distressed. Like other well functioning communities, stronger African American communities (both rich and poor) possess cohesion and informal mechanisms of social control, sometimes called collective efficacy. Evidence indicates that collective efficacy can counteract the effects of disabling social and economic conditions (Sampson et al., 1997). It also forms the foundation for community-building efforts (Bell & Fink, 2000).

Family Structure

In 2000, there were approximately 9 million African American families in the United States. On average, African American families are larger than white families; (65% versus 54% of families had three or more members), but smaller than families from other racial and ethnic minority groups (76% had three or more members). On the other hand, many African American children grow up in homes with only one parent. Only 38 percent were living in 2-parent families compared to 69% of all children in the United States. For children who lived with one parent, African Americans were more likely to live with their mothers than were U.S. children overall (92% versus 69%)(U.S. Census Bureau, 2001c).

Those who study African American life have argued that these trends are offset by an extended family orientation that calls for mutual material and emotional support (Hatchett & Jackson, 1993). This perspective has found wide acceptance and is reflected in policies such as family foster care, where children and youth removed from their homes are placed with relatives. African Americans participate extensively in family foster care in numbers proportional to their representation in foster care in general (Berrick et al., 1994; Landsverk et al., 1996; Altshuler, 1998).

Increasingly, however, researchers have discovered gaps and limitations in extended family support. Analyzing data from the National Survey of Families and Households, a large, community survey, Roschelle (1997) demonstrated that African American women were more likely than other women to provide assistance with child care and household tasks, but were less likely to receive such assistance in return. Respondents reported during in-depth interviews that levels of intergenerational support provided to teen mothers had waned (McDonald & Armstrong, 2001). They further indicated that several factors, including the youth of many grandmothers and the burden of problems brought on by urban poverty, had undermined supportive traditions.

Education

African Americans have shown an upward trend in educational attainment throughout the latter half of the 20th century. By 1997, there was no longer a gap in high school graduation rates between African Americans and whites. The number of African Americans enrolled in college in 1998 was 50 percent higher than the number enrolled a decade earlier. By 2000, 79 percent of Arican Americans age 25 and over had earned at least a high school diploma and 17 percent had attained a bachelor’s or graduate degree. These rates are in comparsion to 84% and 26%, respectively, for Americans overall (U.S. Census Bureau, 2001c).

Income

When considered in aggregate, African Americans are relatively poor. In 1999, about 22 percent of African American families had incomes below the poverty line ($17,029 for a family of 4 in 1999) but only 10 percent of all U.S. families did (U.S. Census Bureau, 2001c). The difference in poverty rates has shrunk over the past decade, however, and the socioeconomic distribution of African Americans has become increasingly complex.

At one end of the income spectrum, the official poverty rate may understate the true extent of African American poverty. African Americans are more likely than whites to live in severe poverty, with incomes at or below 50 percent of the poverty threshold; the African American rate of severe poverty is more than three times the white rate. Children and youth are especially affected; while the national poverty rate for U.S. children is nearly 20 percent, almost 37 percent of African Americans 18 and younger live in poor families (U.S. Census Bureau, 1999b). There is considerable turnover in the poverty population. Most of the poor move out of poverty over time but are replaced by others. African Americans move in and out of poverty, but their periods of poverty tend to last longer, making African Americans more likely than whites to suffer from long-term poverty (O'Hare, 1996).

African American families fall well below white families on an important measure of aggregate financial resources: total wealth. Net worth, the value of assets minus liabilities, is a useful indicator. The median net worth of whites is about 10 times that of blacks (U.S. Census Bureau, 1999a). This wide disparity reflects limited African American family assets, lower rates of home ownership, limited savings, and few investments (O'Hare et al., 1991). Because most are descendants of deeply impoverished rural agricultural workers, many contemporary African Americans can expect to borrow only modest sums from relatives and can expect only small inheritances. Most African Americans have little financial cushion to absorb the impact of the social, legal, or health-related adversity that often accompanies mental illness.

African American poverty is associated with family structure. Despite historical patterns to the contrary and a slight reduction in recent years, African American children in particular, are especially likely to live in single-parent, mother-only families. This pattern reflects relatively low and declining marriage rates; the number of never-married African American adults almost equals the number of those who are married. Taking cohabitation into account reduces, but does not eliminate differences in the domestic partnership rates of African Americans versus other groups (Statistical Abstract of the United States, 1999).

The disparity in poverty rates affects older adults as well. Older African Americans are almost three times as likely as whites to be poor. The poverty rate among single African American women living alone or with non-relatives is very high (Ruiz, 1995). Older African American women are far more numerous than older African American men because of different mortality rates.

While many African Americans live in poverty, many others have joined the middle class. Between 1967 and 1997, African Americans benefited from a 31 per-cent boost in their real median household income, a raise that contrasts with an 18 percent increase for whites (U.S. Census Bureau, 1998). Nearly a quarter of all African Americans had incomes greater than $50,000 in 1997, and the median income of African Americans living in married-couple households was 87 percent that of comparable whites. Almost 32 percent of African Americans lived in the suburbs (Thernstrom & Thernstrom, 1997).

Thus, in socioeconomic terms, the African American population has become polarized. Many African Americans are very poor and sometimes suffer an added burden from living in impoverished communities. African Americans, poor and nonpoor alike, possess relatively few financial assets. However, a large and increasing number of African Americans—more than once expected—have taken up well-earned positions in the middle class.

Physical Health Status

As a group, African Americans bear a disproportionate burden of health problems (DHHS, 2000a). Mortality rates until age 85 are higher for blacks than for whites (National Center for Health Statistics, 1996). Disparities in morbidity, too, are pronounced. The African American rate of:

• diabetes is more than three times that of whites;
  
• heart disease is more than 40 percent higher than that of whites;
  
• prostate cancer is more than double that of whites;
  
• HIV/AIDS is more than seven times that of whites (In the past decade, deaths due to HIV/AIDS have increased dramatically in the African American population, and this disease is now one of the top five causes of death for this group.);
  
• breast cancer is higher than it is for whites, even though African American women are more likely to receive mammography screening than are white women (DHHS, 2000a);
  
• infant mortality is twice that of whites.

The disparity in infant mortality rates, which are considered sensitive indicators of a population's health status, is particularly stark. It is not entirely accounted for by socioeconomic factors. Although infant mortality tends to decrease with maternal education, the most educated black women have infant mortality rates that exceed those of the least educated white women (DHHS, 1998).

High rates of African American HIV/AIDS pose special challenges related to mental health. HIV infection can lead to mental impairment, from minor cognitive disorder to full-blown dementia, as well as precipitate the onset of mood disorders or psychosis. Opportunistic infections, use of psychoactive substances associated with HIV infection, and adverse effects from treatment can gravely compromise mental functioning (McDaniel et al., 1997).

Disparities in access to appropriate health care partially explain the differences in health status. In 1996, about 76 percent of whites had an office-based usual point of care, which facilitates preventive and primary care treatment. This compared to only 64 percent of African Americans (Kass et al., 1999). Only 10 percent of African Americans, versus 12 percent of other Americans, made a visit to an outpatient physician in 1997; African Americans made 26 percent fewer annual visits than whites. African Americans are especially likely to obtain health care from hospital outpatient and emergency departments. In 1997, African Americans made about 22 percent of emergency department visits (U.S. Census Bureau, 1999b). As will be shown in the next section, the pattern of mental health treatment for African Americans is characterized by low rates of out-patient care and high rates of emergency care.