Black Mental Health: Black Americans’ Behavioral Health Needs Outpace Access To Care

Accessing behavioral healthcare—seldom simple under the best of circumstances—can be especially difficult for people from racial minority groups. Long-standing economic and healthcare disparities, combined with a cultural stigma, often impose significant barriers to Black mental health care.  

The need for mental health services for the Black community, however, is acute and growing. Pandemic-fueled depression and anxiety among Black people have exacerbated long-term behavioral disorders associated with the psychic burden of historical oppression, violence, poverty, and racism. 

These disorders can contribute to costly and debilitating physical illnesses, ranging from drug addiction and liver disease to diabetes and heart problems. It is therefore essential that payers, providers, employer groups, and others work collaboratively to improve behavioral health access for Black people and other historically marginalized populations. 

Black mental health disparity is fueling a behavioral health epidemic 

Black Americans make up about 13% of the U.S. population, or nearly 46 million people. About 16%, or roughly 7 million individuals, report having experienced a mental illness in the past year. Although that percentage is equivalent to the rate of incidence among White people, Black people are more likely to experience chronic and persistent—as opposed to episodic—mental illness. 

As the pandemic began to take hold in 2020, behavioral health visits for all races increased by 17% from the previous year. Over the same time period, mental health-related emergency department visits for adolescents jumped by 31%. 

Driving long-term behavioral health problems among Black people are the cumulative and lingering adversities associated with the legacy of slavery, notably race-based exclusion from health, educational, social, and economic resources. The resulting impacts on Black mental health and communities at large are diffuse and far-reaching. Those who are impoverished, homeless, formerly incarcerated, or have substance use problems are at higher risk for poor mental health. Consider: 

• Black people living below the poverty line are twice as likely to report serious psychological distress.
• Black teenagers are more likely to attempt suicide than white teenagers (9.8% versus 6.1%).
• Black people are nearly twice as likely as White people to be diagnosed with schizophrenia. 
• Over 25% of Black youth exposed to violence have proven to be at high risk for post-traumatic stress disorder (PTSD).
• 40% of youth in the criminal justice system and 45% of children in foster care are Black. 

Dysfunctional system made worse by cultural ambivalence  

Despite the growing need, only one in three Black adults that require mental healthcare receive it, and just 10% of Black people over the age 12 with a substance use disorder get treatment. Access to proper mental and behavioral healthcare for the Black community is constrained by many of the same structural inequities and social determinants that limit Black Americans’ ability to receive high-quality, physical care.

It doesn’t help that the vast majority of psychiatric and psychological research, education, training, and delivery has been grounded from the outset in scientific racism and a Caucasian-centric worldview. In a 2021 apology for its support of systemic racism in psychiatry, the American Psychiatric Association acknowledged that psychological and behavioral data has long been used to “justify social policies that harmed people of color, including racial segregation, diminished educational opportunities, restrictions on immigration, institutionalization, forced sterilization, and anti-miscegenation laws.”

Other factors that reduce access to mental health care for the Black community

Aggravating mistrust of psychiatry in the black community and further limiting access is the scarcity of culturally competent Black psychologists (2% of the nationwide total). 

Other determinants that reduce availability of mental health care:  

• About 27% of Black Americans live below the poverty line, compared 10.8% of Whites.
• 11.5% of Black people are uninsured, versus 7.5% of White people.
• Black people are more than 7 times as likely to live in high-poverty neighborhoods with limited or no access to mental health services. 
• Black people are less likely to receive guideline-consistent care and less likely to be included in research. They’re also more likely to use more costly emergency room care for situational interventions, as opposed to mental health specialists offering longer-term support. 

Black Mental health stigma creates barriers to care

Contributing to access difficulties is the stigma that many Americans continue to associate with mental illness, a response that is especially pronounced in Black culture. One study found that nearly two-thirds of Black respondents believe a mental health condition is a sign of personal weakness. Research further shows that mild depression or anxiety would be considered “crazy” in some racial social circles, and that discussions about mental illness would not be considered appropriate, even among family members. 

Employer coverage and provider limitations promote Black mental health care disparities

Employers provide health coverage to about 50% of Americans. As such, they increasingly recognize the enormous costs associated with failing to address employees’ mental health issues. A 2015 peer-review study found that the total annual cost of depressive disorder was $210 billion, an increase of 153% since 2000. Roughly half the impact was attributed to absenteeism and productive costs, while half reflected treatment expense.  Costs also include the direct correlation between mental illness and serious medical conditions like diabetes, cancer, and coronary artery disease. What’s more, the inverse is also true: Patients experiencing chronic illness face an enhanced risk for depression and other behavioral health issues. 

Despite passage of the 2008 Mental Health Parity and Addiction Equity Act requiring that behavioral health benefits be comparable to physical health coverage, mental health benefits continue to be costly and difficult to access for all races. A 2017 report found that an office visit with a therapist was five times more likely to be out-of-network than an office visit with a primary care practitioner. 

Clinician shortages intensify access difficulties. Data compiled in 2018 by the Kaiser Family Foundation determined the nation needs about 7,000 additional mental health clinicians to achieve appropriate behavioral health staffing levels. 

Improving mental and behavioral health care for the Black community - turning the ship 

In response to growing awareness of the major healthcare disparities people of color face, stakeholders have been working to reduce barriers to behavioral health for groups that historically have been economically and socially marginalized. The American Psychological Association, for example, has made a series of recommendations for improving health equity in mental health and substance use. These include: 

• Increase the availability of culturally and linguistically competent mental and behavioral health services available to people from racial and ethnic groups.
• Foster positive relationships and programs within racial and ethnic communities to increase awareness of mental health issues and prevent environmental factors that may put individuals at risk.
• Increase funding for behavioral health professionals.
• Develop programs based on empirical research that can help ensure equitable culturally informed, evidence-based strategies for population health.
• Advocate for local, state, and national funding agencies to incorporate culturally and linguistically competent guidelines into program proposals for racial and ethnic minority children, youth, and families. 

The National Council for Mental Wellbeing also has developed a toolkit stakeholders can use to help address racial inequalities that lead to mental health and substance use treatment disparities.

Primary and mental health care integration for Black patients

Strengthening integration between behavioral health and primary care is viewed as the gold standard for substantially improving both physical and mental health outcomes for all patients. For Black Americans, culturally informed, integrated care can help alter the perception of mental health conditions as being different or “other” than chronic health conditions like diabetes. Shifting the conversation to frame mental health conditions as being treatable chronic medical conditions can help reduce stigma and increase engagement in treatment.

One prominent primary care-behavioral health integration approach, known as the GATHER model, incorporates a behavioral health generalist capable of routinely working with patients of any age on any behavioral concern and who can educate both clinicians and patients with respect to patient psychosocial needs. 

Similarly, the Collaborative Care Model is a population health approach built around close collaboration between primary care and behavioral health providers and relies on evidence-based care and measurement-based treatment to deliver accountable care. 

For its part, the federal Substance Abuse and Mental Health Services Administration is working to reduce disparities in mental health and substance use disorders across a range of racial and ethnic populations by developing effective strategies around data, policy, quality, and workforce development. 

If you’d like to learn more about how your organization can begin to address behavioral health disparities, connect with one of our health equity consultants today.