Provided by David Satcher, M.D., Ph.D.
Surgeon General of the United States of America
Chapter 2
Overview of Cultural Diversity and Mental Health Services
African Americans
The prevalence of mental disorders is estimated to be higher among African
Americans than among whites (Regier et al., 1993a). This difference does not
appear to be due to intrinsic differences between the races; rather, it appears
to be due to socioeconomic differences. When socioeconomic factors are taken
into account, the prevalence difference disappears. That is, the socioeconomic
status-adjusted rates of mental disorder among African Americans turn out to be
the same as those of whites. In other words, it is the lower socioeconomic
status of African Americans that places them at higher risk for mental disorders
(Regier et al., 1993a).
African Americans are underrepresented in some outpatient treatment populations,
but overrepresented in public inpatient psychiatric care in relation to whites
(Snowden & Cheung, 1990; Snowden, in press-b). Their underrepresentation in
outpatient treatment varies according to setting, type of provider, and source
of payment. The racial gap between African Americans and whites in utilization
is smallest, if not nonexistent, in community-based programs and in treatment
financed by public sources, especially Medicaid (Snowden, 1998) and among older
people (Padgett et al., 1995). The underrepresentation is largest in privately
financed care, especially individual outpatient practice, paid for either by
fee-for-service arrangements or managed care. As a result, underrepresentation
in the outpatient setting occurs more among working and middle-class African
Americans, who are privately insured, than among the poor. This suggests that
socioeconomic standing alone cannot explain the problem of underutilization
(Snowden, 1998).
African Americans are, as noted above, overrepresented in inpatient psychiatric
care (Snowden, in press-b). Their rate of utilization of psychiatric inpatient
care is about double that of whites (Snowden & Cheung, 1990). This difference is
even higher than would be expected on the basis of prevalence estimates.
Overrepresentation is found in hospitals of all types except private psychiatric
hospitals.25 While difficult to explain definitively, the problem of
overrepresentation in psychiatric hospitals appears more rooted in poverty,
attitudes about seeking help, and a lack of community support than in clinician
bias in diagnosis and overt racism, which also have been implicated (Snowden, in
press-b). This line of reasoning posits that poverty, disinclination to seek
help, and lack of health and mental health services deemed appropriate, and
responsive, as well as community support, are major contributors to delays by
African Americans in seeking treatment until symptoms become so severe that they
warrant inpatient care.
Finally, African Americans are more likely than whites to use the emergency room
for mental health problems (Snowden, in press-a). Their overreliance on
emergency care for mental health problems is an extension of their overreliance
on emergency care for other health problems. The practice of using the emergency
room for routine care is generally attributed to a lack of health care providers
in the community willing to offer routine treatment to people without insurance
(Snowden, in press-a).
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