Mental health disparities refer to the large gap between different populations in their quality of mental health and frequency and severity of mental health problems, especially among queer and trans people, people living near or below the poverty line, and people of color.

While the fact that mental health disparities exist for groups facing more societal barriers to equitable quality of living may seem to be common sense, in reality, common sense does not provide the concrete evidence necessary to create legislation, the research necessary for nonprofits to secure fund grants for their work, or the media necessary to educate and convince the unaware of the importance of these public health subjects.

Without thorough research to document these realities in detail, making real change, funding further research that will lead to improvements in quality of life, and closing the gaps in care between groups is nearly impossible.

Poor mental health is a significant burden on the people who suffer with little practical recourse and on the public as a whole, and it is much more prevalent than commonly believed. Mental and substance use disorders are the third leading cause of disability in the United States.

In 2021, over 14 million adults in the U.S. had a serious mental illness, meaning their daily functions were disrupted and putting them at higher risk of other health conditions. Social determinants of health lead to disparities not just in poor mental health, but also in the care the health care system can provide for mental health needs, ranging from access to care to levels of treatment engagement related to trust in the medical system.

As always, groups other than white, cisgender, straight, middle- or upper-class people were disproportionately impacted. Racial and ethnic health disparities cost the U.S. economy $451 billion dollars in 2018, an amount which was significantly greater than the 2014 estimate anticipated. National estimates suggest that Black people who received a high school level of education compose the group who bore the brunt of that economic burden. This recent and groundbreaking information was revealed in the very first study to estimate the total economic burden of health disparities across racial and ethnic groups and education levels. The magnitude of the problems caused by layered manifestations of discrimination and their nuanced consequences was not shown by common sense or even with calculated estimates, after all.

“Half the people with a mental health diagnosis are not receiving care in any given year,” said presenter Dr. Joshua Gordeon, director of the National Institute of Mental Health, in a webinar on mental health disparities. “That means half of the people with a mental health diagnosis are not receiving care in any given year. And the fact that these are chronic illnesses means that people who need care are likely not getting it. But that story is even more concerning when one breaks out that percentage by racial and ethnic category, and it shows that individuals who are Black or Asian or Hispanic have dramatically lower rates of receiving any care for mental health in the past year.”

People who identify as American-Indian or Alaska Native have much higher rates of death by suicide than people who are white, and although other racial or ethnic minorities have historically had less risk of suicide for reasons that are not yet understood, that has changed in recent times. This is especially true among youth, particularly amongst Black youth, where rates of death by suicide have dramatically increased over the last 5 years such that Black preteens and teens are dying by suicide at equal or higher rates compared to white children.

“In areas such as examining mental illness trajectories across the lifespan and developing novel treatments, we’ve emphasized NIMH’s commitment to funding research that aims to reduce mental health disparities and promote health equity,” Dr. Gordeon said. “With that, especially, is a renewed interest in understanding and importantly mitigating the impact of social determinants of health on mental illness trajectories. In particular, we have a focus on children. We have a focus on development because mental illnesses have their roots in early development, whether we’re talking about genetic causes, environmental causes, or social causes, and so we need to understand and mitigate those impacts early in life.”

The NIMH is supporting a range of projects to test strategies to enhance mental healthcare and reduce disparities, including the use of telehealth to increase access to care for disadvantaged, minoritized, and rural populations; a telemedicine tool to identify Autism Spectrum Disorder which is tailored to children from traditionally underserved groups where the diagnoses of autism are often made later and the outcomes are historically worse than the majority population; a video-based therapy for mothers with perinatal depressive symptoms who live in rural communities; and an intervention to encourage family medicine providers to offer HIV prevention services in the Deep South, focusing on populations that are at the greatest risk for HIV.

“We knew before the pandemic about disparities and mental health outcomes driven by social determinants of health, as I mentioned before, including racism, housing, and food insecurity, access to, and quality of care,” Dr. Gordon said. “During the pandemic, we also knew that some populations were particularly vulnerable. These include the same populations that were suffering mental health disparities, people with preexisting mental and substance use disorders, and the healthcare workforce.”

These were the individuals who were faced with the brunt of the pandemic, who had to go to work regardless of the need to protect themselves, who had the least capacity to engage in and take advantage of opportunities to protect themselves. Their communities were hardest hit by the pandemic. “We know that those who are hardest hit by any disaster are the most likely to develop mental health consequences,” Dr. Gordon said. “We also saw their direct associations between rising symptoms of depression and suicidal ideation and experiences of discrimination, and that was shown through studies that were funded by NIMH, all of us, and other organizations examining the mental health impact of the pandemic.” Dr. Gordon said this was true with both depression symptoms and suicidal ideation. The effects of discrimination increased and worsened these symptoms in the context of the pandemic.

Some potential mitigation efforts had positive impacts on mental health. For example, the state eviction moratoriums that were put in place across the United States were shown to be associated with improvements of mental health through studies funded by the NIH and NIMH, such that in the 30 days after the inaction of a state moratorium, or the 30 days after its withdrawal, data indicated that those moratoriums reduce the number of days not in good mental health and reduce the likelihood of an individual to experience frequent mental distress.

Expanding cash assistance by easing the rules associated with that cash assistance led to similar improvements in mental health and decreasing the number of days not in good mental health. A number of different interventions were tried in different states. Each of them led to positive outcomes, such as giving emergency cash benefits to those who were not participating before the pandemic, subsidizing wages for people whose work hours were cut, wave work requirements for benefits waived or paused sanctions and automatically recertifying benefits. All of these reduced the number of days not in good mental health.

Ongoing research is still looking at the effects of structural inequalities that contributed disparities in COVID-19-related mental health outcomes. These include how pandemic-related stressors and state-level policies jointly shape these disparities. “The impact of COVID-19 and racial discrimination on health outcome in black, pregnant, and postpartum people is a particular interest,” Dr. Gordon said, “and a community-based intervention to address inequalities and disparate consequences of the pandemic on immigrants and refugees from ethnic minority populations.

These are examples of ongoing research. So if I could summarize the COVID-19 data, it’s clear that COVID-19 increased the degree of mental health disparities in the United States, increased our attention on them, and provided opportunities to understand how to mitigate the determinants of these disparities that can be used in intervention studies moving forward aimed at reducing the disparities.”

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