CHAPTER 3

Mental Health Care for African Americans

The Need for Mental Health Care

Historical and Sociocultural Factors that Relate to Mental Health

Historical adversity, which included slavery, sharecrop-ping, and race-based exclusion from health, educational, social, and economic resources, translates into the socioeconomic disparities experienced by African Americans today. Socioeconomic status, in turn, is linked to mental health: Poor mental health is more common among those who are impoverished than among those who are more affluent (Chapter 2). Also related to socioeconomic status is the increased likelihood of African Americans becoming members of high-need populations, such as people who are homeless, incarcerated, or have substance abuse problems, and children who come to the attention of child welfare authorities and are placed in foster care. Members of these groups face special circumstances not fully explained by socioeconomic differences, however.

Racism is another aspect of the historical legacy of African Americans. Negative stereotypes and rejecting attitudes have decreased, but continue to occur with measurable, adverse consequences for the mental health of African Americans (Clark et al., 1999). Historical and contemporary negative treatment have led to mistrust of authorities, many of whom are not seen as having the best interests of African Americans in mind.

The overrepresentation of African Americans in the South, especially in impoverished rural areas, is another result of history. Hardship in these communities is notable, and a limited safety net provides relatively few services to address high levels of mental health need (Fox et al., 1995).

Key Issues for Understanding the Research

When seeking to explain differences between African Americans and whites, it is important that researchers first consider the impact of black-white demographic and socioeconomic differences. This is because disparities found in research sometimes are attributable to differences in poverty and marriage rates, regional distribution, and other population characteristics. However, investigators often continue to observe black-white differences after controlling for differences in social status and demographics and must look elsewhere to explain their findings. One of many possible explanations is racial bias: African Americans might, under the circumstances being investigated, be victims of adverse treatment because they are black.

Researchers must conceive and evaluate other explanations also. Differences in access to insurance and other mechanisms to defray costs, in levels of illness or pat-terns of symptom expression, in health-risk behaviors, and in beliefs, preferences, and help-seeking traditions can also explain disparities. Citing a large-scale study of Medicare beneficiaries (McBean & Gornick, 1994), Williams (1998) reported numerous black-white disparities in health care and mortality. The findings were consistent with the presence of race-based discrimination, but other possibilities were also noted: "A greater percentage of black Medicare beneficiaries made out-of-pocket payments;" "There may be higher levels of severity of illness among black patients;" "Blacks may be more likely than whites to refuse procedures recommended by their physicians;" and "Whites may be more aggressive in pursuing medical care" (p. 312).

Survey researchers face challenges when they attempt to generalize findings from household samples to the larger African American population. Because of African American overrepresentation in high-need populations, community surveys that do not include persons living in jails, shelters, foster care, or other institutional settings are likely to undercount the number of African Americans with mental illness. Furthermore, mistrust causes large segments of the African American population not to participate in the U.S. Census, making accurate accounting difficult and having what are estimated to be dramatic effects on population-based rates of health and social problems (Williams & Jackson, 2000).

The legitimacy accorded assessment procedures widely used to measure mental illness and mental health, when they are applied to African American and other minority groups, is sometimes questioned (Snowden, 1996). If African Americans do not disclose symptoms as readily as other groups, for example, or if they present their symptoms in a distinctive manner, then attempts to accurately assess African American mental illness will suffer. For many procedures, neither validity nor lack of validity among African Americans has been demonstrated; the issue has not yet been addressed. Variation in reliability and validity can be and should be assessed (Chow et al., in press).

Mental Disorders

Adults

The Epidemiologic Catchment Area study (ECA) of the 1980s sampled residents of Baltimore, St. Louis, Durham-Piedmont, Los Angeles, and New Haven and assessed samples from both the community at large and institutions such as mental hospitals, jails, residential drug or alcohol treatment facilities, and nursing homes (Robins & Regier, 1991). In total, it included 4,638 African Americans, 12,944 whites, and 1,600 Hispanics. A more recent study, the National Comorbidity Survey (NCS), included a representative sample of persons living in the community that included 666 African Americans, 4,498 whites, and 713 additional U.S. residents (Kessler et al., 1994). Participants of both studies reported whether or not they had experienced symptoms of frequently diagnosed mental disorders in the past month, the past year, or at any time during their lives.

Results for certain disorders are presented in Table 3-1. After taking into account demographic differences between African Americans and whites, the ECA found that African Americans were less likely to be depressed and more likely to suffer from phobia than were whites (Zhang & Snowden, 1999). The NCS findings also indicate that African Americans were less likely than whites to suffer from major depression.

The studies revealed gender differences in rates of mental illness. Prevalence rates of depression, anxiety disorder, and phobia were higher among African American women than African American men. These differentials paralleled those found for white women and men.

In light of the findings, whether African Americans differ from whites in rate of mental illness cannot be answered simply. On the ECA, African Americans had higher levels of any lifetime or current disorder than whites. This was true both over the respondent's lifetime (Robins & Regier, 1991) and over the past month (Regier et. al., 1993). Taking into account differences in age, gender, marital status, and socioeconomic status, however, the black-white difference was eliminated. From the ECA then, it appears that African Americans in the community suffer from higher rates of mental illness than whites, but that the difference is explained by differences in demographic composition of the groups and in their social positions.

Evidence from the NCS, on the other hand, indicated that even without controlling for demographic and socioeconomic differences, African Americans living in the community had lower lifetime prevalence of mental illness than did white Americans living in the community (Kessler et al., 1996). This difference existed for all of the disorders assessed.

The results from these major epidemiological surveys appear to converge on at least one point: The rates of mental illness among African Americans are similiar to those of whites. Yet this judgment, too, is open to challenge because of African American overrepresentation in high-need populations. Persons who live, for example, in psychiatric hospitals, prisons, the inner city, and poor rural areas are not readily accessible to researchers who conduct household surveys. By counting members of these high-need groups, higher rates of mental illness among African Americans might be detected.

Table 3-1 shows results from the Epidemiologic Catchment Area study and the National Comorbidity Survey of mental health care for African Americans and white Americans. These figures are based on 12-month and lifetime prevalence rates of select mood and anxiety disorders.

Children and Youth

Mental health epidemiological research on children and youth provides little basis for conclusions about differences between African Americans and whites. Certain studies suggest higher rates of symptoms or of certain types of full-blown mental illness among African American children and youth than among whites: functional enuresis (Costello et al., 1996), obsessive-compulsive disorder (Valleni-Basile et al., 1996), symptoms of conduct disorder (Costello et al., 1988), and symptoms of depression (Roberts et al., 1997). Other studies have reported no differences between rates for blacks and whites (Siegel et al., 1998). Underlying patterns are masked by differences in the regions from which the samples were drawn, in the age of respondents, in assessment methods, and in other methodological considerations.

A study discussed in the Surgeon General's report on mental health (DHHS, 1999b) included an assessment of how much mental health care children in four geographic regions received. Children were identified as having unmet need if they were impaired because of mental illness and had had no mental health care in the preceding six months; African American children and youth were more likely to have unmet need than were white children and youth (Shaffer et al., 1996).

Box 3-1: A Child's Grief

John (age 10)
A 10-year-old African American male, "John," suffered from declining grades. Formerly a B and C student, he now received Ds. His mother could not explain his drop in academic achievement. John was unable to concentrate on homework and was sick to his stomach when studying. When questioned, John said that his father, now deceased, had formerly helped him carry out his assignments.

John told this story of his father's death: He and his father had been entering an elevator. They came upon two men arguing; one drew a gun and began to shoot. John's father, an innocent bystander, was shot in the stomach. He died on the moving elevator. The shooting and death produced a nauseating smell; John became sick and threw up.

Studying reminded John of his father's death and triggered nausea. This recognition helped to guide treatment. The focus was on providing a supportive relationship in which John could grieve his father's death. Overwhelmed, his mother had been unable to tolerate John's grief. Over time, John was able to transform his remorse into academic effort as a memo-rial to his father. His grades gradually improved. (Bell, 1997).

Older Adults

Little is known about rates of mental disorders among older African Americans. Older African American ECA respondents exhibited higher rates of cognitive impairment than did their counterparts from other groups. The rate of severe cognitive impairment continued to be higher for African Americans even after the researchers con-trolled for differences in demographic factors and socioeconomic status. Cognitive impairment is strongly related to education; simple measures may fail to assess fully the long-term impact of excluding African Americans from good schools.

Even less is known about the mental health of older African Americans whose physical health is poor. It appears that many living in nursing homes need psychiatric care (Class et al., 1996). In addition, 27 percent of older African Americans living in public housing needed mental health treatment (Black et al., 1997).

Several studies have examined rates of depressive symptoms in older African Americans living in the community. Three of the more rigorous research efforts reported few differences in depressive symptoms between African Americans and whites (Husaini, 1997, Blazer et al., 1998; Gallo et al., 1998). As with older whites, elevated symptoms of depression in African Americans have been related to health problems (Okwumabua et al., 1997; Mui & Burnette, 1994).

Mental Health Problems

Symptoms

Sometimes symptoms are considered not as markers of an underlying mental disorder but as mental health problems in their own right. Although much remains to be learned about symptom distress, it can pose significant problems. Symptoms of depression have been associated with considerable impairment in the performance of day-to-day tasks of living, comparable to that associated with common medical conditions (Wells et al., 1989). Among African Americans especially, symptoms of depression are associated with increased risk of hypertension (Pickering, 2000).

Before the advent of the epidemiological studies discussed above, parallel studies addressed symptoms of depression. Vega and Rumbaut (1991) conducted a comprehensive review of the research focusing on African American-white comparisons. Sometimes African Americans reported more distress than did whites, but investigators were often able to attribute the differences to socioeconomic and demographic differences (Neighbors, 1984).

Somatization

Somatization is an idiom of distress in which troubled persons report symptoms of physical illness that cannot be explained in medical terms. In some people, somatization is thought to mask psychiatric symptom distress or full-blown mental illness; somatic symptoms may be a more acceptable way of expressing suffering than psychiatric symptoms. Severe forms of somatization, which qualify as a disorder, are relatively rare; less severe forms are more common.

Somatization is not confined to African Americans, but somatic symptoms are more common among African Americans (15%) than among white Americans (9%) (Robins & Regier, 1991). Milder somatic symptoms, too, are expressed more often in African American communities (Heurtin-Roberts et al., 1997).

Culture-Bound Syndromes

Some distress idioms are more confined to particular racial and ethnic groups. Several are characterized in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM–IV; American Psychiatric Association, 1994), in an Appendix devoted to culture-bound syndromes. One is isolated sleep paralysis, a state experienced while awaking or falling asleep and characterized by an inability to move (Bell et al., 1984, 1986). Another such syndrome, a sudden collapse sometimes preceded by dizziness, is known as falling out. (See DSM–IV, 1994, Appendix I, "Outline for Cultural Formulation" and "Glossary of Culture-Bound Syndromes," p. 846.) How widely these syndromes occur among African Americans is unknown.

These syndromes are examples of what anthropologists describe as a rich indigenous tradition of ways for African Americans to express psychiatric distress and other forms of emotion (Snow, 1993). Researchers have demonstrated that the symptoms reported in anthropological literature resemble those of certain established mental disorders, and that they are linked among African Americans to a tendency to seek assistance (Snowden, 1999a).

Suicide

Because most people who commit suicide have a mental disorder (DHHS, 1999b), suicide rates indicate potential need for mental health care. Official statistics indicate that whites are nearly twice as likely as African Americans to commit suicide (National Center for Health Statistics, 1996).

Suicide among African Americans has attracted significant scholarly interest (Baker, 1990; Gibbs & Hines, 1989; Griffith & Bell, 1989). Attempts to explain the disparity between African Americans and whites have brought to light several qualifying considerations. It has been noted that much of the difference is attributable to very high rates of suicide among older white males. When looking at other age groups, "the risk of suicide among young African American men is comparable to that of young white men" (Joe & Kaplan, 2001). Moreover, the disparity has shrunk appreciably over time (Griffith & Bell, 1989; Baker, 1990). The increasing convergence is associated with striking increases in suicide rates among African American youth. Between 1980 and 1995, for example, the suicide rate among African Americans ages 10 to 14 increased 233 percent; the suicide rate for comparable whites increased 120 percent (Centers for Disease Control and Prevention [CDC], 1998).

A coroner judges whether someone has died by suicide. The accuracy of suicide determinations, especially in the case of African Americans, has also been called into question (Phillips & Ruth, 1993). Mohler and Earls (2001) notably reduced the gap in suicide rates between African American and white youths and young adults after correcting for attribution to other causes.

High-Need Populations

Owing to a long history of oppression and the cumulative impact of economic hardship, African Americans are significantly overrepresented in the most vulnerable segments of the population. More African Americans than whites or members of other racial and ethnic minority groups are homeless, incarcerated, or are children in foster care or otherwise supervised by the child welfare system. African Americans are especially likely to be exposed to violence-related trauma, as were the large number of African American soldiers assigned to war zones in Vietnam. Exposure to trauma leads to increased vulnerability to mental disorders (Kessler et al., 1994).

Individuals Who Are Homeless

African Americans make up a large part of the homeless population. One attempt to consolidate the best scientific estimates reported that 44 percent of the people who are homeless were African American (Jencks, 1994). Other estimates concur, concluding that the African American proportion is no lower than 40 percent (Barrett et al., 1992; U.S. Conference of Mayors, 1996). Proportionally, 3.5 times as many African Americans as whites are homeless. This overrepresentation includes many African American women, children, and youth (Cauce et al., 1994; McCaskill et al., 1998).

People who are homeless suffer from mental illnesses at disturbingly high rates. The most serious disorders are the most common: schizophrenia (11 to 13% of the homeless versus 1% of the general population) and mood disorders (22 to 30% of homeless versus 8% of the general population) (Koegel et al., 1988; Vernez et al., 1988; Breakey et al., 1989). Homeless and runaway youth also suffer from mental disorders at high rates (Feitel et al., 1992; Mundy et al., 1989; McCaskill et al., 1998).

Individuals Who Are Incarcerated

Nearly half of all prisoners in State and Federal jurisdictions are African American (Bureau of Justice Statistics, 1999), as are nearly 40 percent of juveniles in legal custody (Bureau of Justice Statistics, 1998; Bureau of Justice Statistics, 1999). African Americans are also overrepresented in local jails (Bureau of Justice Statistics, 1999).

African American jail inmates and prisoners have somewhat lower rates of mental illness than comparable white American populations, but African American and white differences are overshadowed by the high rates of mental illness for incarcerated persons in general (Teplin,1999; Teplin et al., 1996). A study conducted on women entering prison in North Carolina (Jordan et al., 1996) is illustrative. Investigators found that while lifetime rates of mental disorders among African American were slightly lower than those for whites, rates for both incarcerated groups typically were eight times greater than rates observed among African American and white American community residents. Incarcerated African Americans with mental illnesses are less likely than whites to receive mental health care (Bureau of Justice Statistics, 1998)

Children in Foster Care and the Child Welfare System

African American children make up about 45 percent of the children in public foster care and more than half of all children waiting to be adopted (DHHS, 1999a). Children come to the attention of child welfare authorities because they are suspected victims of abuse or neglect. Often they are removed from their homes and placed elsewhere—and then again placed elsewhere if an initial placement cannot be continued. These conditions carry a high risk of mental illness, as confirmed in epidemiological research. After investigating a large representative sample, Garland, and colleagues (1998) reported that around 42 percent of children and youth in child welfare programs met DSM-IV criteria for a mental disorder.

Individuals Exposed to Violence

Blacks of all ages are more likely to be the victims of serious violent crime than are whites (Griffith & Bell, 1989; Jenkins et al., 1989; Gladstein et al., 1992; Bureau of Justice Statistics, 1997; Jenkins & Bell, 1997). In one area, a community survey revealed that "nonwhites," many of whom were African American, were not only at greater risk of being victims of physical violence, but also at greater risk of knowing someone who had suffered violence (Breslau et al., 1998). The greater risk could not be attributed to socioeconomic differences or differences in area of residence.

The link between violence and psychiatric symptoms and illness is clear (Fitzpatrick & Boldizar, 1993; Breslau et. al, 1998; Schwab-Stone et al., 1999). One investigator reported that over one-fourth of African American youth who had been exposed to violence had symptoms severe enough to warrant a diagnosis of PTSD (Fitzpatrick & Boldizar, 1993).

Box 3-2: Fragmentation in the Foster Care System

Michael (age 17)
A 17-year-old African American male in foster care, "Michael," was referred for mental health care. He was described as "hostile"; he had recently dropped out of school.

Michael was surly and irritable initially, but ultimately began to cry. Eventually he spoke about his past.

His father lost his job when Michael was 9 and was unable to support Michael, his mother, and his three siblings. In desperation, Michael's father began to sell drugs. Michael's mother came to use the drugs being sold by his father. She became unable to care for her four children, resulting in their placement in foster care.

Michael reported living in five foster homes; lack of continuity undermined his educational success. He had seen none of his siblings for some time and knew nothing of their whereabouts or of his parents' well-being. He revealed that he had suffered crying spells for over a year (Bell, 1997).

Vietnam War Veterans

Although 10 percent of U.S. soldiers in Vietnam were black and 85 percent were white, more black (21%) than white (14%) veterans suffer from PTSD (Kulka et al., 1990). Investigators attribute this difference to the greater exposure of blacks to war-zone trauma, which increases risk not only for PTSD but also for many health-related and psychosocial adversities (Fairbank et al., 2001). African American and white veterans used Veterans' Administration (VA) mental health care equally, but African Americans proved less likely to use supplemental care outside the VA system (Rosenheck & Fontana, 1994).