Mental Health Inequities and Disparities among African American Adults in the United States: The Role of Race

Although the rate of mental illness among African Americans and Whites in the United Sates are similar, African Americans tend to have the worst mental health outcomes in the country. This is due to several inequities, particularly those associated with race such as discrimination, provider bias, stereotyping, weak socio-economic status, limited access to health insurance, poor quality mental health care, treatment gaps, culture, and stigma related to mental health care. Recognizing that the differences in mental health outcomes among minority populations in the United States is also driven by race and not just by brain chemistry, or environmental exposures, and developing strategies that target the issue of race, will not only lead to increased access to mental health services among African Americans, but will generally improve upon their mental health status. This article discusses mental health disparities among African Americans, the inequities that cause them, and strategies for addressing the disparities with a focus on race.

closely knit to inequities associated with one's race.
In the past two decades, the issue of mental health disparities has received increased attention in the US (Safran et al., 2009). Based on the 2001 Surgeon General's report on Mental Health, Culture, Race and Ethnicity, and based on the extent of mental health disparities among minority populations in the country, the US Institute of Medicine and the National Institutes of Health (NIH) put mental health disparities on their research agenda. Former President George W. Bush's President's New Freedom Commission on Mental Health launched in 2002, also sort to address disparities in mental health. As such, the Commission included the elimination of mental health disparities as one of its six goals for transforming the US mental health system.
Irrespective of these efforts, mental health disparities continue to exist and even more so among African American's (McGuire, 2008). At present, many African Americans experience striking mental health disparities when it comes to access and the utilization of mental health services compared to Whites. This population is less likely to receive needed care and is also more likely than Whites to delay or not seek mental health treatment at all. When African Americans do seek care, they are less likely than Whites to receive the best available treatments for their mental health issues (e.g., depression and anxiety) and are more likely than Whites to terminate treatment prematurely. As a result, African Americans experience unmet mental health needs and greater loss to their overall health and productivity. Given the fact that the US is a nation that draws strength from its cultural diversity, it is important that the mental health status of all, including that of African Americans, is given adequate attention, so this population too can realize its full mental health potential (Office of the Surgeon General, 2001).

Mental Illness Burden by Race
About 17 percent of the US population lives in a state of optimal mental health, and an estimated 26 percent lives with a mental health disorder in any given year (Reeves et al., 2011). African Americans have a disproportionately higher burden of disability resulting from mental disorders compared to other races. Even though the rate of depression is lower among African Americans (25 percent) compared to Whites (35 percent), this condition is more persistent among African Americans (Budhwani et al., 2015). In 2015, African Americans were 20 times more likely than Whites to report serious psychological distress and almost twice as likely to be diagnosed with schizophrenia. Results from three community mental disorder prevalence studies conducted in the US showed a higher incidence of schizophrenia diagnosis among African Americans than among Whites. Even though evidence suggests that clinicians over diagnose schizophrenia and under diagnose mood disorders in African Americans than among Whites with the same symptoms, African Americans tend to report lower risks of psychiatric disorders compared to their White counterparts (Neighbors et al., 2006). According to extant literature, African Americans experience higher rates of anxiety than other racial groups and are more likely than Whites to be diagnosed with post-traumatic stress disorder (PTSD). Regarding www.scholink.org/ojs/index.php/rhs Research in Health Science Vol. 5, No. 3, 2020 26 Published by SCHOLINK INC.
diagnosis-based need for mental health care among adults, 38 percent of Whites compared to 25 percent of African Americans receive treatment . This statistic is consistent with the US Institute of Medicine's (IOM) findings on operationalization of disparities based on need (Office of the Surgeon General, 2001).

Race and Mental Health Disparities
In the US, race is a determinant of several things (Morgan et al., 2017) including one's overall mental health status. The mental health disparities African Americans experience are due to a host of inequities associated with their race and manifest in the form of racism, discrimination, provider bias and stereotyping, poor quality care, low socioeconomic status, and inadequate access to health insurance.
Additional race-associated factors that negatively impact African American mental health outcomes are the distrust of the health care system, culture, the nature and role of the mental health workforce, and social stigma.

Racism and Discrimination
Referred to as the beliefs, attitudes, and practices of individuals or groups that denigrate others because of their phenotypic characteristics (skin color and facial features) or racial group affiliation, racism continues to negatively affect the mental and behavioral well-being of African Americans (Williams & Williams-Morris, 2000). Presenting in several forms, racism causes profound feelings of pain, harm, humiliation, despair, and social exclusion. Stemming from perceptions of White superiority to African Americans, racism in the US has not only promoted the unjust and prejudicial treatment of African Americans but has also excluded this population from access to much needed health, educational, social, and economic resources fundamental to their mental health. Tied in with racism is racial discrimination, which often ranges from individual overt demeaning daily treatment of African Americans (Krieger & Coakley, 1999), to actions that increase stress and exacerbate mental conditions.
Institutions and individuals perpetrate bias, racism, and discrimination against African Americans, intentionally or unintentionally.
Efforts to reduce racism and race-based discrimination in all spheres of life including health care settings in the US have been unsuccessful. In fact, studies show a persisting trend. In the US, bias, racism, and discrimination in mental health care settings manifest in the form of fewer diagnostic and treatment procedures for African Americans compared to Whites (Clark et al., 1999). In their study on racial discrimination and psychopathology among three ethnic minority groups in the US, Chou et al., found that African Americans experienced more instances of discrimination than Asians, Hispanics, and White Americans (Chou et al., 2012). Confirming this fact, Williams and Williams-Morris also found that African Americans who experienced the most racism were also more likely to have symptoms of PTSD. For most African Americans, racism is a source of chronic strain and psychological distress that results in "racial battle fatigue", which in turn creates anxiety and worry, hyper-vigilance, headaches, increased heart rate and blood pressure, and other physical and psychological symptoms.

Provider Bias and Stereotyping
Conscious and unconscious provider bias and stereotyping based on race have been found to be major sources of mental health inequities and disparities among African Americans in the US (Sheifer & Schulman, 2000). These behaviors negatively impact the diagnosis, treatment, prescription of medications, and referrals for African Americans with mental health disorders (Giles et al., 1995).
White mental health care providers harboring bias against African Americans believe that this population is less likely to comply with treatment than Whites, and thus, often put less effort in the mental health care they provide. This disparity in care may explain why African Americans have elevated levels of psychological distress, increased chronic psychiatric disorders, and frequently use emergency psychiatric services than Whites.
On the issue of stereotyping, a study on mental health found that young African Americans who behaved in similarly aggressive ways, as their White counterparts were often physically restrained.

Stereotyping African Americans as violent people, is what sometimes causes White mental health care
providers to use such measures in their treatment (Bond et al., 1988). An additional study on racial stereotyping and mental health care found that, White mental health therapists readily rated a videotape of an African American client with depression more negatively than they did a White patient with identical symptoms (Jenkins & Hall, 1991). Long held claims based on evidence further show that due to inherent racial bias and stereotyping, White mental health providers often misdiagnose African American patients with schizophrenia and under diagnose them for depression and anxiety (Borowsky et al., 2000).

Quality of Mental Health Care
Upon completion of their medical education, physicians in all fields of specialty take an oath to treat all patients well and equally. This is however not always the case in the US, as some populations receive better care than others. Generally, less than 50 percent of adults with mental health disorders in the US seek and receive treatment for their condition. While Whites who seek treatment are provided with the best of care, African American patients often receive poor quality care in a number of areas including not being involved in treatment decisions and provider provision of inadequate explanations of their mental health conditions (Borowsky et al., 2000). Corroborating this fact, Young et al found that unlike Whites, African Americans do not receive the best available treatments for conditions like depression and anxiety (Young et al., 2001), and are less likely to be offered evidence-based medication therapy or psychotherapy. Also confirming the issue of poor quality care, the US IOM and other organizations found substantial documented gaps in care for mental disorders among African Americans, particularly in the areas of quality diagnosis and follow-up care (Institute of Medicine, 2006).

Socioeconomic Status
Historical adversities including slavery, sharecropping, race-based exclusion from health, lack of access to educational, social and economic resources, as well as structured and institutional racism, have created socioeconomic disparities for African Americans. As is generally known, differences in socio-economic status (SES) have health consequences and are strong predictors of positive mental health outcomes. As revealed by the Epidemiologic Catchment Area Study (ECA), the largest population-based US study on specific psychiatric disorders among persons in and not in treatment, adults in the lowest quartile of SES (based on income, education and occupation) were almost three times more likely to have a psychiatric disorder than those in the highest quartile (Robins & Regier, 1991 As observed by Reiger et al. (1993), the mental health system in the US is not as effective as it could have been. This is because while it provides a range of services to patients, it fails to address the mental health needs of patients who have the least financial resources and who often tend to be the ones in most need -African Americans. Though reduced costs are supposed to increase access to mental health care, evidence on the ground suggests that this alone will not eliminate mental health disparities. The inequities founded on race such as racism, bias, and discrimination among others need to be addressed before the gaps in access to, and the utilization of mental health services between minorities and Whites, can be reduced and eventually eliminated.

Access to Health Insurance
There are great disparities in wealth among the racial and ethnic groups in the US. In 2010, the median wealth of African American families was $4,900 compared to a median wealth of $97,000 for Whites.
About 33 percent of African Americans were almost twice as likely as Whites (19 percent law, called for equal coverage for mental and non-mental health plans, but unfortunately the legislation did not require plans to include mental health coverage. With low income due to socio-economic disadvantage and health insurance bottlenecks around mental health care access, African Americans are unable to meet their mental health care needs (Sohn, 2016).

Distrust of the Health Care System
Many African Americans are hesitant to seek any form of medical care or to remain in an institution for treatment in the US due to their distrust of the health system and health care professionals. The distrust is due to the fear of being misdiagnosed or being inadequately treated like the African American men in the infamous Tuskegee Syphilis Study. It must be noted that the lack of trust is geared more towards health systems in general and not to mental health treatment facilities in particular (Carroll, 2016).
Highlighting African American distrust, a 1980 ECA study found that African Americans with major depression disorders were more likely not to seek mental health treatment owing to the fear of hospitalization and treatment. In their study, Sussman et al. (1987) also found that about 50 percent of African Americans compared to 20 percent of Whites, reported being afraid to seek mental health treatment. Based on a survey conducted by the Kaiser Foundation, 12 percent of African Americans compared to 1 percent of Whites felt a doctor or health care provider had judged them unfairly or treated them with disrespect because of their race or ethnic background (Brown et al., 1999) -further deepening any pre-existing distrust. Distrust of the health system by African Americans is a major issue that must be addressed.

Culture
Culture is a dynamic force that influences people's attitudes towards mental illness and determines whether they will seek out or respond to mental health care. Studies on African American beliefs around mental illness show a tendency of this population to downplay the condition. For many African Americans, mental illness is not a health issue, but a condition that will resolve on its own. According to Bailey et al. (2011) approximately 31 percent of African Americans believe that depression is not a health problem and about 63 percent see depression as personal weakness. As such, 30 percent of African Americans prefer to handle depression themselves, and 20 percent prefer to seek help from friends and family. These attitudes create disparities and have implications for psychological openness and decisions for mental health care. According to other literature, some African Americans prefer to turn to religion than to seek mental health care. In their 2008 study, Chatters et al. (2008) found that about 90 percent of African Americans reported that they used religious coping to address their mental health issues. Specifically, they relied on prayer, talking to a pastor, and developing a relationship with God as ways to handle their mental illness.

Mental Health Workforce
Given the fact that race is a determinant of higher educational opportunities in the US, it is not

Social Stigma
Stigma is the negative perception of an individual or a group because of certain distinguishing characteristics or personal traits that are thought to be a disadvantage. Unfortunately, negative attitudes and beliefs toward people who have a mental health condition are common (Bradford et al., 2009).
Stigma is a major obstacle to the seeking and utilization of mental health services. This is especially true for African Americans. In most African American communities, it is taboo to openly discuss mental health issues. Sitting down and talking to a "stranger" (a therapist), is perceived as weakness and airing one's dirty laundry in public. It is also seen as reflecting poorly on families and an admission that something is wrong with the family unit. As a result of the stigma associated with mental illness, there is a fear of being "found out" and hence, an intense need for anonymity, confidentiality, and reassurance (Mishra et al., 2009). A study conducted in 2008 revealed that even among African Americans who were already mental health service consumers, over 30 percent felt that discussing their mild depression or anxiety would cause them to be considered "crazy" (Snowden & Kaiser, 2008).
Mental illness is frequently stigmatized and misunderstood in the African American community.
According to Clement et al. (2015), when stigmatized people come to find out that a negative label has been applied to them and that they are viewed as less trustworthy, unintelligent, dangerous, and incompetent, they conceal their mental health symptoms and avoid treatment. www.scholink.org/ojs/index.php/rhs Research in Health Science Vol. 5, No. 3, 2020 31 Published by SCHOLINK INC.

Addressing the Role of Race in Mental Health Disparities
Addressing inequities and disparities in mental health among African Americans in the US requires a thorough assessment of the existing mental health care paradigm and the role of race (Feagin & Bennefield, 2014). While increased access to mental health care will help to reduce mental health disparities among African Americans, it is not sufficient to eliminate the issue. Since the source of the disparities are social issues grounded in race, efforts that target and focus on training and creating a culturally competent and diverse mental health workforce, changing policy, reducing stigma, and promoting mental health education are crucial.

Culturally Competent Mental Health Workforce
Increasing the number of African Americans in the mental health workforce will not only provide culturally appropriate treatment for African American patients, but will also help to allay their anxieties, fears and discomfort with regards to seeking care, and will build trust. Closing the gap in mental health care disparities will not occur overnight. It will require widespread, intentional, and collective steps towards African Americans, and the tailoring of interventions to meet their unique needs.
The White mental health workforce can help to eliminate disparities by educating themselves on the culture of their African American patients, reconsidering their values and biases that influence their interactions with African American patients, and assuming an ethno-relativistic approach to service delivery. They also need to make African American patients feel safe and understood, show them respect and empathy, and commit to upholding their natural and fundamental human rights (Walker & Sonn, 2010). A sensitivity and responsiveness to cultural pluralism means White mental health care providers will try to find out what matters most to their African American patients, improve upon communication, and increase African American patient role in their personal treatment and care. Overall sensitivity to African American cultural differences in perceptions of mental illness will significantly improve treatment experiences and increase African American utilization of mental health care services.

Policy Change
Increased federal government funding for the training of the mental health workforce in cultural competency in the US is needed. As mental health disparities are mostly rooted in inequities founded on race, policies at the highest level of government that expressly focus on addressing racism need to be made and enforced. These policies must seek to change social conditions that negatively affect African Americans and must be applied in the same way for all populations across the board (Alegrí a et al., 2003).
It is important for mental health policies to be separated from general healthcare policies. This argument arises from the notion that unless this happens, mental health will not be treated as a separate area of health and will continue to make mental health care access even more difficult for African Americans (Blau & Abramovitz, 2014). Having a separate policy that embraces universal coverage for mental health care will significantly improve African American access to mental health care, as the majority of this population already lacks access to general health insurance. Prohibitive insurance and health care costs often make it difficult for African Americans to seek care.
Policy makers need to work towards expanding access to publicly financed insurance safety nets for African Americans (Office of the Surgeon General, 2001) as these mechanisms are an important resource in the provision of health care to this population. Policy makers also need to address inequities in housing, and education, as these inequities have been shown to be linked to mental health disparities.

Destigmatization, Awareness Creation, and Education
Promoting social inclusion is key to the elimination of mental health disparities among African Americans. Interventions that promote social inclusion and minimize the impact of attitudinal, structural, and behavioral drivers of social exclusion towards people with mental illness need to be developed (Patel et al., 2018). Increased positive public opinion, greater tolerance, and understanding of mental illness itself and the people who suffer from such conditions need to be encouraged, as this can help to reduce the feelings of stigma among African Americans. Mass and social media platforms need to be used to promote mental health literacy and to create public awareness about the negative effects of mental health stigma. Improved public awareness of the scientific realities of mental illness will help to erase myths and stereotypes associated with mental illness and will also help to boost mental health seeking behavior among African Americans.
The African American community must be reeducated on mental health issues and the importance of being mentally healthy (White, 2019). Specifically, they need to be educated about the fact that mental illness is not a weakness, but that it is like any other medical condition-arthritis -for which medical treatment and care is needed. This education can also be provided in schools. If awareness about mental health is created from a young age, it is possible to break the cycle of stigma and to shape future generations approach to mental health in a new and positive way. To address the issue of stigma, the narrative needs to change from mental illness to one that focuses on something positive -mental wellness. An educated and informed African American population is likely to use mental health care services.

Conclusion
The lack of attention paid to the mental health needs of African Americans and the inadequate provision of culturally appropriate mental health care in African American communities demonstrates a clear need for partnerships to close the gap in disparities. The federal government has a critical role to play in addressing the issue of racial disparities in mental health status and mental health care so as to improve the health and well-being of African Americans (American Psychological Association, 2019).
Given the fact that the mental health disparities African Americans experience are rooted in issues associated with their race, it is expedient that the strategies employed to address the issues, not only focus on access to mental health care, but also on the root causes.