Steps to Promoting Equity in Behavioral Health

In June 2020, amid a deadly pandemic that disproportionately impacted Black, Hispanic, and Asian populations, and protests across the US in response to the police killings of George Floyd, Breonna Taylor, and many others, a number of cities declared racism a health crisis.

Their voices were joined by healthcare leaders and organizations that have since called for an end to health inequity and acknowledged that systemic racism has a negative impact on the health of their patients. For example, one 36-hospital coalition outlined a commitment to partner with community groups, improve access to care, and eliminate racial biases that contribute to health disparities. Additionally, the American Medical Association (AMA), Centers for Disease Control and Prevention (CDC), and US Department of Health & Human Services (HHS) have recognized racism as an urgent threat to public health, with the AMA calling for partnerships to dismantle discriminatory policies in healthcare and HHS declaring “racism as a serious public health threat that affects our mental and physical well-being.”

That threat has persisted in 2021, with Asian Americans being deemed as the “source” of the coronavirus and subjected to harassment, hate speech, and physical violence—the most conspicuous example being the Atlanta shooting of six women of Asian descent this past March.

Many health systems are looking for ways to build strategies that address the long-standing inequities that have put people of color at greater risk of poor health outcomes. To succeed in promoting health equity, decision-makers need to pay as much attention to the gaps in behavioral health as they do to physical health.

Behavioral Health’s Equity Challenges

In many Black, Hispanic, Asian American, and American Indian/Alaska Native communities, behavioral health needs are high; access to appropriate, high-quality care is often lacking; and treatment variation exists. ^[1] Additionally, Blacks and Asian Americans are more likely than Whites to delay or fail to seek mental health treatment.

There continues to be a treatment gap based on race for certain behavioral health services. For example, depressive disorder treatment is either not sought out or is not adequate to address the specific needs of Latino, Asian, and African American communities, relative to non-Latino whites. Even once treatment is started, such as alcohol and drug treatment, Blacks and Hispanics are 3.5 to 8.1 percentage points less likely than Whites to complete it.

Lastly, behavioral health needs for people of color may go underreported for a number of reasons (e.g., culture, stigma, access barriers); and in the case of the pandemic, the invisibility of certain groups (e.g., Asian Americans) from publicly reported health data creates difficulty in tracking diseases and other health needs of this population.^[2] Therefore, the data we have likely does not capture the full extent of need in these communities. For example, figures 1 and 2 shows some communities as having lower percentages of serious mental illness, attention-deficit disorder and serious emotional or behavioral difficulties; the actual rates may be much higher for Black, Asian, American Indian/Alaska Native, Hispanic, Native Hawaiian or Other Pacific Islanders.

Source: https://www.apa.org/pi/disability/resources/mental-health-disparities

Source: https://www.cdc.gov/nchs/data/hus/2019/012-508.pdf

Acknowledging Racism as a Root Cause

Health systems, in partnership with community organizations, have an opportunity to close the care gap and meet the behavioral health needs of communities where various levels of racism—systemic/structural, institutional, interpersonal, and internalized—have influenced mental health status and served as a barrier to care.

Source: Keith Lawrence, Terry Keleher. “Structural Racism,” Race and Public Policy Conference, 2004. https://drive.google.com/file/d/1niSBHRjR8pXJov_lW…

Many people of color are at increased risk of trauma that can lead to reduced behavioral health status, and many encounter discrimination and cultural barriers that limit their engagement with mental healthcare. Below are five key areas that decision-makers must consider in building a more equitable behavioral health.

• Violence-Related Trauma: Rates of gun violence, which can cause anxiety, depression, and PTSD, are nearly double for Blacks compared to Whites and Hispanics.
• Toxic Stress and Adverse Childhood Experiences (ACEs): ACEs—which are found in all communities and are extremely common in poor and underserved communities where Black, Hispanic, or multiracial people are more likely to live—can lead to a physiological toxic stress response and increase the risk of mental health conditions such as depression, PTSD, anxiety, sleep disorders, and suicide.
• Institutional Racism: Discriminatory practices have made it more difficult for Blacks and Hispanics to obtain care, including the ability to get an appointment and treatment for mental health issues.
• Historical Abuse and Mistrust: The Black community continues to mistrust the healthcare system due to a long history of misdiagnosis on top of outright medical abuse and neglect (including the infamous “Tuskegee Study of Untreated Syphilis in the Negro Male”). This mistrust contributes to higher rates of negative health outcomes.
• Cultural Barriers to Seeking Behavioral Health Services: Hispanic, Black, Asian American, American Indian/Alaska Native, and people of two or more races are underrepresented as providers in the behavioral healthcare system.^[3] For example, one study conducted by the American Psychological Association Center for Workforce studies found that while 12% of the US population is Black/African American, only 4% of the psychology workforce is Black/African American. This creates an uneasiness for Hispanics and Asians to proactively seek care because they may get a provider who knows little about their cultural values, backgrounds, traditions, or methods of healing. Additionally, in many Latino and Asian communities, strong perceptions of stigma or shame exist that prevent acknowledgment of mental health needs, thereby discouraging individuals from seeking external, professional help.^[4]

Building Health Equity into a Behavioral Health Strategy

Addressing these inequities starts with viewing behavioral health through the lens of health equity. In order for behavioral health programs and interventions to promote equity, decision-makers must commit to helping fix systemic discriminatory practices, address community needs previously overlooked, and take actions aligned with their organizations’ mission statements.

Decision-makers must ask questions that get to the root causes of racial inequities and ensure that programs do not exacerbate them. For example:

• How do we reach and support people who are vulnerable and have traditionally fallen through the cracks?
• Does our behavioral health strategy augment or ameliorate barriers caused by structural racism?
• Are we doing enough to provide culturally and linguistically competent services through a diverse workforce?

Figure 3 summarizes four practical steps that health systems and behavioral health providers can take to promote behavioral health equity.

Setting a Course to End Behavioral Health Inequity

As we begin recovering from the COVID‑19 pandemic and continue to strive for social justice, it becomes increasingly imperative that organizations make health equity a focal point of their behavioral health strategy. The data-driven and collaborative approach outlined above will guide health system leaders in applying a health equity lens to examine the current strategy for the future of behavioral health.

Published May 12, 2021