Mental Health Equity in the Twenty-First Century: Setting the Stage

Group of WomenSignificant disparities persist in the screening, diagnosis, and treatment of mental health issues for racial and ethnic minorities compared with white people.  Reducing mental health disparities, and ultimately achieving mental health equity, requires understanding the wide range of factors that influence health outcomes at multiple social-ecological levels.  To achieve equity, in a recent Psychiatric Clinics of North America article, Christina Mangurian, MD, MAS and colleagues detail four components of an effective strategy.

Payment and delivery system models that incorporate improvement in value and quality outcomes are critical factors in achieving mental health equity.  Federal and state systems-level change in payment and delivery models are needed to incentivize population-based care, a key element in achieving mental health equity.  Current fee-for-service models reward volume regardless of the quality of service.  As health systems move toward reimbursing bundled episodes of care, they will be more likely to incorporate changes in their systems that improve the overall health of individuals; mental health disorders will need to be better implemented in this reform.  Disparities created by states that have opted out of the Affordable Care Act (ACA) Medicaid expansion also need to be addressed.
Mangurian and colleagues illustrate needed delivery system reforms to increase access such as addressing structural barriers, including availability and proximity of appropriate facilities in a geographic location and limited mental health referrals, which affect marginalized populations’ ability to access quality mental health care.  Shifting care from high-cost inpatient and hospital-based emergency services to community-based locations providing crisis services, care coordination, and increased community support also helps with increasing equity.  As health systems bear more of the risk and cost for care, the system take on the responsibility of improving the social determinants of health in order to improve health care conditions, including mental health, which can take the form of providing housing or transportation services as examples.

Working directly with communities and coalitions to improve services is another recommendation of the authors.  Partnering with community-based programs and key sociocultural institutions within vulnerable communities is critically important in achieving mental health equity.  One example of a mental health intervention that can work synergistically within trusted institutions and community sites (eg, faith-based organizations, schools, beauty salons, barbershops) is Mental Health First Aid (MHFA).  MHFS is a skills-based course that trains participants to identify signs of a mental health or substance use crisis and assist others to obtain help.  Another example is crisis intervention teams (CITs) to address mental health disparities.  Nationwide, CITs bring together law enforcement, mental health professionals, consumers and their advocates to develop and implement strategies to divert individuals with mental illness from the criminal justice system, where they are disproportionately represented.
Increasing the pipeline and diversifying the workforce is another component Mangurian and colleagues endorse.  The authors propose that the best approach to diversify the mental health workforce is an anti-stigma and recruitment campaign throughout the education system, starting in elementary school and continuing through residency.  There is a clear need to not only strengthen the pipeline but also for institutions to support those who are working in public psychiatry settings, using supports including mentorship, sponsorship, and funding.

Finally, the authors recommend empowering patients with interpersonal interventions and developing structural competence in providers.  Racial and ethnic diagnostic disparities within psychiatry is a persistent problem and has implications across the continuum from assessment to diagnosis to intervention.  Providers should be given training in structural competence so that they have tools to address challenges facing their patients and families, including considering the ability of patients to follow recommended treatment regimens in their environments and make suggestions on how to achieve treatment goals in their context.  Provider interventions such as using shared decision making, speaking with jargon-free language, tailoring communication and treatment plans to patient preferences, discussing clinician backgrounds, acknowledging power differentials, and observing differences in communication styles may improve participation in treatment.

“I think that partnering with community-based programs and thinking outside of the box is key right now to reach all of our populations of color, especially during COVID-19,” said Mangurian.  “This work is happening across the country and locally through ZSFG Psychiatry. I am also proud (and incredibly encouraged) by the strength of a group I started of diversity leaders in psychiatry.”

At the core of the social-ecological model lies the intrapersonal level where interventions can specifically target patients’ mental health knowledge and beliefs about mental illness, including internalized stigma and skillfulness in navigating a complex mental health landscape.
Christina MangurianChristina Mangurian, MD, MAS

Dr. Mangurian is a professor of Clinical Psychiatry and the UCSF Department of Psychiatry’s Vice Chair for Diversity and Health Equity.  She founded and directs the UCSF Program of Research on Mental health Integration among Underserved and Minority populations (PReMIUM).  Dr. Mangurian’s research focuses on improving diabetes screening and HIV care of people with severe mental illness (e.g.; schizophrenia, biopolar disorder), particularly among underserved minority populations.

Mental Health Equity in the Twenty-First Century: Setting the Stage.
Alves-Bradford JM, Trinh NH, Bath E, Coombs A, Mangurian C. Psychiatr Clin North Am. 2020 Sep;43(3):415-428. doi: 10.1016/j.psc.2020.05.001. Epub 2020 Jul 15.