World Mental Health Day, a day for raising awareness around mental health and how it impacts all of our lives. Each year, World Mental Health Day is assigned an accompanying theme, and this year it’s ‘mental health for all’. This got us thinking, is mental healthcare available and working for all of us?
Vast inequalities still exist between white people and ethnic minorities when it comes to healthcare, and mental health is no exception. In recent UK government statistics, white people have consistently been the ethnic group that benefits most out of therapeutic interventions for depression and anxiety, with ethnic minorities showing less improvement:
60.8% of Bangladeshi patients improved after therapy interventions compared with 68.1% of white patients.
5.5% of white women deteriorated after therapy, compared with 8% of Bangladeshi women and 7.8% of Asian (other) women.
On top of this, the risk of psychosis in Black Caribbeans is estimated to be seven times greater than in the White population, and detention rates under the Mental Health Act during 2017/18 were four times greater in the Black British population than the White British population. In terms of depression, suicide rates are higher among young Black African and Black Caribbean men, and middle-aged Black African, Black Caribbean and South Asian women, compared with their White British counterparts. Evidently, something isn’t right.
So, what’s causing these disparities in mental health care?
Barriers preventing adequate care in mental health treatment include:
Medical mistrust due to historical mistreatment of ethnic minorities within healthcare
Lack of understanding of stereotyping and discrimination burdens
Changes in symptoms displayed due to moral, religious, political and social crises
Avoidance of medical attention due to cognitive, affective, physical and value-orientation barriers or previous experiences of discrimination
Clinical bias in diagnosis due to misunderstanding of cultural beliefs and values
All the barriers above indicate that cultural safety is extremely important in the diagnosis and treatment of mental disorders in ethnic minorities.
These disparities extend to mental health clinical trials too
The actual drug treatment received by ethnic minorities is of particular importance too. Across all disciplines of medicine, ethnic minorities are often underrepresented in clinical trials, even though treatment response can vary with ethnicity. So, we don’t know if everyone is truly receiving the safest and most effective treatment for them. There are many barriers that prevent the fair representation of ethnic minorities in mental health clinical trials, many of which overlap with the barriers in mental health services, including: negative attitudes to psychotherapy, language barriers, medical mistrust, religious beliefs and stigma.
Multiple papers have reported that attitudes towards psychotherapy could be a barrier in the recruitment of ethnic minorities, with one paper finding that African Americans with emotional problems would prefer alternatives to mental health services, or to not seek help at all. In addition to this, there is emphasis on the role of religion and family in supporting mental health problems, which can hinder health seeking behaviours outside of these circles.
Participants whose first language isn’t English have often described communication barriers as a problem in patient recruitment, and this is further exemplified in patients with mental illnesses. The issue of communication barriers in addition to having a serious mental illness can be an overwhelming barrier in terms of patient recruitment. To combat this, we need to make sure patient recruitment materials are being translated in a way that is culturally sensitive, as specific terms and phrases can be alarming to minority groups. One paper said that through listening to the views of African American women, researchers were able to identify language and expressions commonly used by African Americans, which could aid patient recruitment.
Many studies have highlighted the views of ethnic minority groups towards mental health services, and their associated clinical trials. Some of which have reported direct links between perceptions of clinical trials and the Tuskegee scandal, which has led to minority groups mistrusting clinical trials generally. Studies have also found that in some communities, psychiatrists are likened to policemen, and as a result there is fear around being involuntary hospitalised. Willingness to participate in clinical trials requires a large amount of trust, so putting in effort to build meaningful relationships between researchers and people from ethnic minority communities is essential.
Lastly, the stigma around mental health can be felt across all ethnic groups. But research shows that the stigma around mental health could be a greater problem among ethnic minorities. One difference lies in the perceived consequences of psychiatric treatment. While older white people may be concerned over their own reputation following a diagnosis, older minorities may be troubled over the impact a psychiatric diagnosis would have on their family’s reputation. This subtle difference can lead to an impression of a burden bigger than oneself, and therefore adds to the negative stigma surrounding mental health and creates a barrier to patient recruitment.
The barriers discussed may directly prevent people from taking part in a clinical trial, but could also lead to people never receiving a formal diagnosis and therefore never knowing a clinical trial is available to them. The issues surrounding mistrust are deeply rooted in many communities, but simple changes, such as cultural safety training for healthcare professionals and those involved in clinical research, can go a long way. It’s these changes that can ultimately help make mental health care available for all.