Progress in Improving Mental Health Services for Racial-Ethnic Minority Groups: A Ten-Year Perspective
Abstract
Objective
This study examined progress in making the mental health workforce more diverse and in better representing racial-ethnic minority groups in randomized intervention trials of common mental disorders since the publication of the U.S. Surgeon General’s 2001 report Mental Health: Culture, Race, and Ethnicity.
Methods
Data on the mental health workforce were drawn from a work group comprising research staff from the American Psychiatric Association, American Psychological Association, and the National Association of Social Workers; representatives of professional psychiatric nursing; and staff from the National Institute of Mental Health. Additional data were pooled from clinical trials published between 2001 and 2010, which were examined for inclusion of racial-ethnic minority populations. Proquest, PubMed, and Google Scholar were searched for the terms “clinical trials” and “randomized trials.” The search was constrained to trials of adults with bipolar disorder, schizophrenia, and major depression, along with trials of children and adults with attention-deficit hyperactivity disorder.
Results
Between 1999 and 2006, professionals from racial-ethnic minority groups increased from 17.6% to 21.4% in psychiatry, from 8.2% to 12.9% in social work, and from 6.6% to 7.8% in psychology. Reporting race-ethnicity in clinical trials has improved from 54% in 2001 to 89% in 75 studies of similar disorders published by 2010, although few ethnic-specific analyses are being conducted.
Conclusions
Little progress has been made in developing a more diverse workforce; racial-ethnic minority groups remain highly underrepresented. There is more representation of racial-ethnic minority populations in randomized intervention trials, but their numbers often remain too small to analyze. Recommendations for improving both areas are considered.
Over ten years ago, a team of mental health researchers wrote a report for U.S. Surgeon General David Satcher, titled Mental Health: Culture, Race, and Ethnicity (1). This report was a supplement to Mental Health: A Report of the Surgeon General (2). In the supplemental report, the team of mental health researchers made several recommendations that needed either research or policy and practice action to improve mental health care and outcomes for racial-ethnic minority groups in the United States. In this review article, we discuss the progress made toward two of these recommendations.
The first recommendation we discuss is the need to train more mental health providers who are from racial-ethnic minority groups. The 2001 report documents that “Racial and ethnic minorities continue to be badly underrepresented, relative to their proportion in the U.S. population, within the core mental health professions—psychiatry, psychology, social work, counseling, and psychiatric nursing. Although it is certainly not the case that only people from a minority group can understand or treat persons of like race or cultural background, minority providers treat a higher proportion of minority patients than do white providers. There is also evidence that ethnic match between provider and client encourages consumers to stay in treatment” (1). The report goes on to suggest that an integral part of reducing mental health care disparities is increasing the diversity of the workforce. Although progress is being made in efforts to improve the diversity of the workforce, research suggests that there is continued need for progress in this area (3,4). In this article, data are presented to look at the rates of minority providers who make up the mental health professional workforce and to examine what progress has been made since the 2001 report was published.
The second recommendation discussed in this article relates to evidence-based treatment. Mental Health: Culture, Race, and Ethnicity (1) documented that racial-ethnic minority groups were largely left out of the evidence base for treating mental health problems. The research used to generate professional treatment guidelines for most mental health interventions did not include or report large enough samples of racial and ethnic minority populations to allow group-specific determinations of efficacy. Although the Surgeon General’s original report on mental health (2) documented that a comprehensive range of interventions for treating mental disorders had been empirically validated, the samples of racial-ethnic minority populations included in these studies were not large enough to determine whether the interventions were effective for the nation’s diverse range of Americans. After much consideration, the 2001 team upheld the recommendation that individuals from minority groups seek and obtain evidence-based mental health care but also strongly recommended that the field improve the science in this area.
Racial-ethnic minority groups have generally been underrepresented in randomized trials within psychiatry and psychology, in addition to broader medical and health fields. For example, this problem has been documented in randomized clinical trials published in the major medical journals (5,6) and in studies utilized in developing the American Heart Association guidelines for cardiovascular disease (7). A review of mental health treatment and outcomes studies from 1981–1996 also documented this problem (8). More recent reviews suggest that although some progress is being made in reporting ethnicity and gender in mental health clinical trials, underrepresentation of racial-ethnic minority groups remains a problem (9). In this review, we examined the progress that has been made in including these minority groups in mental health randomized trials focusing specifically on the disorders examined in the original 2001 report in order to provide a clear comparison.
The National Institutes of Health (NIH) have long struggled with the issue of including diverse populations within their research portfolios. In 1993, the U.S. Congress passed legislation to create within NIH the Office of Research on Minority Health. This office was formed to increase the representation of minority groups in all aspects of biomedical and behavioral research. In November 2000, the office was elevated to the National Center on Minority Health and Health Disparities, which subsequently became an institute. This has given the NIH increased programmatic and budgetary authority for research on minority health issues and health disparities. In addition to this specific programmatic funding, the NIH published its Guidelines on the Inclusion of Women and Minorities as Subjects in Clinical Research (10) 19 years ago. With this document, the policies of the NIH regarding the inclusion of women and racial-ethnic minorities in study populations were significantly strengthened. These guidelines require that phase III clinical trials must ensure that women and minority groups and their subpopulations are included so that valid analyses of differences in intervention effects can be evaluated. Further, the policy states that the NIH must initiate programs and support for outreach efforts to recruit these groups into clinical studies. Because there is often a long time between subject recruitment and publication of study results, the impact of this policy is likely best evaluated with a time lapse. In this review study, we evaluated the literature since 2001 for the inclusion of racial-ethnic minority populations in randomized treatment trials concerning bipolar disorder, schizophrenia, major depression, and attention-deficit hyperactivity disorder (ADHD).
To summarize, we examined the current level of racial-ethnic minority providers in our mental health system and the extent to which racial-ethnic minority populations are included in mental health clinical trials, and we determined whether separate analyses were conducted to report racial-ethnic differences in outcomes.
Methods
Mental health providers from racial-ethnic minority groups
In the report Mental Health: Culture, Race, and Ethnicity (1), we examined the workforce availability of racial-ethnic minority providers in the mental health field. In this review, we looked at changes in workforce available since the report. We obtained data directly from the 2000 and 2010 Mental Health, United States reports (11,12). The methodology for obtaining workforce data for the Mental Health, United States series comes from a work group that originated in late 1987. Research staff from the American Psychiatric Association, American Psychological Association, and the National Association of Social Workers and representatives of professional psychiatric nursing formed a work group on human resources data with staff from the National Institute of Mental Health. This work group developed a common, basic data set that has been updated and used in subsequent reports.
Racial-ethnic minority inclusion in 2001–2010 clinical trials
In the Surgeon General’s report Mental Health: Culture, Race, and Ethnicity (1), the underrepresentation of racial-ethnic minority populations in mental health treatment studies was documented by examining the treatment guidelines for four disorders: bipolar disorder, schizophrenia, major depression, and ADHD. In the 2001 report, the team considered the representation of racial-ethnic minority populations in the studies used by the American Psychiatric Association in developing their treatment guidelines for adults with bipolar disorder (13), schizophrenia (14) and major depression (15). Studies identified by the Agency for Healthcare Research and Quality (AHRQ) (16) were used to develop treatment guidelines for children and adults with ADHD.
Our goal was to replicate these efforts in order to examine the progress made since the original 2001 report. To be consistent with the 2001 report, we focused on adult clinical trials for bipolar disorder, schizophrenia, and major depression. We focused on both child and adult trials for ADHD, consistent with the AHRQ methodology (16). Thus we conducted a literature search of clinical trials to examine the participation of racial-ethnic minority groups in these new trials. To make our search relevant to the United States, for all searches we included “United States only” and “English language only” as search parameters. We searched Proquest, PubMed, and Google Scholar for the terms “clinical trials” and “randomized trials.” Within the previous parameters, we searched for the terms “bipolar disorder,” “bipolar,” “schizophrenia,” “major depression,” and “attention-deficit hyperactivity disorder.” We searched for studies published between January 2001 and December 2010. We excluded studies that had been published previously, so that we were not reporting on the same trial multiple times.
Results
Mental health providers from racial-ethnic minority groups
Table 1 shows data from the Mental Health, United States reports for 2000 and 2010 (11,12), detailing the percentage of clinically trained mental health professionals by race and ethnicity compared with the racial-ethnic minority groups’ percentage of the U.S. population for the same year. As shown in Table 1, psychiatrists had the highest percentage of racial-ethnic minority providers across time (17.6%−21.4%), followed by social workers (8.2%−12.9%) and then psychologists (6.6%−7.8%). Social workers showed the greatest gains over time. African-American and Latino psychologists were least well represented, comprising only 19% and 20% of their U.S. representation, respectively, in 2006.
| Racial-ethnic minority representation | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Psychiatry | Psychology | Social work | ||||||||||
| Group | 1999 cliniciansa | 1999 U.S. population | 2006 cliniciansb | 2006 U.S. population | 1999 cliniciansc | 1999 U.S. population | 2006 cliniciansd | 2006 U.S. population | 1996 clinicianse | 1996 U.S. population | 2004 cliniciansf | 2004 U.S. population |
| American Indian or Alaska Native | .1 | .7 | .4 | .9 | .6 | .7 | .4 | .9 | .6 | .7 | .5 | .7 |
| Asian American or Pacific Islander | 10.4 | 3.7 | 13.1 | 5.0 | 1.5 | 3.7 | 2.0 | 5.0 | 1.7 | 3.5 | 1.6 | 4.6 |
| Latino | 4.4 | 11.5 | 4.7 | 14.8 | 2.4 | 11.5 | 2.9 | 14.8 | 2.8 | 10.6 | 4.5 | 13.1 |
| Black or African American | 2.7 | 12.1 | 3.2 | 13.4 | 2.1 | 12.1 | 2.5 | 13.4 | 3.1 | 12.0 | 6.3 | 12.1 |
| White | 81.5 | 71.9 | 78.6 | 65.3 | 93.4 | 71.9 | 92.2 | 65.3 | 91.8 | 73.2 | 87.1 | 68.8 |
a
The 1999 American Psychiatric Association membership residing in the United States, excluding medical students, psychiatry residents, corresponding psychiatrists, and inactive members. Race-ethnicity was not specified for 6.2%.
b
The 2006 American Psychiatric Association membership residing in the United States, excluding medical students, psychiatric residents, international members and fellows, inactive members, associates, fellows, and honorary fellows. One race-ethnicity was not specified for 7.9% (data were missing or respondents reported multiethnicity).
c
American Psychological Association data. Race-ethnicity was not specified for 5.5%.
d
American Psychological Association Member Directory 2006. Compiled by APA Center for Workforces Studies. One race-ethnicity was not specified for 20.5% (data were missing or respondents reported multiethnicity).
e
Association for Social Work Board estimates. Race-ethnicity not specified for .8%
f
The Association for Social Work Board estimates the number of licensed social workers to be 310,000. This number excludes bachelor level, doctorate level, and nondegreed licensed social workers. An estimated 79% of this number, or 244,900, have M.S.W. degrees and are thus eligible to hold clinical licenses. The proportion with an M.S.W. degree and a clinical license is unknown. Hence, for purposes of this table, the total number of clinically trained social workers was considered to be 244,900.
Racial-ethnic minority groups in clinical trials, 2001–2010
Table 2 was generated by examining from the original 2001 report each clinical trial report listed that included analyses of specific racial-ethnic minority groups for one of the four mental illnesses covered in the report. Table 3 shows our updated report from our 2001–2010 review. Our search resulted in a total of 75 studies. In the Surgeon General’s report Mental Health: Culture, Race, and Ethnicity (1), 54% of the published trials reviewed included racial-ethnic data of participants within studies. In our new review, race-ethnicity was reported for 89% of participants. In comparing the two tables, it appears that more participants from racial-ethnic minority groups are being reported within trials than previously. Unfortunately, with only a few exceptions, analyses of specific minority groups are not presented.
| Disorder studied | Total N | White | Unspecified nonwhite | Black or African American | Hispanic | Asian American/Pacific Islander | American Indian/Alaska Native | Total of subgroups | % of total sample | Analyses of specific racial-ethnic group |
|---|---|---|---|---|---|---|---|---|---|---|
| Bipolar disorder | 921 | 234 | 39 | 32 | 0 | 0 | 0 | 305 | 33 | 0 |
| Schizophrenia | 2,813 | 1,314 | 305 | 376 | 44 | 5 | 0 | 2,044 | 73 | 0 |
| Major depression | 3,860 | 1,571 | 241 | 27 | 0 | 2 | 0 | 1,841 | 48 | 0 |
| ADHD | 1,672 | 545 | 71 | 126 | 55 | 4 | 0 | 801 | 48 | 0 |
| Total | 9,266 | 3,664 | 656 | 561 | 99 | 11 | 0 | 4,991 | 54 | 0 |
| Disorder studied | Total N | White | Unspecified nonwhite | Black or African American | Hispanic | Asian American/Pacific Islander | American Indian/Alaska Native | Total of subgroups | % of total sample | Analyses of specific racial-ethnic group |
|---|---|---|---|---|---|---|---|---|---|---|
| Bipolar disorder | 4,983 | 3,528 | 468 | 140 | 31 | 2 | 1 | 4,170 | 84 | 1 |
| Schizophrenia | 1,638 | 612 | 125 | 711 | 41 | 19 | 1 | 1,509 | 92 | 0 |
| Major depression | 4,862 | 3,018 | 251 | 409 | 943 | 121 | 6 | 4,748 | 98 | 4 |
| ADHD | 3,163 | 1,826 | 364 | 250 | 155 | 10 | 7 | 2,612 | 83 | 1 |
| Total | 14,646 | 8,984 | 1,208 | 1,510 | 1,170 | 152 | 15 | 13,039 | 89 | 6 |
Discussion
In this literature review, we focused on two recommendations from the Surgeon General’s report written over ten years ago. We examined whether the United States is making progress toward increasing the diversity of its mental health workforce and whether research is including more individuals from racial-ethnic minority groups in clinical trials in an effort to determine whether interventions are equally effective across groups. The data showed that some progress is being made, but disparities still exist in both areas.
Diversity in the mental health workforce
Racial-ethnic minority populations are vastly underrepresented among clinically trained mental health practitioners in the United States. With the exception of Asian-American psychiatrists, minority groups are still poorly represented among mental health professionals, with only very small improvements over time. Psychologists are less diverse than are either psychiatrists or social workers, suggesting that the field has much work to do. In fact, according the 2006 statistics, the proportion of African-American psychologists was equal to only 19% of the African-American population in the United States, and the proportion of Latino psychologists was equal to only 20% of the Latino population in the United States. Still, it is important to note that there is some movement toward a more diverse workforce. In social work, the percentage of African Americans and Latinos appeared to double from 1996 to 2004. The social work field may have important insights into the strategies that boosted recruitment of underrepresented groups.
When we consider the entire workforce, as is done with the data presented here, recent efforts to improve diversity may be less apparent because they take time to build. For example, the training of mental health professionals can be quite lengthy. Time needed to train mental health professionals after high school is often a minimum of 11 to 12 years for psychiatrists, eight to ten years for psychologists, and five to six years for social workers. Unfortunately, calls for increasing the diversity of the workforce have been in existence for several decades. A number of initiatives have been and remain active to increase the diversity of mental health professionals. The data presented in this article suggest that these initiatives have not resulted in substantial gains in increasing the diversity of the workforce.
One possible problem is that current programs are often focused on a particular education level, such as undergraduates or high school seniors. These specific programs may leave gaps in support for students from minority groups who may have fewer resources to sustain the education demands necessary to become mental health professionals.
A unified effort to support promising students from high school through graduate internships may be necessary to truly eliminate disparities in mental health care associated with too few providers from racial-ethnic minority groups. For example, the Medical Education Resources Initiative for Teens in Baltimore identifies underrepresented students in high school and provides intensive resources and programs in high school (including research experiences at Johns Hopkins Bayview Medical Center and the National Institute on Drug Abuse), as well as ongoing mentorship and support through college and medical school. These types of long-term programs may improve the pipeline in mental health–related fields.
Vasquez and Jones (4) suggest that affirmative action policies can help but that we must go beyond those efforts. Graduate programs that have successfully recruited and retained nonwhite doctoral students had several common factors: a critical mass of students of color, opportunities for students to collaborate with faculty on diversity issues and research, at least one diversity issues course, faculty who were involved in a wide array of campus-based diversity initiatives, and a commitment to recruiting and retaining students from racial-ethnic minority groups at the institutional level (3). Furthermore, creating linkages with historical institutions of color and offering good financial aid packages also appeared to improve the pipeline for recruiting students from racial-ethnic minority populations (3).
Despite the underrepresentation of racial-ethnic minority groups in psychology, the American Psychological Association has worked to increase racial-ethnic minority representation among their ranks. One important effort was the project called “Developing Minority Biomedical Research Talent in Psychology: A Collaborative and Systemic Approach for Strengthening Institutional Capacity for Recruitment, Retention, Training and Research.” With $4 million in funding from the National Institute for General Medical Sciences, the American Psychological Association organized this major initiative to repair the pipeline by increasing the number of racial-ethnic minority students ready for research (17). These types of intensive efforts appear helpful; this initiative resulted in increased engagement of racial-ethnic minority students in research and doctoral programs and provided important suggestions for long-term sustainability. Such intensive efforts are often short lived, however. Sustaining long-term programs to increase the number of racial-ethnic minority psychologists in our workforce is needed. Hall (18) took a stages-of-change perspective and noted that despite a call for such programs, the field of psychology is moving very slowly toward diversification, suggesting an early stage of change and a need to work toward commitment and action.
Reporting race and ethnicity in clinical trials
With regard to our second aim, we found that reporting on race and ethnicity has improved in clinical trials, although racial-ethnic minority populations are often not represented in large enough numbers to result in separate analyses, a finding consistent with Mak and colleagues’ (9) review of studies from 1995 to 2004. Exceptions found in this study include examining rates of adherence by race and ethnicity (19). Additional studies that included analyses of specific racial-ethnic groups did not find differences in treatment outcome on the basis of race or ethnicity (20–22). Another study reported racial-ethnic analyses in a large trial on ADHD (23). In this study, African-American and Latino children were more symptomatic than Caucasian children on some ratings, although response to treatment did not differ significantly by ethnicity after analyses controlled for public assistance. Racial-ethnic minority families benefited significantly from combination treatment.
Although few studies were able to conduct meaningful analyses on the basis of race-ethnicity, much more is known today about the response of racial-ethnic minority groups to evidence-based mental health care than was known when the Surgeon General’s report was published in 2001. For example, Huey and Polo (24) conducted a meta-analysis of studies of youths from minority groups. Among these youths, effect sizes were larger for evidence-based treatments than for treatment as usual. In this study, race-ethnicity, problem type, clinical severity, diagnostic status, and culture-specific tailoring of treatments did not moderate treatment outcomes. A review conducted by Miranda and colleagues (25) found that a growing literature supports the effectiveness of evidence-based care for minority groups. After an extensive review, they concluded that the largest and most rigorous literature is in the area of evidence-based depression care and clearly demonstrates that such care is equally effective, or superior, for African Americans and Latinos compared with white Americans. The data we present also suggest that when analyses are conducted of specific racial or ethnic groups, participants from underrepresented groups benefit equally from treatment. However, our review also suggests that when racial-ethnic minority groups are included, African-American and Latinos are most often represented. Very few studies are available for Asian-American and American Indian or Alaska Native populations within the effectiveness literature.
Including racial-ethnic minority groups in randomized trials, as is currently the practice at the NIH, often does not result in large enough minority samples to analyze separately. Although inclusion of racial-ethnic minority groups remains an important strategy for understanding treatment effectiveness across groups, trials specifically focused on racial-ethnic minority populations (19,26,27) have been very successful in increasing our knowledge about the impact of evidence-based care on racial-ethnic minority populations. In addition, important methodologies, such as the meta-analyses conducted by Huey and Polo (24), have been very useful for identifying the impact of evidence-based care on minority populations. Similarly, Miranda and colleagues (28) conducted an instrumental variables analysis of a large randomized health services research study and determined that African-American, Latino, and white patients responded similarly when receiving evidence-based depression care. Thus, in order to continue to expand our understanding of the impact of evidence-based care on racial-ethnic minority groups, we must continue to include members of underrepresented groups in clinical trials and conduct trials that focus on specific groups. In particular, Asian-American/Pacific Islander and American Indian/Alaska Native populations remain vastly understudied.
Although it would be difficult and expensive to conduct clinical trials for every treatment or nuanced treatment change, it might be especially important to conduct additional trials of treatments with racial-ethnic minority groups when there is a substantive advance in an area to ensure that the new treatment is effective with these populations. We acknowledge that many racial-ethnic minority groups may be understandably wary of participating in clinical trials because of historical persecution and unethical research conduct (such as with the 1932–1972 Tuskegee syphilis study). Thus community partnership approaches that build trust and include extensive outreach may be needed to recruit and retain participants in clinical trials.
Conclusions
In interpreting the data in this review, several cautions need to be considered. A modest amount of data was missing from the data regarding mental health professionals, which may have had a modest effect on the estimates. In fact, the estimates appear fairly stable over time. Further, although the data presented represent the most comprehensive compilation known, the methodology was limited in that it gathered data from multiple sources (such as membership surveys and licensure data), and some information was not known. For example, although Asian-American psychiatrists were well represented, it is not clear what proportion were U.S. born, calling for additional research. The literature search for our evaluation of the inclusion of participants from racial-ethnic minority groups in randomized trials focused solely on major depressive disorder, bipolar disorder, schizophrenia, and ADHD, thus limiting broad generalizations. We used these data only to look at trends in inclusion of minority groups. Despite these shortcomings, this review found evidence of slight progress in making our workforce more diverse and including racial-ethnic minority groups in our evidence base. Eliminating disparities in mental health care for racial-ethnic minority populations will undoubtedly require further work on both of these issues.
Acknowledgments and disclosures
This research was supported by grants 1P30MH082760 and T32MH073517 from the National Institute of Mental Health (NIMH). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIMH or the NIH.
The authors report no competing interests.
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Cover: Snowbound, by N. C. Wyeth, 1928. © Copyright 2014 National Museum of American Illustration™, Newport, Rhode Island. Photo courtesy Archives of the American Illustrators Gallery™, New York.
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Published in print: February 2014
Published online: 15 October 2014
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