Challenges faced by underserved populations can be divided in several ways.
Racial-Ethnic Minority Groups: Challenges and Barriers to Accessing Mental Health Care
Populations in racial-ethnic minority groups represent a considerable proportion of the entire population in the United States, yet they experience major mental health disparities: They often have less access to health care, and the available care is frequently of poorer quality than that available to the white population (
6,
7). The goal of decreasing mental health disparities between minority groups is currently a national effort. The implementation of the ACA (Medicaid, Medicare, and other government safety-net programs) has contributed to a reduction in the odds of an individual with mental illness not being able to afford mental health care, lower barriers in accessing treatments, and a reduction in the delay in seeking help among African Americans, Latinos, and other minority populations—but the gap is not yet closed (
8).
The problem is multifaceted. It includes a lack of community-based interventions, unequal access to evidence-based practices, and a lack of resources to fund health services. Overall, the literature shows that individuals in racial-ethnic minority groups also receive less-than-optimal care in the following ways. These individuals are 20%–50% less likely to initiate mental health service use and 40%–80% more likely to drop out of treatment prematurely (
9). They are more likely to utilize psychiatric emergency services, to enter emergency treatment by means of law enforcement, and to be involuntarily hospitalized. Despite the utilization of emergency services and inpatient facilities, they are less likely to receive regular outpatient care after discharge. They are also less likely to experience symptom remission and less likely to improve their global functioning to return to work (
7,
10).
Unconscious bias and stereotypes, as explained in this issue by Moreno and Chhatwal (
11), have a major impact. For instance, African-American patients are more likely to receive a schizophrenia-spectrum diagnosis than a bipolar diagnosis and more likely to have higher rates of severe depression yet lower rates of treatment, compared with the white population. Misdiagnosis has significant implications in limiting the opportunity for adequate treatment. Reports also suggest that these differences are mainly attributable to racial-ethnic bias or misattribution of psychotic symptoms (
12,
13).
Studies suggest that culturally competent treatment regimens in populations with different sociocultural backgrounds may help address racial bias in diagnosis formulation and lead to more appropriate treatment recommendations. Culturally sensitive interventions (as an integration of awareness of culture, acquisition of knowledge about cultural aspects, and capacity to distinguish between culture and pathology) reduce the levels of perceived stigma, increase treatment seeking among individuals from racial-ethnic minority groups, increase treatment duration, and improve outcomes for individuals from these groups (
14). For instance, the cultural formulation model, addressed in this issue by Jarvis and colleagues (
15), aids practitioners in rendering accurate psychiatric diagnoses and formulating treatment across cultural boundaries. Mental health services that are culturally sensitive and consider the needs of individuals from racial-ethnic minority groups may increase service utilization in both the medical and the community settings (
7). Addressing language barriers may also decrease the possibility of diagnostic assessment bias, diagnostic errors, and errors in management as well as increase retention in depression care (
16).
Additionally, studies show that underrepresentation and limited participation of individuals from racial-ethnic minority groups are present in research as well. Individuals in racial-ethnic minority groups are less likely to be included in important genomic studies, leading to a gap in representation in biological research. This disparity in research represents a missed opportunity to address individuals from underserved and underrepresented minority groups (
17). For instance, individuals of African and Latin American ancestry and native or indigenous peoples represent less than 4% of the 35 million samples included in the Genome-Wide Association Study (GWAS) catalog (
18). Various reasons, including lack of transparency and research malpractice, spread mistrust and justified individuals’ unwillingness to share personal health information, including DNA, with the research community (
19). However, larger and more inclusive GWASs are necessary to ensure that advances in genomic medicine, including improved risk prediction, benefit all of humanity (
20).
Furthermore, as treatment research becomes more focused on polygenic risk scores, not having this data on individuals from racial-ethnic minority groups means that more effective treatment regiments for these individuals will not be developed. For this reason, The African Ancestry Genomic Psychiatry Cohort is already supporting a large expansion of the Genomic Psychiatric Cohort (GPC) network of individuals of African ancestry (
21). More initiatives, such as the
All of Us research program as the cornerstone of the larger Precision Medicine Initiative, seek to overcome these obstacles and truly engage underrepresented populations as partners in genomic research (
https://allofus.nih.gov/).
Sexual and Gender Minority Groups: Stigma Experienced Within Mental Health Services
Approximately 10 million people in the United States identify as lesbian, gay, or bisexual, and 700,000 adults are transgender (
22,
23). LGBTQ+ individuals have been historically marginalized within society and may encounter a range of stressors such as prejudice, discrimination, and stigma. Meta-analysis data have found that populations in a sexual and gender minority position experience a considerably greater prevalence of depressive episodes, substance misuse, and suicidal ideation and attempts, compared with the general population (
24). The greater risk for LGBTQ+ individuals of developing severe mental illnesses has been directly associated with exposure to discrimination, social isolation, and violence based on sexual and gender identity (
25).
State legislation legalizing same-sex civil unions is associated with lower levels of stigma, perceived discrimination, depressive symptoms, and hazardous drinking, especially among individuals experiencing multiple marginalized statuses. Research on the topic strongly supports the finding that policies for civil rights that are LGBTQ+ inclusive have a great and long-term positive effect on mental health outcomes in LGBTQ+ populations (
26).
Additionally, there is growing evidence that the mental health services available to LGBTQ+ individuals are often scarce and that they might offer inadequate and stigmatizing treatments (
27). In fact, although it has been more than 30 years since the American Psychiatric Association (APA) removed homosexuality as a diagnosis in the
DSM and recognized it as a normal variant of human sexuality, today “reparative” or “conversion” therapies are still suggested by some mental health professionals (
28,
29). Authoritative professional organizations such as the World Psychiatric Association (
30), American Psychoanalytic Association (
31), and the APA (
32) have stated that interventions aimed at changing sexual orientation are unethical and harmful for patients.
With the transition to the
ICD-11, the transgender identity is also no longer considered a mental disorder and has been renamed as “gender incongruence” and moved from the mental disorders chapter to the new sexual health chapter. Gender incongruence is not proposed for elimination in the
ICD-11 because, in many countries, access to relevant health services is contingent on a qualifying diagnosis (
33). Still, therapists often lack the skills to work effectively with transgender clients and are often ignorant and insensitive toward transgender issues (
34,
35).
Reports show that these negative and stigmatizing attitudes toward LGBTQ+ clients are influenced by antigay prejudice or, more commonly, by lack of knowledge about individuals from sexual minority groups. These results suggest the need for more efforts in promoting training for mental health service providers about sexual and gender identity as well as increasing cultural competence. Reducing stigma, especially in mental health care settings, would also create a more sensitive, welcoming, and understanding environment that will allow more LGBTQ+ patients to seek care (
35,
36). Affirmative practice, as explained in this issue by Mendoza and colleagues (
37), is the way to provide knowledgeable and unbiased services to LGBTQ+ individuals. In the long term, we expect greater mental health improvements where inclusive policies for civil rights are implemented (
26).
Underserved Urban Communities: Individuals Experiencing Homelessness or Incarceration, Individuals With Severe Mental Disorder, Individuals With a Drug Addiction, and Immigrant Populations
A growing body of data are available on the extreme health inequities among populations who experience considerable exclusion from mainstream society, such as those experiencing homelessness or imprisonment, those with severe mental disorders, and those experiencing drug addiction, extreme poverty, or both. The systematic review and meta-analysis led by Aldridge and colleagues (
38) highlights that these inequities across a wide range of health conditions persist not only in low-income countries but also in high-income countries.
The National Law Center on Homelessness and Poverty (
39) currently estimates that, each year, at least 2.5 to 3.5 million Americans sleep in shelters, transitional housing, and public places not meant for human habitation. An additional 7.4 million have recently lost their own homes because of economic necessity, lack of affordable housing, unemployment, poverty, mental illness, and substance abuse as well as the lack of community-based support services and long-term availability of psychiatric hospital beds (
40). Homeless individuals have a mortality rate three times higher than that of the general population. The average homeless person has a life expectancy of only 47 years, compared with an average of 77 years for the general population. Many factors affect the higher mortality rates among homeless adults: increased risk for mental illness, trauma, suicide, and medical comorbidities, as well as excessive alcohol and substance use. Approximately 33% of adults who are homeless suffer from some form of severe and persistent mental illness (
41).
Housing First is an effective community-based approach that provides permanent housing, which is considered as a right and not something that should be earned through compliance with psychiatric treatment or abstinence from drugs. People are offered, in parallel with housing, support from a multidisciplinary team. Studies have demonstrated that the Housing First program yields quicker and more sustained housing retention, compared with the ubiquitous continuum of care model, in which treatment is a requirement as a precondition for housing (
42,
43).
Mobile outreach teams, in which professionals move around a city bringing services to people, are another approach that is considered a good practice. As a rule, services need to move toward people rather than wait for people to move toward them. Engagement is the key: Any contact with homeless individuals is an opportunity to connect them with services and provide necessary care (
44).
Additionally, randomized controlled trials (RCTs) have shown that peer navigator programs (PNPs) had a positive impact on the health of participants and on their domicile and insurance coverage status as people who received services provided by professionals or paraprofessional staff. Participants perceived that peer navigators (i.e., individuals with similar life experiences) have better empathy for members, are more emotionally present, and are better listeners than nonpeer providers (
45).
Another underserved and disenfranchised population is the over 20 million Americans who are currently inmates or have been incarcerated in the past. The United States is the world leader in incarceration, which disproportionately affects black communities. Mass incarceration also shapes inequality in health.
Nearly one in three black men will be imprisoned in their lifetime. In addition, nearly half of black women currently have a family member or extended family member who is in prison. For white women, the risk of having an incarcerated family member is only one quarter as high, at 12%, as opposed to nearly 50% (
46,
47). Considering the indirect health consequences of incarceration, having an incarcerated family member also harms the mental and physical health of nonincarcerated female partners and children. In fact, parental incarceration leads to increased drug and alcohol use among children, affecting subsequent generations and the entire community (
47–
49).
For the inmates themselves, the correctional facilities have become a front line for mental health care. Almost half of inmates have been diagnosed with a mental illness, of whom approximately 25% had a serious mental illness; rates range from two to four times the rates of the general population (
50). About 75% of prisoners who have a mental health problem meet the criteria for substance dependence or abuse and often are incarcerated for nonviolent crimes related to illegal substances (
51,
52). As a result, there are now 10 times more individuals with serious mental illness in U.S. prisons and jails than there are in state mental hospitals. Inmates with a mental illness are also at greater risk for recidivism, hospitalization, and suicide on release (
52–
55).
Public policies addressing homelessness and improved care modalities for substance abuse disorders will go a long way toward diminishing the incarceration rates of those with mental illness. An increasingly global and complex challenge is also represented by the opioid overdose crisis associated with high rates of morbidity and mortality (
56). Given the high rate of relapse and overdose deaths after prison release, it is essential to establish tighter coordination between the health and criminal justice systems to ensure prevention measures and treatment programs during and after release (
57). Access to comprehensive, evidence-based, and quality treatment for opioid use disorders in a continuum of care model has proved to be a key strategy to address this crisis. Appropriate services should be provided: from low-threshold outreach interventions to multistage rehabilitation and social reintegration programs, including treatment for medical and psychiatric comorbidities. Participants had fewer convictions, fewer days in jail, and more days in outpatient mental health treatment (
58). Increasing community access to outpatient psychiatric services after incarceration should also be the cornerstone of any mental health reform.
Severe mental disorders (SMD) (e.g., schizophrenia and bipolar disorder) are emerging as a prominent health disparity category, given estimates that individuals in this group die 10–20 years younger that the general population. Persons with SMD often have limited access to general health care and are more likely to be poor and at risk for homelessness (
59). From our dataset of individuals participating in the GPC (
21), they are also at greater risk of developing PTSD (Blanck C, Georgakopolous P, Pato MT, unpublished manuscript) and at an increased risk of smoking, heavy alcohol use, heavy marijuana use, and recreational drug use than the general population (
60). Delivering appropriate care is extremely important for overlapping marginalized groups as shown from the link between mental illness, homelessness, drug abuse, and incarceration.
Immigrants may bring with them experiences of racism, trauma, war, economic hardship, enforced relocation, or homelessness to their new country. In modern times, when high-income countries are absorbing a massive influx of refugees, the condition in which they are welcomed, the acceptance by the host society, and administrative support are fundamental to preventing serious social exclusion (
61). Clinicians, policy makers, and service providers need to be aware of specific needs that migrants may have to avoid disparities if these needs are not met adequately (
62). Policies should recognize the root causes of exclusion and the structural disadvantages experienced by people, households, and communities living in persistent or recurrent poverty. Health inequalities result from social inequalities, with the worst effects on people who experience the most extreme forms of material deprivation (
63).