The Use of Professional Services and Informal Support Among African Americans and Caribbean Blacks with a Mental Disorder

Abstract

Objectives

This study investigated the use of professional services and informal support among African Americans and Caribbean Blacks with a lifetime mood, anxiety, or substance disorder.

Methods

Data were from the National Survey of American Life (NSAL). Multinomial logistic regression was utilized to test the use of professional services only, informal support only, both, or no help at all. Analyses controlled for sociodemographic characteristics, disorder-related variables, and family network variables.

Results

The analytic sample included 1,096 African Americans and 372 Caribbean Blacks. Forty-one percent used both professional services and informal support, 14% relied on professional services only, 23% used informal support only, and 22% did not receive help. There were no significant differences in help-seeking between African Americans and Caribbean Blacks. Having co-occurring mental and substance disorders, a severe 12-month disorder, more people in the informal helper network, and being female increased the likelihood of receiving help from both professional services and informal supports. When men did receive help they were more likely to rely on informal helpers. Marital status, age, and socioeconomic status were also significantly related to help-seeking.

Conclusions

The significant proportion of black Americans with a mental disorder who are relying on informal support alone, professional services alone, or receiving no help at all suggests potential unmet need among this group. However, the reliance on informal support for assistance may also be evidence of a strong protective role that informal networks play in the lives of African Americans and Caribbean Blacks.

Introduction

Research on mental health service utilization has consistently found that most adults with a mental disorder do not receive treatment. According to recent national surveys less than half of adults with a mental disorder used services in the twelve months before the interview (1,2). Racial and ethnic minorities, in particular, underutilize mental health services. African Americans, for example, have been found to be less likely than whites to use outpatient mental health services (1,3,4,5,6,7). Only 32% of black Americans with any mental disorder have been found to use professional services (2), while only 22% of Caribbean Blacks and 48% of African Americans with severe symptoms of major depression receive treatment (8). These findings suggest that the service needs of a significant proportion of black Americans with mental disorders are not being met.

It is possible, however, that those who do not use professional services receive help from informal support networks instead. Evidence for this is mixed. One study of older African American residents of public housing, found that respondents were more likely to use professional services than informal help (9). Other studies have found a tendency for adults with a mental disorder to use informal support as a complement to rather than a substitute for professional services (10,11,12,13). These studies, however, have samples with limited generalizability or focus on the receipt of informal care as a predictor of professional service use.

In contrast, research using the National Survey of Black Americans (NSBA) examines the use of professional services and informal support simultaneously. These studies found that, when faced with a personal problem, roughly equal proportions of African Americans used informal support only or both professional services and informal support while much smaller proportions relied on professional services only or did not receive help at all (14). Informal support was, therefore, an important source of assistance used both in conjunction with and in place of professional services.

This study examines the use of four help-seeking options—the use of professional services only, informal support only, a combination of the two, or not receiving help at all—among African American and Caribbean Black adults who meet diagnostic criteria for a mental disorder. This study builds on existing knowledge in several ways. First, it considers the characteristics of nonusers in relation to both professional services and informal support to broaden our understanding of the help-seeking process among adults with a mental disorder. Second, it examines individuals who meet diagnostic criteria for a lifetime mood, anxiety, or substance disorder to better understand how both mental and substance disorders are related to patterns of help-seeking. Third, it includes Black Caribbeans in the United States, a small but significant portion of the general black American population.

Methods

Sample

This study uses data from the National Survey of American Life: Coping with Stress in the 21^st Century (NSAL) (15). The NSAL is based upon an integrated national household probability sample of 6,082 African Americans, non-Hispanic whites and blacks of Caribbean descent aged 18 or older. Data were collected between February 2001 and June 2003 by the Program for Research on Black Americans at the University of Michigan's Institute for Social Research. After complete description of the study to the participants, informed consent was obtained. This study was approved by the University of Michigan Institutional Review Board.

The analytic sample includes 1,096 African Americans and 372 Caribbean blacks who met diagnostic criteria for a mood disorder (major depression, dysthymia, bi-polar I & II), anxiety disorder (panic, social phobia, agoraphobia without panic, generalized anxiety, post-traumatic stress), or substance disorder (alcohol abuse and dependence, drug abuse and dependence) (n=1,468). Mental disorders were assessed using the Diagnostic and Statistical Manual (DSM-IV) World Mental Health Composite International Diagnostic Interview (WMHCIDI), a fully structured diagnostic interview (16).

Measures

The dependent variable consists of four mutually exclusive categories describing patterns of help respondents could use for a mental disorder—professional services only, informal support only, both professional services and informal support, or no help at all. For each disorder, respondents were asked two questions related to help-seeking. For example, for depression respondents were asked “Did you ever in your life talk to a medical doctor or other professional about your (sadness/or/discouragement/or/lack of interest)”? and “Did you ever in your life receive any help from family, friends, or other acquaintances for your (sadness/or/discouragement/or/lack of interest)”? These questions were asked for each disorder using the appropriate descriptors.

Demographic characteristics include ethnicity (African American, Caribbean Black), age (in years), gender, and marital status (currently married, previously married, never married). Socioeconomic status is measured by employment status (working, not working); education (high school or less, some college, or a college degree or higher); and a poverty index (ratio of family income to the census poverty threshold for 2001). There is also a dichotomous measure of whether or not the respondent has health insurance.

A three-category variable indicates whether the respondent has a mental disorder only, a substance disorder only, or co-occurring mental and substance disorders. A four-level rating of overall mental illness severity was determined for the 12 months before the interview (severe/serious, moderate, mild, or none) (17). Because the sample for this paper is limited to those with a lifetime disorder, the fourth category corresponds to those who meet criteria for a lifetime disorder, but have not experienced an episode within the last twelve months.

Finally, three variables describe the family network of respondents: a continuous measure of the size of the helper network; frequency of contact with family members (0 = “never” to 6 = “nearly everyday”); and subjective family closeness (0 = “not close at all” to 3 = “very close”).

Analysis

Cross-tabulations are presented to illustrate the independent effect of each predictor on the use of professional services and informal support. The Rao-Scott chi-square for categorical variables and an F means test for continuous variables are presented. Multinomial logistic regression analysis was used to test the use of professional services and informal support controlling for sociodemographic characteristics, disorder-related variables, and family network variables. The reference category is using both professional services and informal support. All statistical analyses were performed using the survey commands in STATA 9.2, accounting for the complex multistage clustered design of the NSAL sample, unequal probabilities of selection, nonresponse, and poststratification to calculate weighted, national representative population estimates and standard errors. All percentages reported are weighted.

Results

Forty-one percent of respondents (n=598) used both professional services and informal support, 14% (n=197) relied on professional services only, and 23% (n=339) used informal support only. Twenty-two percent (n=334) did not receive any help at all. Table 1 presents the bivariate analysis of the independent variables on the source of help. Respondents who relied exclusively on informal support were on average younger than those who utilized other categories of help-seeking. More men than women did not receive help while almost half of women used both professional services and informal support.

Table 1.

Description of sample and bivariate relationships between predictors and help-seeking categories among African Americans and Caribbean Blacks with a mood, anxiety, or substance disorder

	Total (n=1468)		Professional only (n=197)		Informal only (n=339)		Both (n=598)		None (n=334)
Characteristic	Na	%	Na	%	Na	%	Na	%	Na	%	Test statistic	pb
Race/ethnicity
African American	1096	94	151	14	257	24	454	41	234	22	1.21	0.305
Caribbean Black	372	6	46	12	82	15	144	48	100	25
Age (M±SD)	40.12±14.20		43.36±13.39		35.85±13.74		41.36±13.67		40.24±15.41		23.37	<.001
Gender
Male	509	43	74	14	119	24	161	33	155	29	9.89	<.001
Female	959	57	123	14	220	23	437	47	179	16
Education
less than HS	396	29	56	16	88	21	145	27	107	27
HS	490	33	66	15	126	26	189	39	109	20	1.76	0.130
Some college or higher	582	39	75	12	125	23	264	49	118	19
Poverty Index (M±SD)c	2.53±2.66		2.25±2.05		2.87±3.34		2.65±2.67		2.12±2.09		3.58	0.020
Employment status
Working	952	66	121	13	242	26	354	38	235	24	5.41	0.002
Not working	516	34	76	17	97	18	244	48	100	18
Insurance coverage
Yes	1148	78	162	14	249	23	487	42	250	21	0.87	0.455
No	320	22	35	13	90	24	111	39	84	26
Marital status
Currently married	460	37	56	10	111	29	183	42	110	23
Previously married	473	30	76	19	91	18	215	44	91	19	3.84	0.002
Never married	535	33	65	13	137	26	200	37	133	24
Disorder
Mental disorder only	1016	64	132	13	257	26	411	42	216	19
Substance disorder only	225	18	38	18	39	18	53	21	95	43	11.65	<.001
Mental & substance disorders	227	18	27	12	43	18	134	59	23	11
Severity
Lifetime, not 12-month	616	43	90	16	158	28	191	29	177	28
Mild, 12-month	301	19	31	9	73	25	119	42	78	25	9.96	<.001
Moderate, 12-month	389	25	56	16	91	22	181	48	61	14
Severe, 12-month	162	12	20	11	17	8	107	71	18	10
Network variables (M±SD)
Size of helper network	7.38±10.23		5.37±9.00		7.22±9.78		8.36±10.53		7.00±10.74		6.31	0.001
Frequency of contact w/familyd	4.95±1.38		4.58±1.62		5.04±1.29		5.06±1.29		4.89±1.45		3.87	0.014
Subjective family closenesse	2.48±.75		2.18±.87		2.56±.67		2.51±.73		2.53±.75		6.57	0.001

^aUnweighted n

^bFor differences across the four categories (F test for means and design-corrected χ² for %s)

^cPoverty index ranges from 0 to 33 with higher scores indicating household income is further away from the poverty threshold

^dPossible scores range from 0 to 6 with higher scores indicating more frequent contact with family

^ePossible scores range from 0 to 3 with higher scores indicating more closeness to family

On average, the ratio of income to the poverty threshold was higher for those who relied on informal support only or both professional services and informal support than for respondents who used professional services only or received no help at all. A higher proportion of respondents who were working used informal support alone or did not receive help at all. A smaller proportion of those who were previously married did not receive any help or relied on informal support only.

In terms of disorder-related variables, a greater proportion of those with a substance disorder only did not receive help compared to respondents with a mental disorder only and those with co-occurring disorders. A greater proportion of respondents with a mental disorder only relied exclusively on informal support compared to those with a substance disorder only or co-occurring disorders. Almost three-quarters of respondents with a severe 12-month disorder used both professional services and informal support which is substantially more than for those with less severe disorders.

Finally, a greater proportion of respondents who had smaller helper networks used professional services only. Those with more frequent contact with family used both professional services and informal support or informal support alone while respondents who had lower levels of subjective family closeness used professional services only.

In multinomial logistic regression analyses (Table 2), all variables except ethnicity and having insurance coverage were significantly related to help-seeking. Younger adults had a higher likelihood of using informal support only as compared with using both professional services and informal support exclusively. Men were more likely than women to use informal support only or to not receive help at all compared to using both professional services and informal support.

Table 2.

Multinomial logistic regression of sociodemographics, disorder-related variables, and family network variables on patterns of help-seeking with using both professional services and informal support as reference category^a

Variable	Professional only			Informal only			None
	Coeff	se	P	Coeff	se	P	Coeff	se	P
Race/ethnicity
African American	−0.02	0.40	0.962	0.73	0.41	0.082	−0.14	0.35	0.698
Caribbean Black (reference)
Age (cont)	0.01	0.01	0.316	−0.04	0.01	<.001	−0.004	0.01	0.709
Gender
Male	0.36	0.26	0.176	0.61	0.19	0.002	0.91	0.22	<.001
Female (reference)
Education
HS or less (reference)
Some college	−0.18	0.28	0.519	−0.19	0.21	0.381	−0.52	0.2	0.012
College degree or higher	−0.55	0.36	0.136	−0.61	0.27	0.026	−0.64	0.25	0.012
Employment status
Working	0.17	0.21	0.413	0.39	0.19	0.047	0.74	0.29	0.013
Not working (reference)
Marital status
Married (reference)
Previously married	0.60	0.21	0.006	0.06	0.19	0.758	−0.12	0.24	0.630
Never married	0.48	0.25	0.057	0.09	0.22	0.669	0.41	0.26	0.114
Poverty Index (cont)b	−0.03	0.05	0.584	0.04	0.04	0.329	−0.15	0.06	0.014
Has health insurance
Yes	0.13	0.28	0.651	−0.06	0.16	0.735	−0.19	0.21	0.376
No (reference)
Disorder
Mental disorder only (reference)
Substance disorder only	0.67	0.38	0.091	−0.13	0.36	0.724	0.84	0.32	0.010
Both mental and substance	−0.58	0.27	0.028	−0.76	0.22	0.001	−1.26	0.28	<.001
Severity
Lifetime, not 12-month	1.18	0.33	0.001	2.04	0.29	<.001	1.64	0.36	<.001
Mild, 12-month	0.29	0.39	0.472	1.53	0.38	<.001	1.28	0.39	0.002
Moderate, 12-month	0.78	0.36	0.032	1.24	0.33	<.001	0.72	0.37	0.057
Severe, 12-month (reference)
Network variables
Size of helper network	−0.03	0.01	0.020	−0.02	0.01	0.000	−0.02	0.01	0.041
Frequency of contact with familyc	−0.04	0.06	0.509	0.01	0.06	0.900	0.01	0.08	0.935
Subjective family closenessd	−0.44	0.14	0.003	0.22	0.17	0.187	0.09	0.16	0.570

^aUsing both professional services and informal support help is comparison group

^bPoverty index ranges from 0 to 33 with higher scores indicating household income is further away from the poverty threshold

^cPossible scores range from 0 to 6 with higher scores indicating more frequent contact with family

^dPossible scores range from 0 to 3 with higher scores indicating more closeness to family

Respondents with a college degree or higher were less likely than those with a high school degree or less to use informal support alone compared to using both professional services and informal support and those with some college or a college degree or higher were more likely to receive help. Respondents who were working were more likely than those who were not working to rely exclusively on informal support or to not receive any help at all. Those who were previously married were more likely than those who were currently married to use professional services only compared to using both professional services and informal support. The higher the ratio of household income to the poverty threshold the more likely the respondent received help; that is, those living closer to poverty were less likely to receive any help.

The type of disorder was related to the pattern of professional and informal support. Respondents with co-occurring disorders were more likely than those with a mental disorder only to use both professional services and informal support. Similarly, respondents with a severe 12-month disorder were more likely than those with less severe disorders to use both professional services and informal support. Those with a substance disorder only were more likely than those with a mental disorder only to not receive any help at all.

Finally, in terms of the family network, the larger the helper network, the less likely respondents relied on professional services only, informal support only, or to not receive help while the closer respondents felt to their family the less likely they used professional services alone.

Discussion

The findings of this study add to our understanding of help-seeking among black Americans with a mental disorder. Less than half of black Americans in this study received help from both professional services and informal support. The remainder relied exclusively on informal support (23%), professional services alone (14%), or received no help at all (22%). While relying on informal support alone can limit the assistance available, it may be sufficient for more mild and less persistent disorders. Relying on professional services alone, however, may limit the day-to-day help that individuals receive. The significant proportion of black Americans with a mental disorder who are relying on informal support alone, professional services alone, or receiving no help at all suggests potential unmet need among this group.

It is important to note that informal support may play a protective role against the development of disorders. Previous research has found that, despite greater social disadvantages and stressors, members of racial and ethnic minority groups consistently experience a lower lifetime prevalence of mood and anxiety disorders than non-Hispanic whites (8,18,19). Indeed, the fact that over 60% of black Americans in this sample relied on informal support either alone or in conjunction with professional services suggests the presence of a strong social fabric that may buffer individuals from mental health problems as well as providing help in a time of need. Additional research on the protective role of informal supports as well as the type and adequacy of help provided by both informal and professional sources would help clarify the extent to which underutilization of services equates to unmet need. In addition, the protective role of support from extended family, religious participation and non-kin (e.g., church members) should be investigated given the important role these resources have been found to play in the lives of black Americans (20,21).

Respondents with co-occurring mental and substance disorders and those with a more severe 12-month disorder were more likely to receive help overall and to use both professional services and informal supports than those with a mental disorder only or those with a less severe disorder. However, those with a substance disorder only were less likely to receive any help. These findings are consistent with previous research on professional service use (22,23,24) and indicate that greater severity increases the overall intensity of help and the variety of sources from which help is received. In addition, the help-seeking process appears to be different for substance and mental disorders. Other studies have also found that those with a substance disorder are less likely to use services than those with a mental disorder (1) and that many individuals with co-occurring disorders only receive treatment for substance disorders after entering mental health services (22). One reason for this may be that those with a substance disorder are less likely to perceive a need for help (25). This study expands upon previous research by including the use of informal support.

Respondents with larger helper networks are more likely to use both professional services and informal support. This finding is consistent with previous research and indicates that family members provide informal support and help facilitate access to professional services (12,26,27).

Previous research on service use has found that men are less likely than women to use professional services for a mental disorder (1,28) and are less likely in general to rely on informal support (29,30,31). This study suggests a more nuanced relationship. Women are not only more likely than men to seek help, but are also more likely to seek help from a wider range of sources. These results are consistent with findings from the NSBA (14). In addition, when men do receive help, they are more likely to rely exclusively on informal helpers. For men informal support networks may be more likely to act as a substitute and/or a barrier to professional service use. This has implications for the quality of help men receive since informal support networks are less equipped than professional service providers to deal with serious mental illness. This relationship between gender and the use of informal support is significant for African Americans, but not for Caribbean Blacks (analyses not shown) suggesting ethnic differences in gender and help-seeking that should be investigated further.

Divorced, separated, or widowed respondents were more likely to use professional services only while those who were currently married were more likely to use both professional services and informal support. One possible explanation for this finding is that spouses may facilitate access to professional services in addition to providing support themselves. Conversely, individuals who were separated or divorced as a consequence of mental illness are by necessity more likely to rely exclusively on professional services.

This study also found that the likelihood of using informal support alone declines with age. In particular, those aged 18–29 were more likely to rely on informal support alone while all other age groups were more likely to use both professional services and informal support. Studies that have only considered the use of professional services have found that that those aged 18–29 are more likely to receive treatment than older adults (1,32). In addition, Horwitz and Uttaro (1998) found that younger adults were more likely than other age groups to receive help from both family and professional services (11). These studies, however, did not examine differences within racial groups. One possible reason for these contrasting findings may be that younger black Americans face more barriers to accessing professional services compared to black Americans in other age groups. Alternatively, disorders among the younger age group may be less severe than for other age groups and have been successfully managed by informal support alone.

Several measures of socioeconomic status were related to help-seeking. Respondents with more education were more likely to receive help and to receive help from both professional services and informal support. Higher levels of education may be associated with more acceptance of seeking help for a mental disorder by the individual as well as network members. In addition, education may be associated with a host of other barriers, stresses, and constraints faced by individuals of lower socioeconomic status that influence both the availability of and access to mental health services (33). Those who are working were more likely to not receive any help at all or to rely exclusively on informal support. Respondents who are working may have a less serious disorder and be able to continue working with the help of informal support. In fact, almost half of those currently working experienced a lifetime disorder only, while a greater proportion of those not working experienced a moderate or severe 12-month disorder. Finally, in terms of income, the lower the household income the less likely respondents were to receive any help at all. This is consistent with previous research that has found that lower income is associated with less service use (1,32,34) as well as less receipt of informal support (29,35).

It should be noted that the use of measures of lifetime diagnosis and help-seeking limits our ability to understand help-seeking as a process. In particular, it is impossible to determine whether those who used both professional services and informal support used them simultaneously or serially. Similarly, for those who used informal support only or did not receive help at all it is impossible to determine the extent to which that help met their needs. Indeed, help-seeking for a mental illness is acknowledged to be a complicated and dynamic process during which individuals move in and out of professional services, change the intensity of services used over time as their needs fluctuate, and experience shifts in their informal networks (27). Despite these limitations, this study makes an important contribution to our understanding of help-seeking for a mental disorder among black Americans.

Conclusion

In this study, those who use professional services only tend to be separated, divorced, or widowed; have fewer family available to help; and are less subjectively close to their family. These findings suggest that these individuals are isolated from their informal networks, although the reasons for that disconnection can not be determined. These individuals could potentially benefit from interventions targeted toward enhancing relationships with existing informal helpers or creating new informal support connections. Additionally, informal supports may buffer black Americans from developing a disorder in the first place. The role of informal support as a protective factor deserves further study.

There is an increasing emphasis on helping adults with serious mental illness live in the community. This goes beyond simply maintaining individuals to improving their overall functioning and quality of life. Both professional services and informal support networks are crucial elements to make this successful. Adults with serious mental illness need help in a variety of domains including, but not limited to, mental health services. This assistance needs to be long-term and flexible because of the often chronic and persistent nature of mental disorders. Having access to multiple sources of support that can meet a variety of needs is crucial (36,37).