Systematic racism is at the core of mental health disparities and social determinants of mental health (SDoMH). This embedded cultural norm refers to societal systems in place that create and maintain racial inequality in nearly every facet of life for people of color (Yancy-Bragg, 2020). Rapidly emerging data reveals the impact of systematic racism on mental health access for populations historically identified as marginalized, as well as those vulnerable to societal bias and practice. The translation is that persons most in the need of mental health care are least able to access it.

People who identify as Black, Indigenous, and of color (BIPOC) are less likely to have access to, and receive mental health care reflective of their needs (American Psychiatric Association, 2017; Gibbs et al., 2020; Mental Health America, 2020; Rogers, 2020). Members of the LGBTQ+ community and persons with disabilities (physical and/or mental illness) face a sad reality in obtaining culturally affirming mental health, with oppression and judgement often accompanying their treatment experience (Altiraifi & Rapfogel, 2020). Upstream factors of racism and stigma obstruct patient access to necessary and appropriate mental health assessment, timely intervention, with treatment for these populations often reflecting poorer quality, and ending prior to completion of treatment (Altiraifi & Rapfogel; 2020; Rogers, 2020; American Psychiatric Association, 2017). COVID-19 and the recent pandemic have only amplified these factors, further widening meso and micro-level gaps in care. These realities mandate immediate change in how mental health care is considered, provided, and reimbursed.

Intersection of the Pandemic and the SDoMH

The intersection of pandemic and SDoMH has yielded fierce gridlock. Populations were forced pre-pandemic to cope with systematic racism’s impact on mental health access to appropriate care (e.g., BIPOC, gender identity, sexual orientation, persons with disabilities). These groups now experience further insult to injury from being forced to deal with higher rates of unemployment and lack of insurance coverage, illness transmission and death of family members and friends, disrupted socialization, and forced isolation. In addition, rising numbers of persons formally identified as the “haves” in society have become “have nots”. This latest reality has meant intense competition for already insufficient mental health resources.

Over 28 million people in the United States (U.S.) are receiving unemployment (Shierholz, 2020) with numbers expected to rise. Increased numbers of persons are at risk of housing insufficiency from loss of income due to  job furloughs, layoffs, and employer closures. With eviction protections and moratoriums rescinded approximately 40 million persons are at risk of homelessness (De La Garza, 2020). Food insecurity is at dangerously high levels, with 35.2 million persons living in food insecure households (USDA, 2020). This number is expected to increase secondary to pandemic-related closures of meal services, food pantries, and limits to available resources. Many persons are fearful of virus transmission from venturing out to the market. This issue only contributes to increased isolation and manifestation of depression and anxiety in poorer communities where virus transmission continues to peak.

Research affirms the SDoMH reality for persons dealing with housing and food insecurity especially. Sandel et al., (2018) studied over 22,000 families who experienced impact to their psychosocial circumstances (e.g., housing, food insecurity, caregiver instability). Persons who were behind on rent dealt with (Sandal et al., 2018) :

• quadruple rates of food insecurity,
• twice the rate of maternal depression, and
• higher rates of child hospitalizations and developmental delays compared to those with stable housing.

Ettman et al. (2020) identified especially high rates of depression both prior to and during the U.S. pandemic. Individuals across racial and ethnic populations with lower incomes and less than $5000 in savings experienced especially severe symptoms of depression (Ettman et al., 2020). The manifestation of severe mental health exacerbation has continued to be a significant cost burden for the healthcare industry by driving unnecessary emergency department (ED) visits. With access to mental health care at issue, EDs may be the only site to access care, which poses added financial drain on providers, and the industry. Patient with psychiatric needs directly cost an ED up to $2,264 per visit, easily presenting dozens of times annually from inability to access appropriate and timely psychiatric follow-up or their prescriptions (Schall et al., 2020).

Case(s) in Point: Evidence in Action

          My initial intent for this blog post was to provide a case scenario detailing the SDoMH. However, abundant data and happenings around the states speak volumes about the prevalence of systematic racism, plus continued mental health disparities. The realities listed below are more meaningful than any case scenario and offer compelling validation of the mandate for change:

• Recent action by the Texas Board of Social Work to remove discrimination protections for persons with disabilities and the LGBTQ+ community from state practice regulations at the Governor’s request (NASW of Texas, 2020). (Note: as of 10/27/20 this action has been reversed by the Texas Board of Behavioral Health Executive Council, with all language reinserted within the social work code).
• Members of the LGBTQ+ community more likely than non-LGBTQ+ persons to have mental health disorders, with
• LGBTQ+ persons who identify as BIPOC at higher risk than other populations (e.g., white) of mental health exacerbation, and most likely at risk for:
  • alcohol/substance abuse disorders
  • anxiety
  • depression
  • eating disorders, and
  • psychosis (Mental Health America, 2020)
• Native American and Indigenous persons at higher risk for bipolar disorder and post-traumatic stress disorder than the general population (Mental Health America, 2020)
• Sixty-nine percent of Black adults with mental illness and 42% of black adults with serious mental illness received no treatment in 2018 (Gibbs et al., 2020)
• Children and adolescents living amid poverty diagnosed with mental illness experience access to care challenged related to insufficient WIFI or appropriate digital devices to access virtual health platforms for appointments (Gibbs, et al., 2020)
• The criminal justice system has a high concentration of persons identified as BIPOC (Sawyer & Wagner, 2020):
  • over 50% of those incarcerated with mental health concerns, and
  • quality of mental health treatment in prisons identified as subpar
• SAMHSA’s recent reports (2020a, 2020b) on opioid use across BIPOC communities note:
  • high incidence of trauma and discrimination experienced by the Latinx population contributing to increased substance use and abuse, and
  • Non-Hispanic Blacks experiencing a sharp rise in deaths from synthetic opioids, up 818% compared to all races/ethnicities
• Peverill & McLaughlin (2020) identified children in families with a low socioeconomic status display greater psychopathology, particularly depression and anxiety.
• Continuing stigma exists with respect to mental health and reimbursement (NAMI, 2017):
  • Medicaid remains the primary payment source behavioral health and substance use, paying significantly lower than other payment sources, and
  • rejection of patients with Medicaid continues at higher than average rates
  • lengthy wait lists of 3-9 months for psychiatrists, with lapses in prescription medication evaluation and management.

Advancing Action

Solid recommendations to address the SDoMH will advance action to mitigate the deepening voids in care. Each recommendation is a blog post of itself, with the list below compiled to ignite your efforts towards greater system change:

1. Expand coverage and reimbursement for mental health.
2. Assure providers and communities in need receive their share of immediate funding promised (e.g., Coronavirus Aid, Relief, and Economic Securities (CARES)Act, Families First Coronavirus Response Act).
3. Advance grant funding for roles to engage and grow community-based mental health programs (e.g., peer support, community health workers).
4. Grow and implement Anti-racist interventions through use of Cénat’s (2020) guidelines to provide anti-racist care focused on:
   1. awareness of racial issues
   2. assessment adapted to the real needs of Black individuals
   3. use of a humanistic approach to medication
   4. treatment approaches that address the real needs and issues related to racism experienced by Black individuals
5. Implement trauma-informed cultures and interventions that address rather than retrigger oppression and trauma in populations.
6. Stay informed on, plus use current data to make your own case to provide anti-racist and culturally inclusive care:
   1. The ACES Connection serves as a global clearinghouse for data on anti-racism, trauma, and interventions toward change.
   2. The American Psychological Association and Centers for Disease Control and Prevention (CDC)’s National Center for Health Statistics continue to update their data sites.
   3. Mental Health America expanded their data clearinghouse and resources on assorted related topics including racism and mental health, BIPOC and LGBTQ+ populations.
   4. National Association of Mental Illness (NAMI) provides data, resources, and guidance for patients and practitioners across identity and cultural dimensions.
   5. SAMHSA has continued to inform the industry on behavioral health equity practices.

New and evolving research and interventions validate the vast human and financial toll of the SDoMH. Now is the time to directly focus on systematic racism, and the other upstream factors that exacerbate patient harm. Proactive attention to these disrupters is key to assure appropriate attention to population-focused mental health, and mitigation of the SDoMH.

This blog first appeared as an assignment for Cummings Graduate Institute of Behavioral Health Studies, DBH: 9016, Fall 2020. #DBH #DBHRocks #SDoMH

Bio: Ellen Fink-Samnick is an award-winning industry thought leader who empowers healthcare's interprofessional workforce. She is a sought out professional speaker, author, and educator for her innovative content and vibrant presence. Ellen is an international national expert on the Social Determinants of Health, Workplace Bullying, Professional Ethics, Professional Case Management Practice, and Wholistic Case Management™. Her recent books include, The Essential Guide to Interprofessional Ethics for Healthcare Case Management The Social Determinants of Health: Case Management's Next Frontier, and upcoming End of Life for Case Management, all through HCPro. Along with several academic teaching appointments, Ellen is Lead for RISE's SDoH Community and Doctor in Behavioral Health (DBH) candidate at Cummings Graduate Institute for Behavioral Health Studies. View more on her LinkedIn Profile.

References

Altiraifi, A., & Rapfogel, N. (2020, September 10). Mental health care was severely inequitable, then came the coronavirus crisis. Center for American Progress. Retrieved from  https://www.americanprogress.o...-coronavirus-crisis/

American Psychiatric Association (2017). Mental health facts for diverse populations, Mental Health Disparities.Retrieved from https://www.psychiatry.org/psy.../mental-health-facts

Cénat, J.M. (2020). How to provide anti-racist mental health care. The Lancet Psychiatry. 7(11), p. 929-931, DOI: 10.1016/S2215-0366(20)30309-6

De La Garza, A. (2020, September 21) 'How Am I Going To Make It?' Months of Eviction Uncertainty Are Taking a Toll on Millions of Families. Health-COVID-19. Time. Retrieved from https://time.com/5890184/evict...ental-health-crisis/

Ettman, C.K., Abdalla, S.M., Cohen, G.H., Sampson, L., Vivier, P.M., & Galea, S. (2020). Prevalence of depression symptoms in US adults before and during the COVID-19 pandemic. JAMA Network Open. 2020;3(9):e2019686. doi:10.1001/jamanetworkopen.2020.19686

Mental Health America (2020) BIPOC mental health. Retrieved from https://www.mhanational.org/bipoc-mental-health

National Association of Mental Illness (NAMI) (2017). The doctor is out: continuing disparities in access to mental and physical health care: author.

National Association of Social Workers Texas (2020) Statement by texas chapter of the national association of social workers in response to the Texas state board of social worker examiners change to the social work code of conduct,  NASW, Texas, Retrieved from https://cdn.ymaws.com/www.nasw...ement_10.15.2020.pdf

Peverill, M., Dirks, M.A., Narvaja, T., Herts, K.L., Comer, J.S., & McLaughlin, K.A. (2020). Socioeconomic status and child psychopathology in the United States: A meta-analysis of population-based studies. Clinical Psychology Review. Pre-proof, https://doi.org/10.1016/j.cpr.2020.101933

Rogers, K. (2020, October 10). People of color face significant barriers to mental health services. CNN Mental Health. Retrieved from https://www.cnn.com/interactiv...e-of-color-wellness/

Sandel, M., Sheward, R., Ettinger de Cuba, S., Coleman, S.M., Frank, D.A., Chilton, M., Black, M., Heeren, T., Pasquariello, J., Casey, P., Ochoa, E., & Cutts, D., ( 2018). Unstable housing and caregiver and child health in renter families. Pediatrics. February 2018,  141 (2) e20172199; DOI: https://doi.org/10.1542/peds.2017-2199

Sawyer, W., and Wagner, P. (2020, March 24). Mass incarceration: the whole pie 2020. Prison Policy Initiative. Retrieved from https://www.prisonpolicy.org/reports/pie2020.html

Schall, M., Laderman, M., Bamel, D., & Bolender, T. (2020) Improving Behavioral Health Care in the Emergency Department and Upstream. IHI White Paper. Institute for Healthcare Improvement.

Shierholz, H. (2020, October 1). With millions of workers receiving unemployment benefits and no end in sight for the COVID-19 pandemic, Congress must act, Economic Policy Institute. Retrieved from https://www.epi.org/blog/with-...c-congress-must-act/

Substance Abuse and Mental Health Services Administration (2020a). The Opioid Crisis and the Black/African American Population: An Urgent Issue. Publication No. PEP20-05-02-001. Office of Behavioral Health Equity. Substance Abuse and Mental Health Services Administration, 2020.

Substance Abuse and Mental Health Services Administration (2020b). The Opioid Crisis and the Hispanic Population: An Urgent Issue. Publication No. PEP20-05-02-002. Office of Behavioral Health Equity. Substance Abuse and Mental Health Services Administration, 2020.

United States Department of Agriculture (USDA) (2020). Food security in the United States. Key statistics & graphics. Retrieved from https://www.ers.usda.gov/topic...aphics.aspx#insecure

Yancy-Bragg, N. (2020, June, 15). What is systemic racism? Here's what it means and how you can help dismantle it. USA Today.Retrieved from https://www.usatoday.com/story...oes-mean/5343549002/