Racial-Ethnic Disparities in Outpatient Mental Health Visits to U.S. Physicians, 1993–2008

We found large and persisting racial-ethnic differences in use of mental health treatment provided by physicians. Differences varied by disorder and appear to have increased between 1993 and 2008. Differences were particularly marked for a number of diagnoses that have received little attention in the health disparities literature. Compared with non-Hispanic whites, racial-ethnic minority groups received less outpatient mental health care from physicians for most disorders. However, non-Hispanic blacks received more treatment than whites for psychotic disorders, and both minority racial-ethnic groups showed a nonsignificant trend toward more treatment for drug and alcohol use disorders. Differences in visits to psychiatrists were larger than differences in visits to nonpsychiatrist physicians, and racial-ethnic differences were less pronounced among older patients.

Our diagnosis-specific analysis found differences that were largest and most consistent across racial-ethnic groups for anxiety disorders—particularly obsessive-compulsive disorder—as well as dysthymia, personality disorders, nicotine use disorder, and attention-deficit hyperactivity disorder. Little direct attention has been paid to disparities in the treatment of anxiety disorders in general, and particularly for obsessive-compulsive disorder, although one study found that African Americans and Caribbean blacks with obsessive-compulsive disorder were highly unlikely to receive evidence-based treatment, even though both groups had high levels of illness severity and functional impairment (14). A recent comprehensive review of racial-ethnic differences in the prevalence, diagnosis, and treatment of personality disorders (38) identified only three studies that examined treatment, one of which was conducted in the United States. This study found that adults from racial-ethnic minority groups, especially Hispanics, were significantly less likely than whites to receive a range of outpatient services and that those with the most severe personality disorders were the least likely to receive treatment (15). Adults from minority groups are less likely to receive nicotine replacement therapy (39), and persons with mental illnesses are far more likely than others to smoke (40). Little attention has been paid to adult treatment disparities for attention-deficit hyperactivity disorder or for dysthymia. However, unlike this study, a previous study found little evidence of racial-ethnic differences for these disorders (41).

As Table 4 shows, racial-ethnic differences in the prevalence of mental disorders that have been observed in national epidemiologic samples (24,42–46) are too modest to fully explain the treatment differences that we found. For instance, although prevalence rates of anxiety disorders are roughly equal across racial-ethnic groups and there is evidence that certain disorders such as obsessive-compulsive disorder may be more prevalent among minority groups, we found that persons from racial-ethnic minority groups received far less treatment for most anxiety disorders.

Studies have sought other explanations for observed racial-ethnic differences in mental health treatment, including language barriers and immigration status (47–49); patient preferences (50); sociodemographic factors, such as poverty and insurance status (3,17,18,51,52); clinician-related factors (53); and structural factors, such as hospital segregation (54,55) and geographical location (56). Our stratified analyses may help to further explain observed differences. The regional variation in treatment differences that we observed may arise from factors related to the health care delivery system and from cultural factors. For instance, research has shown regional variation between Hispanic subgroups in use of mental health care (57). The finding that racial-ethnic differences were smaller for visits to nonpsychiatrist physicians supports the integration of mental health care into nonspecialty health care services as a potentially important avenue for disparity reduction (58). Our finding that differences ameliorated with age—particularly for elderly Hispanics—suggests that access to public insurance such as Medicare may mitigate disparities in mental health care. Research has indicated that entry into Medicare narrows differences in health care use and health between previously insured and uninsured individuals (59), although recent work has also documented racial-ethnic differences in depression treatment among Medicare beneficiaries (60).

Our finding that members of racial-ethnic minority groups, particularly non-Hispanic blacks, received more mental health care for psychotic disorders represented a striking divergence from the pattern of less treatment for most other disorders. Several explanations are possible. Previous work has shown that compared with whites, African Americans are more likely to be diagnosed as having psychotic disorders (61–64), to receive higher dosages of antipsychotic medications and more depot antipsychotics (65–67), and to be prescribed second-generation antipsychotics and clozapine less often (66,68–71). Such differences could be influenced by provider diagnostic bias (72) and by treatment setting, because African Americans are more likely to use inpatient and emergency services (67,73–75). We also found that minority groups received more treatment for certain substance use disorders, which are not more common in minority groups than among non-Hispanic whites (42). Overrepresentation of minority groups in the U.S. criminal justice system may result in increased enrollment in mandated substance abuse treatments (76). There is some evidence that members of minority groups may receive more restrictive treatment for substance use disorders than non-Hispanic whites (65,77).

The study had a number of important limitations in generalizability and potential sources of error. Our findings of differences in treatment volume are not sufficient to characterize disparities in treatment because NAMCS and NHAMCS data are restricted to outpatient treatment users and do not provide information from standardized diagnostic assessments or about patient preferences and prior treatment. It is therefore important to interpret these results only as racial-ethnic differences in treatment. Because the NAMCS and NHAMCS sample individual visits and not treatment courses, the VPRs we calculated did not distinguish between treatment entry and intensity and might have been driven by racial-ethnic differences in either component of care. Therefore, our findings can be precisely interpreted only as average volumes of physician treatment provided to population groups. However, research has found striking racial-ethnic differences in both initiation and delay of mental health treatment among individuals with diagnoses of anxiety and mood disorders (41), and many studies have shown differences in treatment intensity and quality (9,12,25).

Although the data captured a substantial portion of outpatient mental health treatment, some important treatment settings, such as community mental health centers, other public facilities, and nonphysician care were excluded. Members of racial-ethnic minority groups are relatively more likely to receive care in settings not captured in the data set used for this study (78), and the differences in physician care that we found likely exceed differences in total mental health care received. The impact of this omission may have declined recently because public mental health care funding has been subject to continued cuts and cost-shifting. For instance, although care in certain state-funded mental health specialty settings may be more intensive (5), public mental health care funding continues to shift from state-funded specialty care to federally insured (i.e., Medicaid and Medicare) care in general medical settings (79).

Although sampling provider visits directly avoids error arising from participant recall of mental health care use, provider reports are subject to diagnostic error, which may differ by patient race-ethnicity, and to error in assigning race-ethnicity, which would bias our VPRs toward underestimating true racial-ethnic differences. The frequency of missing information on race and ethnicity in the NAMCS and NHAMCS data has risen, requiring an increasing reliance on imputation, which may increase potential bias toward underestimation of differences. To the extent that particular physicians seen by patients from racial-ethnic minority groups are different from those seen by white patients and that systematic differences may exist in survey response rates between these groups of physicians, survey data could bias our VPRs toward overestimating differences.

We used broad racial-ethnic categories, obscuring variation in factors such as country of origin or immigration status, which have been shown to influence receipt of treatment. Our analyses could not be adjusted for a number of important sociodemographic characteristics, including socioeconomic and insurance status, nor could we adjust for differences in treatment preferences. Experts disagree on how best to conceptualize racial-ethnic disparities. The Institute of Medicine defines disparities as treatment differences unexplained by differences in illness or preferences, which argues against adjusting for sociodemographic factors (80). Finally, our trend data did not measure the potential influence on care of events after 2008, including an extended economic recession, growing emphasis on integrating medical and mental health care, mental health parity legislation, and passage of the Affordable Care Act.

Treatment disparities for specific disorders may arise from different causes and be amenable to different strategies of disparity reduction. The diagnosis-specific patterns we identified highlight disorders worthy of particular focus for disparity reduction efforts and inform speculation about underlying systemic phenomena, which may be helpful to clinicians and policy makers. For instance, it is particularly striking that racial-ethnic minority groups received more treatment than non-Hispanic whites for psychotic and substance use disorders, which are socially disruptive and may carry legal implications, whereas they received markedly less care for a range of anxiety, mood, and personality disorders, which are nonetheless associated with significant distress and functional impairment. These findings might suggest that the contexts and points of entry that often lead to identification of and treatment for psychotic and substance use disorders, such as emergency departments, inpatient units, and law enforcement, could benefit from implementing additional screening for depression and anxiety. At the same time, the settings that commonly provide for identification of mood and anxiety disorders for non-Hispanic whites, such as primary care offices, could better target screening programs for minority groups.

We found substantial racial-ethnic differences in the use of outpatient mental health treatment provided by U.S. physicians. The differences varied substantially by disorder, provider type, and patient age. Many differences were large and did not show evidence of improvement from 1993 to 2008. Findings highlight potentially important diagnostic and sociodemographic patterns. The persistence and magnitude of racial-ethnic differences in care suggest that remediation remains an urgent public health task.

Dr. Manseau received financial and material support for conducting this study from the Residency Training Program in General Psychiatry, New York University School of Medicine. Dr. Case was supported in part by grant K12 DA000357-11 from the American Academy of Child and Adolescent Psychiatry and National Institute on Drug Abuse and by the Leon Levy Foundation Neuroscience Fellowship Program. The authors thank Carole Siegel, Ph.D., and Eugene Laska, Ph.D., for providing statistical consultation. They also thank Dr. Siegel for comments on the manuscript. The views expressed in this article are those of the authors and do not necessarily reflect those of the supporting organizations.

Dr. Case has received research support from the American Academy of Child and Adolescent Psychiatry–Eli Lilly Pilot Research Award and the American Psychiatric Association–AstraZeneca Young Minds in Psychiatry Award and has provided clinical consultation to Blue Cross Blue Shield of Rhode Island and United Behavioral Health. Dr. Manseau reports no competing interests.