Daniel Prude’s death at the hands of Rochester, New York, police in early 2020 represents a microcosm of the realities of mental health care access within the Black community. Law enforcement is often the first point of “care” for those in mental health emergencies, with most Americans reflexively calling 911 for assistance. This in part is why in 44 states, jails and prisons treat more serious mental illness than their largest remaining psychiatric hospitals.
Law enforcement’s function as a stopgap for mental health care access has deadly consequences: Approximately 25 percent of fatal police shootings involve signs of mental illness. Furthermore, according to the Federal Bureau of Investigation’s National Use of Force Data Collection, in 2019, 54 percent of people who died as a result of harm from police and whose race was identified were people of color—including Asian, Black, Hispanic, Native American, and Pacific Islander individuals. When Daniel Prude’s family called 911 for help during his mental health emergency, they tragically realized this fatal distinction.
This tragedy is one of several to occur within the backdrop of the COVID-19 pandemic, which has had adverse population-level effects on mental health. Researchers from the Centers for Disease Control and Prevention (CDC) found that from April to June 2020, US adults reported more symptoms and incidence of generalized anxiety disorder, stressor-related disorder, and substance use, compared to the same period in 2019.
This study comes as no surprise given the economic and emotional stress of the COVID-19 pandemic that threatens income, housing, and basic necessities. These stressors tangentially contribute to the sharp rise in mental health and substance use issues. Additionally, the economic and health impacts of COVID-19 have disproportionately devastated the Black community. Although prior studies have suggested a resilience in mental health within the Black community, there is great need for access to mental health services.
Even before COVID-19, Black Americans were 20 percent more likely to experience mental health issues. Yet, Black patients are less likely than their White peers to use necessary mental health resources, such as therapy, counseling, and psychiatric care. While the US grapples with the persistent effects of racism in all aspects of society, most presciently in the protest movement against the disproportionate impact of police violence in Black communities, addressing these mental health needs will remain important going forward. To enact meaningful progress, we propose the following actionable framework for improving access to evidence-based quality care.
To combat this issue, it is imperative to identify and address areas in greatest need of expanded mental health resources through data collection and transparency. Nationally, as was noted by the Substance Abuse and Mental Health Services Administration, the CDC could disaggregate COVID-19 data, such as testing, hospitalizations, intensive care unit admissions, and fatalities, by race and ethnicity at the local and national level. This data can be accessed through the National Notifiable Diseases Surveillance System and National Vital Statistics System and should be leveraged at the state and local level to direct mental health resources, such as telehealth counseling services and engage community stakeholders in affected local areas.
The Health Resources and Services Administration should further direct all federally funded primary, mental health, and behavioral health care systems to integrate behavioral and mental health approaches when providing care, with the aim of narrowing inequities in mental health outcomes. The integration of behavioral health into primary care services would go a long way toward improving access to much needed care. Studies have shown that integration of behavioral health and primary care services can increase scheduled behavioral health service use by 14 percent and actual use by 9 percent.
States should institute or leverage existing infrastructure to facilitate synergistic data collection. To accomplish this goal, Offices of Behavioral Health should be funded to collect, house, and report data in public-facing dashboards. Colorado provides an example of a state that transparently presents public-facing data. This data would be used to identify areas that would benefit from investments in the mental health workforce. Additionally, state health departments should be funded to run community-engaged campaigns on the importance of mental health in places such as churches, barbershops, and other trusted community centers. Partnership with community centers that are critical for Black social mobilization are necessary to lower stigma over mental health issues in the Black community. For example, when it comes to screening for mental health issues a study from three predominantly African American churches in New York City found that out of 122 participants 19.7 percent had a positive depression screen. An ongoing example is the Health Advocates In-Reach and Research initiative effort that uses barbers and hair stylists in the majority Black Prince Georges County, Maryland, to promote colon cancer screening in the Black community.
It is key that we use our payers to open access to mental health care services within inpatient settings. The Medicaid Institutes for Mental Diseases exclusion does not allow states to use federal Medicaid dollars to pay for in-patient treatment for mental health and substance abuse treatment if the patient is younger than 65 years of age. This policy maintains a class and racial disparity in who has access to in-house substance abuse treatment and mental health services, as Black Americans disproportionately rely on Medicaid for care (21 percent of Black Americans), which accounts for more than 25 percent of all behavioral health spending. Movement in this direction got a boost in 2018 when the Support Act became federal law. This law enables states to create frameworks for Medicaid to pay for in-patient substance abuse treatments. All states should take advantage of the Support Act and pursue Medicaid 1115 waivers to allow Medicaid reimbursement for in-patient treatment in hospitals and psychiatric facilities. Thus far, 31 states have successfully applied for and received this waiver.
Efforts to improve mental health outcomes in the Black community must be rooted in the Black community. A key to engaging the Black community in mental health care is ensuring culturally sensitive care and diversifying the workforce. This is evidenced by the fact that provision of health insurance with access to mental health services does not push members of the Black community to seek these services as much as their White counterparts. This effort involves teaching trainees about tools that can be used to address racial trauma, such as the University of Connecticut Racial/Ethnic Stress and Trauma Scale, and increasing racial awareness within the mental health workforce. Importantly, these plans will not bear fruit if we fail to increase Black representation in the mental health field, from psychiatrists to social workers. Studies have shown time and again that Black patients obtain better outcomes and better adhere to treatment when they have a provider who looks like them and can relate to the psychological effects of racism.
To diversify the physician mental health workforce, tuition waivers or student loan forgiveness for medical students who practice psychiatry in identified areas of need should be considered. Additionally, since the US will never have enough psychiatrists to meet the need, the mental and behavioral health care workforce should hire and train from the communities that need care. For instance, the Behavioral Health Workforce Education and Training Program funds education for community behavioral health paraprofessionals, such as community health workers and peer paraprofessionals, among others. Leveraging such programs allows the creation of a more diverse workforce to serve the mental and behavioral health needs of the Black community. To make these programs sustainable, federal tax credits should be instituted for both professional and paraprofessional mental health providers. This may open the door to rural psychiatry programs to address the lack of mental health infrastructure in rural areas, such as those across the South that have majority non-White and Black populations.
If implemented, these potential policy solutions can help alleviate the racial gap in access to mental health services. However, if we do not deal with societal inequality and racial bias, mental health care will not be enough. We must also address mental health gaps with an antiracist mindset. Only then, can we begin to solve the mental health divide and take meaningful steps to heal our nation’s psyche.