Behavioral health equity means that all people, regardless of their sociodemographic background, have access to affordable, high quality, comprehensive behavioral healthcare that meets their needs. In striving towards this goal, people with serious mental illness (SMI) must be considered. People with SMI are made especially vulnerable to negative clinical and social outcomes such as low treatment adherence and homelessness. These trends are exacerbated for people from racial and ethnic minority groups with SMI.
As payers and providers work towards fostering health equity in their organizations, understanding the nuances of treatment and outcomes for people from racial and ethnic minority groups with SMI will be essential. Reducing racial disparities in serious mental illness treatment will require forward-thinking solutions beyond traditional treatment.
Defining Serious Mental Illness (SMI)
The American Psychological Association defines SMI as “a mental, behavioral or emotional disorder resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities." According to the National Institute of Mental Health, those who experience disability due to SMI are among the most severe cases. SMI is typically inclusive of schizophrenia, major depressive disorder, and bipolar disorder along with a few other disorders.
The 2020 National Survey on Drug Use and Health administered by the Substance Abuse and Mental Health Services Administration (SAMHSA) showed that 14.2 million (5.6%) adults aged 18 or older had SMI. SMI was most prevalent among people who identify as belonging to 2 or more races (9.9%), equaling out to about 1.4 million adults. Of those with SMI, only 9.1 million (64.5%) received mental health treatment.
The vulnerabilities of living with SMI
People with SMI face amplified risks for premature death, hospitalizations, comorbid chronic conditions, and social determinants of health. Living with SMI can be especially challenging due to severity of symptoms, the long duration of conditions, and high utilization of healthcare services.
Racial disparities in mental healthcare for SMI
People from racial and ethnic minority groups are especially vulnerable to overdiagnosis and negative outcomes regarding SMI. A meta-analysis by Maura and Mamani (2017) highlighted different racial disparities that exist for people of color with SMI:
- Several studies showed that people from racial and ethnic minority groups were more likely to receive a schizophrenia diagnosis that White people. These findings are especially pronounced for Black Americans.
- Black Americans with SMI are more likely to be hospitalized than any other racial group.
- People from racial and ethnic minority groups have lower utilization of outpatient treatment compared to White individuals.
- People from racial and ethnic minority groups receive higher doses of antipsychotics and often are prescribed second generation antipsychotics.
- Treatment attrition rates are much higher for people from racial and ethnic minority groups than White individuals.
- People from racial and ethnic minority groups are more vulnerable to negative treatment outcomes such as reduced symptom improvement, less follow-ups after diagnosis, and poor occupational and social functioning.
These findings have been replicated in recent years. Olbert et al (2018) found that Black Americans were 2.4x more likely to be diagnosed with schizophrenia than White Americans. Additionally, in an analysis of the 2019 National Health Interview Survey (NHIS), Kaiser Family Foundation found that almost one third of individuals experiencing severe anxiety and/or depression did not receive treatment. Of those with moderate to severe anxiety and/or depression, Black men were the least likely to receive treatment compared to other racial groups.
Changing the narrative
People of color with SMI must be included in the conversation around equitable mental healthcare. Oftentimes there is extra stigma attached to SMI due to cultural beliefs and negative portrayals in media. Changing the narratives around SMI is critical to ensuring people seek help when they need it. There are additional burdens for people of color seeking treatment such as the lack of clinicians of color, microaggressions during treatment, and cultural mistrust of providers.
Filling the gaps in care for people of color with SMI will require actions from payers, providers, and community organizations to address care access, quality, outcomes, and social determinants of health.
Mental Healthcare coverage, access, and utilization
Insurance coverage is one barrier to appropriate care for people of color. According to the 2021 NHIS, there were more uninsured racial/ethnic minorities than White Americans. Additionally, there were greater proportions of racial/ethnic minorities using public insurance (Medicare, Medicaid, CHIP, military plan, other state sponsored insurance plan) than White Americans.
People with SMI typically qualify for Medicaid through disability status. However, a recent study found that people with SMI experience large rates of Medicaid disruptions that lead to increased utilization of acute inpatient services (Wilson et al, 2021). Further, comorbid substance use disorder increased the likelihood of Medicaid disruptions. While previous research has suggested that the Affordable Care Act (ACA) has decreased Medicaid disruptions, these results have not been found for people with SMI (Goldman & Sommers, 2020).
In response to the pressing needs for people with SMI, CMS has implemented section 1115 demonstrations for people with substance use disorders, serious mental illness, and serious emotional disturbance. Demonstrations specific to SMI are happening in seven different states as of May 2021. These demonstrations provide funding for states reduce emergency care utilization and readmissions for people with SMI while improving crisis services, community health services, and care coordination. Of note, these demonstrations cover costs of treatment at institutions of mental disease (IMDs), which are typically excluded under Medicaid for people 21-65 years old.
The mental and behavioral healthcare delivery journey
Research has demonstrated the importance of early intervention for SMI conditions. As such, health equity for people with SMI must be centered during the first initiation of care. Integrated, coordinated, and person-centered care is needed to prevent negative outcomes for people of color with SMI.
Culturally informed treatment for SMI
One of the main solutions proposed to address health inequities for people of color with SMI is culturally informed treatment. Culturally informed treatment can be defined as new or adjusted treatments that are designed to take into account a patient's cultural background (race, ethnicity, language, gender, sexual orientation, etc.). Several researchers are testing the effectiveness of culturally adapted gold-standard treatments such as culturally tailored cognitive behavioral therapy (CBT).
Aspects of culturally informed care for people with SMI could include providing treatment and psychoeducation in the patient's preferred language, providing services in non-psychiatric settings, incorporating peer support groups, assessment of social determinants of health, and connection to community resources.
Acknowledging the importance of culture in the treatment has the potential to strengthen provider-patient relationships, boost patient experience, and reduce negative outcomes for SMI care such as treatment attrition and low medication adherence.
Reducing medical mistrust
Another key factor at play that prevents people from racial and ethnic minority groups from getting appropriate care for SMI is medical mistrust. In an article titled Medical Mistrust: One Obstacle On The Path To Health Equity, Franzi Rokoske discusses the how medical mistrust is particularly prevalent among people from racial and ethnic minority groups, amplifying negative treatment outcomes.
Historical medical mistreatment of many racial and ethnic minority groups as well as current trends of overdiagnosis and poor outcomes creates hesitation for people of color with SMI to seek treatment. Thus, medical mistrust has the ability to feed the negative trends we see in outcomes for people of color with SMI.
Overcoming medical mistrust requires intentional work from providers to initiate conversations about sociocultural factors that affect treatment. Aggarwal et al (2016) conducted interviews to examine the role of cultural competence among providers, patients, and administrators in the psychiatric department of a community hospital. Patients endorsed the value of providers sharing aspects of their own identity to foster trust and comfort during treatment. Other important strategies for culturally competent treatment included clinicians' ability to thoroughly explain treatment options to patients and respecting patient's wishes. While discussing the role of respecting patient's wishes, one patient was quoted saying "Sometimes the doctors don't listen to you. They should take a few minutes to listen to you before they make a decision. Sometimes they—I had doctors who were judgmental."
Community-based treatment options
While psychotherapy and medication are gold standard treatments for SMI, community-based treatment options can serve as a supplement to traditional treatments to add extra support for patients.
Two examples of evidence-based community treatments for SMI include Assertive Community Treatment (ACT) and Clubhouses for psychosocial rehabilitation. By contrast to traditional treatment, ACT and Clubhouses go above and beyond to meet the clinical and social needs of members. Staff work with members to address social needs such as housing, employment, nutrition, and socialization while also providing assistance with medical tasks such as making appointments and filling prescriptions. Both services are completely voluntary and continuous for as long as the member needs support.
There are slight differences in ACT and the Clubhouse model. ACT relies on an interdisciplinary team consisting of mental and physical health professionals to provide the member with social and clinical supports. By contrast, Clubhouses provide similar supports but have more of an emphasis on autonomy of the member and social relationships. Members interact with one another to uphold the daily operations of the Clubhouse. This is accomplished through a work ordered day where members chose daily operational activities they want to participate in. Additionally, Clubhouses are more cost-effective than ACT.
Relevant healthcare policy for community-based treatments
Community-based treatments should be incorporated into treatment plans and insurance benefits more often. While most state Medicaid plans cover ACT as an optional rehab service, in 2015 only 17 states and the District of Columbia covered Clubhouses (psychosocial rehabilitation). Of note, traditional Medicare does not cover psychosocial rehabilitation or ACT. Coverage of ACT and psychosocial rehabilitation varies by private payers.
One state that is working to increase coverage for psychosocial rehabilitation is New York. In collaboration with Fountain House, Representative Richie Torres recently introduced the Certified Community Behavioral Health Clinic Expansion Act of 2022 on December 12, 2022. If passed, this bill would require hundreds of community behavioral health clinics in the US to add psychosocial rehabilitation to their service offerings.
Increasing community supports for people with SMI is an important aspect of reducing health disparities within SMI. Community-based treatments for people with SMI have the potential to reduce hospitalizations, improve treatment outcomes, and enhance quality of life. These positive outcomes are the result of extra support from trained professionals and peers that helps members keep up with their treatment regimens, create meaningful relationships, and learn new skills.
Moving towards equitable care for people with SMI
Given the high prevalence of health disparities within SMI, stakeholders across the healthcare ecosystem must work together to address gaps in care. Specific attention is warranted for people from racial and ethnic minority groups with SMI due to high rates of diagnoses and negative outcomes.
Several resources exist for providers, payers, and the general public to learn about SMI. Below are some resources from reputable healthcare organizations:
- APA and SAMHSA's SMI Advisor
- APA's guidance for providers treating racial and ethnic minorities with SMI
- SAMHSA's resource library on SMI
- US Department of Veterans Affair's resources on SMI
- AHRQ's report on disparities within serious mental illness
Addressing inequities in behavioral healthcare
Equitable mental healthcare starts with comprehensive strategies from payers and providers to help bridge disparities that exist for historically marginalized populations. RTI Health Advance has the expertise and real-world knowledge to guide healthcare organization on their journey to health equity. Learn more about RTI Health Advance's health equity consulting services.