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. Author manuscript; available in PMC: 2013 Aug 20.
Published in final edited form as: Community Ment Health J. 2008 Oct 16;45(2):85–96. doi: 10.1007/s10597-008-9164-5

Examining racial/ethnic minority treatment experiences with Specialty behavioral health service providers

Michelle L Redmond 1,✉, Sandro Galea 2, Jorge Delva 3
PMCID: PMC3747637  NIHMSID: NIHMS474461  PMID: 18925436

Abstract

This study investigated whether satisfaction and helpfulness of treatment by mental health service provider is related to race/ethnicity and psychosocial factors. Data from the National Co morbidity Survey-Replication study, which administered mental health service use questions for the past 12-months (1332), was analyzed. Data were stratified by service provider and analyzed with multiple logistic regressions. Racial/ethnic minorities were generally more likely to be satisfied with services provided by specialty mental health providers compared to white respondents. Racial/ethnic minorities generally perceived the services provided by specialty mental health providers as more helpful than did other racial/ethnic groups. Those who reported high cultural identity were more likely to find their treatment experience less satisfying and less helpful. Greater attention to specialty referrals for racial/ethnic minority groups may fruitfully contribute to improve help-seeking for these groups. The role culture plays in shaping the mental health treatment experience needs to be further investigated.

Keywords: race, ethnicity, mental health, help-seeking, disparities, treatment barriers

Introduction

Several national household studies have been conducted that document the prevalence of mental disorders and the extent to which mental health treatment needs are being met (Alegria, et al., 2004; Kessler, et al., 1994; Kessler & Merikangas, 2004; Jackson et al, 2004; Regier et al., 1984). The prevalence of any mental disorder (e.g., major depression, anxiety disorders) in the past 12 months has been estimated to be 26% among those 18 years and older (American Psychiatric Association, 1994; Kessler, Chiu, Demler, Merikangas, & Walters, 2005). This translates into more than 50 million people suffering from a mental health problem, with associated cost of treatment in the billions (National Institute of Mental Health, 2006)

Unfortunately, there is ample evidence that most people who are in need of mental health treatment do not seek help, a particularly troubling situation for persons suffering from severe mental illness (Kessler et al., 2005; Wang, et al., 2005). The Surgeon General’s Report on Mental Health in 1999 highlighted this treatment gap in mental health services among the general population, but particularly among racial and ethnic minorities, where it identified a great “burden of unmet need” of mental health services (Department of Health and Human Services, 1999; USDHHS, 2001). This is particularly problematic because among people diagnosed with a mental illness, the disease persists for longer periods among minority populations when compared to whites (Breslau, Kendler, Su, Aguilar-Gaxiola, & Kessler, 2005; Neighbors, 1984).

Despite our growing awareness of potential concerns about limited mental health treatment received by racial/ethnic minorities, the literature on mental health help-seeking behaviors in these populations is sparse (Ronzio, Guagliardo & Persaud, 2006; Atdjian & Vega, 2005; Chow, Jaffee, & Snowden, 2003). Factors that may contribute to disparities in treatment in different racial/ethnic groups may include a general distrust for health/mental health services because of past experiences with this sector (Snowden, 2001; Dancy, Wilbur, Talashek, Bonner, & Barnes-Boyd, 2005; Williams, Neighbors, & Jackson, 2003) irregularities in referral rates to specialty mental health care, cultural factors, level of problem severity, and the reliance on informal methods of help such as strong social networks, community resources, or spiritual guidance (Alegria et al, 2001; Keefe, 1982; Neighbors & Jackson, 1984; Neighbors, 1984; Peifer, Hu, & Vega, 2000; Snowden, 2001). The Surgeon General’s supplemental report clearly suggests that more information is needed to understand the factors underlying racial/ethnic disparities in mental health treatment (USDHHS, 2001).

One way to understand mental health help seeking behaviors among racial/ethnic minorities is to further examine their treatment experiences. In this study we utilize data from the NCS-R to examine the treatment experiences of racial/ethnic minorities.

Methods

Sample and Procedure

Data are from the National Co morbidity Survey-Replication study (NCS-R) (Kessler, et al., 2004). The NCS-R, a lay administered household interview survey, was administered to a national representative sample of 9282 English-speaking respondents aged 18 and older who reside in the coterminous United States from 2001–2003. A detailed description of the sampling methods has been published elsewhere (Kessler, et al.).

Measures

There are two parts to the NCS-R. Part I is a diagnostic assessment based on the World Health Organization Composite International Diagnostic Interview (WHO-CIDI) diagnostic schedule interview which combines the WHO International Classification of Diseases (ICD-10) and the DSM-IV diagnoses. Part II assesses risk factors for psychiatric disorders and service utilization. For the purposes of this study, we were interested in data from part II of the NCS-R, particularly focusing on mental health services utilization.

Dependent variables

All NCS-R respondents were asked to identify if they had seen a professional for problems with their emotions, nerves, or their use of alcohol or drugs during the past 12 months. Those who answered affirmatively were asked which professionals they had ever seen from a list of ten (i.e., psychiatrists, general practitioner, other mental health professionals, minister, and other healers). Respondents who indicated they had seen a professional in the past year were asked about the extent to which they were satisfied with the treatment they received and believed treatment was helpful in the past 12 months. In this study, we report findings for the five mental health/health care service providers most commonly sought out by the U.S. population: psychiatrist, medical doctor, psychologist, social worker and counselor. Our key dependent variables of interest were respondent’s satisfaction with the treatment they received in the past 12 months and the extent to which they believed the treatment was helpful.

Satisfaction with mental health treatment received was measured by asking individuals who received treatment in the last 12 months from the corresponding service provider the question: “How satisfied were you with the treatment you received from _________? for each of these professionals - psychiatrist, medical doctor, psychologist, social worker and counselor. Response categories were 1=very satisfied, 2=satisfied, 3=neither, 4=dissatisfied, 5=very dissatisfied. For purposes of this study, satisfaction was collapsed into a dichotomized response of ‘1=yes satisfied’ (those who said they were very satisfied or satisfied) versus ‘0=not satisfied (those who said they were neither, dissatisfied, or very dissatisfied). Not being satisfied is the reference category.

Treatment helpfulness from each professional was assessed by asking how helpful treatment was when seen by a psychiatrist, medical doctor, psychologist, social worker, or a counselor. Respondents were asked to respond on a 4-point Likert scale as to how helpful the recommended course of treatment really was for each corresponding professional. The possible responses were 1=very helpful, 2=somewhat helpful, 3=a little helpful and 4=not at all helpful. For purposes of this study, helpfulness was collapsed into a dichotomized response of ‘1=helpful’ (those who said treatment was very helpful or somewhat helpful) ‘0= not helpful’ (those who said treatment was a little helpful or not at all helpful). Not helpful was the reference category.

Independent Variables

Race/Ethnicity

In the NCS-R, race/ethnicity was measured by asking individuals to self-identify their racial/ethnic background based on a selection of categorical choices. For purposes of this study the categorical choices are: White=1, African Americans=2, Hispanic=3, and Other=4. Individuals of other racial/ethnic backgrounds were aggregated because the sample sizes for the various groups were too small to permit separate analyses.

Gender

Gender was a dummy coded variable based on respondent’s self-report, with females being the reference category.

Employment

Employment was a categorical variable coded as follows: Working=1, Student=2, Homemaker=3, Retired=4, Other=5. For purposes of this study, employment was collapsed into a dichotomized response of ‘1=employed’ (those who indicated they were working) versus ‘0=unemployed (those who indicated they were a student, homemaker, retired or other) with unemployed being the reference category.

Income

Participants were asked to indicate their income based on a continuum of responses. Individuals whose income ranged from 0 to $30,000 were coded as ‘low’ with higher incomes coded as the reference category.

Education

Participants were asked to indicate their education level based on categorical variables. Reponses were dichotomized into those with a high school education or less and those with more than a high school education. The latter group was the reference category.

Health insurance

Participants were asked to report the type of health insurance they currently held by the following question: “Do you currently have health insurance through ____?” Response categories were: Military, employment/job, Medicare, Medicaid, and private insurance. We dichotomized the responses to these questions. Those who answered yes to any of theses questions were considered to be insured and those who answered no to all of the questions were considered to be uninsured. Uninsured responses were used as the reference category.

Social support

Social support was measured by asking participants to answer several questions about their relationships with relatives, friends and acquaintances considered to be in their social networks. For example, participants were asked: “how much can you rely on relatives who do not live with you for help if you have a serious problem?” Responses ranged from: 1=a lot, 2=some, 3=a little to 4=not at all. Participants were also asked: “how often do you get together with relatives who live outside the home?” Responses ranged from: 1=most everyday, 2=a few times a week, 3=few times a month, 4=once a month to 5=less than once a month. Participants were also asked how comfortable they were with opening up to relatives about their worries and concerns, the responses for this question were similar to the above mentioned examples. Responses from the social network questions were aggregated to create a dichotomous “social support” variable. Responses that indicated strong social network relations with family, friends and acquaintances (a lot, most everyday,) were coded as high social support, those whose responses indicated weak social networks (some, a little, few times a week, few times a month, once a month, not at all) were coded as low social support. Low or weak social support was the reference category.

Cultural identity

Respondents were asked a series of six questions aimed at measuring how close they felt towards their own race or ethnic background, including having similar feelings or ideas as those in the same racial/ethnic group, the amount of time spent with members from their own racial/ethnic group and about how comfortable they would feel marrying outside their own racial/ethnic group. For example, a few of the questions read as follows: “How closely do you identify with other people who are of the same racial and ethnic decent as yourself?” Possible responses were: very close, somewhat close, not very close, and not at all. Responses from the questions were aggregated to create a dichotomous “cultural identity” variable. Responses that indicated strong cultural identity (very close) were dichotomized as high and those whose responses indicated weak cultural identity (somewhat close, not very close, and not at all) were dichotomized as low. Low cultural identity was the reference category.

Analysis

First, we documented the 12-month prevalence of seeking treatment among participants for each of the five mental health service providers, psychiatrist, medical doctor, psychologist, social worker, and counselor, separately for each of the four racial/ethnic groups of interest. Second, for both dependent variables under investigation (treatment satisfaction and treatment helpfulness) we conducted bivariate analyses to measure the associations between independent and dependent variables. Third, we conducted multivariate logistic regression analyses to test for adjusted associations between the independent variables, including sociodemographic variables (gender, employment, income, education, and health insurance) and psychosocial variables (cultural identity and social support) and satisfaction and helpfulness.

All analyses are weighted based on the sample weight measure to allow generalizations to the U.S. population. Standard errors reflect the recalculation of variance using the study’s complex design. These analyses were conducted using the proc survey command in SAS 9.1 which uses the Taylor expansion approximation technique for calculating the complex-design based estimates of variance (SAS, 2005).

Results

These analyses were restricted to those NCS-R respondents who reported receiving any professional treatment for mental health in the past 12 months (N=1332). This sample includes 1105 Whites, 102 African Americans, 40 Hispanics, and 85 individuals of other racial/ethnic backgrounds. A total of 502 men and 830 women sought treatment in the past 12 months. As shown in Table 1, overall, in the past 12 months, a greater number of individuals sought help from medical doctors, followed by psychiatrists, psychologists, counselors, and social workers. (see Table 1).

Table 1.

Past 12-month Mental Health Service Utilization and Satisfaction in the U.S. by Race/Ethnicity and Type of Professional

Professional Treatment Total N White
African American
Hispanic
Other
Past yra Satisfiedb Helpedc Past yr a Satisfiedb Helpedc Past yra Satisfiedb Helpedc Past yra Satisfiedb Helpedc
N % n % n % N % n % n % N % n % n % N % n % n %
Medical Doctor 431 364 84.5 268 73.6 271 74.5 27 6.3 17 63.0 20 74.1 14 3.3 11 78.6 10 71.4 25 5.8 20 80.0 21 84.0
Psychiatrist 341 281 82.4 212 75.4 226 80.4 31 9.1 17 54.8 21 67.7 9 2.6 7 77.8 7 77.8 20 5.87 11 55.0 13 65.0
Psychologist 236 199 84.3 158 79.4 161 80.9 14 5.9 9 64.3 11 78.6 8 3.4 8 100.0 8 100.0 15 6.36 10 66.7 11 73.3
Counselor 222 180 81.1 138 76.7 144 80.0 23 10.3 18 78.3 20 87.0 6 2.7 5 83.3 5 83.3 15 6.76 11 73.3 13 86.7
Social Worker 101 81 80.2 58 71.6 64 79.0 7 6.9 7 100.0 7 100.0 3 3.0 3 100.0 3 100.0 10 9.9 9 90.0 10 100.0
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Note. ‘Past yr’ column represents number of White, African American, Hispanic, and Other individuals who sought mental health treatment by profession. The denominator for columns labeled ‘Satisfied’ and ‘Helped’ is ‘Past yr N’.

a

Represents the number of people by racial group who saw a particular profession in the past 12-months

b

Represents the number of people by race/ethnicity who were satisfied with treatment by a given profession

c

Represents the number of people by race/ethnicity who believed treatment helped by a given profession

Treatment satisfaction and helpfulness by service provider

Table 2 presents the results for bivariate and multivariate analyses predicting treatment satisfaction and helpfulness for seeing each, a medical doctor, psychiatrist, psychologist, counselor and a social worker. Differences in treatment satisfaction and helpfulness from counselors were examined by race/ethnicity. These findings are described below by service provider.

Table 2.

Past 12-month mental health treatment experience, satisfaction with treatment and treatment helpfulness by sociodemographic characteristics among those who sought help from a Medical Doctor, Psychiatrist, Psychologist, Counselor and Social Worker: Results of bivaritate and multivariate analyses.

Sociodemographic Characteristics Sought Treatment from Medical Doctor in Past Year Satisfaction with Treatment Believed Treatment Helped
Bivariate Multivariate Bivariate Multivariate
N % N % Beta SE p-value Beta SE p-value N % Beta SE p-value Beta SE p-value
Total 431 247 72.4 267 78.3
Race/Ethnicity
 White (Caucasian) 364 84.5 268 73.6 271 74.5
 African American 27 6.26 17 63.0 0.018 0.274 0.945 −0.118 0.482 0.806 20 74.1 0.481 0.631 0.445 0.339 0.488 0.486
 Hispanic 14 3.25 11 78.6 0.038 0.385 0.921 −0.085 0.724 0.906 10 71.4 −0.324 0.361 0.369 −0.487 0.394 0.216
 Other 25 5.80 20 80.0 −0.165 0.310 0.594 0.236 0.485 0.626 21 84.0 0.512 0.707 0.469 0.364 0.529 0.491
Gender
 Male 133 30.9 90 67.7 −0.183 0.153 0.231 −0.198 0.171 0.246 93 69.9 0.163 0.186 0.382 −0.189 0.202 0.348
 Female 299 69.4 225 75.3 228 76.3
Income
 Low 160 37.1 113 70.6 −0.119 0.156 0.231 −0.096 0.098 0.326 109 68.1 −0.265 0.156 0.010 −0.175 0.116 0.132
 High 271 62.9 203 74.9 211 77.9
Education
 < = 12 years 191 44.3 149 78.0 0.241 0.124 0.052 0.254 0.129 0.048 146 76.4 0.105 0.122 0.386 0.131 0.114 0.251
 > 12 years 241 55.9 166 68.9 174 72.2
Employment
 employed 267 61.9 193 72.3 −0.059 0.115 0.605 −0.045 0.122 0.707 198 74.2 −0.021 0.103 0.841 −0.045 0.105 0.665
 not employed 164 38.1 122 74.4 122 74.4
Health Insurance
 Yes 308 71.5 228 74.0 0.083 0.111 0.456 0.024 0.124 0.843 239 77.6 0.315 0.122 0.009 0.265 0.158 0.094
 No 124 28.8 88 71.0 81 65.3
Social Support
High 332 77.0 250 75.3 0.249 0.115 0.029 0.171 0.135 0.204 253 76.2 0.223 0.111 0.049 0.064 0.139 0.646
Low 99 23.0 65 65.7 67 67.7
Cultural Identity
High 193 44.8 181 93.8 0.187 0.119 0.115 0.139 0.125 0.264 183 94.8 0.166 0.11 0.131 0.105 0.118 0.372
Low 239 55.4 135 56.5 137 57.3
Sociodemographic Characteristics Sought Treatment from Psychiatrist in Past Year Satisfaction with Treatment Believed Treatment Helped
Bivariate Multivariate Bivariate Multivariate
N % N % Beta SE p-value Beta SE p-value N % Beta SE p-value Beta SE p-value
Total 341 247 72.4 267 78.3
Race/Ethnicity
 White (Caucasian) 281 82.4 212 75.4 226 80.4
 African American 31 9.09 17 54.8 0.412 0.177 0.019 −0.439 0.317 0.166 21 67.7 −0.751 0.356 0.034 −0.241 0.311 0.439
 Hispanic 9 2.64 7 77.8 −0.117 0.432 0.786 0.713 0.743 0.337 7 77.8 −0.371 0.758 0.624 0.259 0.626 0.678
 Other 20 5.87 11 55.0 0.469 0.222 0.034 0.357 0.243 0.141 13 65.0 −0.794 0.603 0.187 −0.386 0.534 0.469
Gender
 Male 140 41.1 99 70.7 −0.067 0.144 0.639 −0.159 0.160 0.321 106 75.7 −0.174 0.150 0.245 −0.244 0.175 0.163
 Female 201 58.9 148 73.6 160 79.6
Income
 Low 147 43.1 98 66.7 −0.265 0.156 0.088 −0.297 0.164 0.070 102 69.4 −0.401 0.187 0.032 −0.383 0.194 0.048
 High 193 56.6 149 77.2 164 85.0
Education
 < = 12 years 148 43.4 113 76.4 0.158 0.118 0.182 0.293 0.107 p<.01 112 75.7 0.064 0.129 0.619 0.080 0.141 0.568
 > 12 years 193 56.6 134 69.4 115 59.6
Employment
 employed 185 54.3 136 73.5 0.064 0.138 0.643 0.011 0.145 0.934 150 81.1 0.119 0.120 0.318 0.024 0.128 0.849
 not employed 157 46.0 111 70.7 117 74.5
Health Insurance
 Yes 227 66.6 165 72.7 0.034 0.131 0.793 −0.034 0.127 0.789 181 79.7 0.075 0.163 0.645 −0.073 0.173 0.674
 No 115 33.7 82 71.3 85 73.9
Social Support
High 261 76.5 193 73.9 0.167 0.178 0.348 0.118 0.179 0.507 208 79.7 0.267 0.185 0.150 0.225 0.172 0.189
Low 80 23.5 54 67.5 58 72.5
Cultural Identity
High 161 47.2 115 71.4 −0.023 0.157 0.884 −0.069 0.181 0.702 124 77.0 0.094 0.155 0.544 −0.187 0.172 0.278
Low 180 52.8 131 72.8 143 79.4
Sociodemographic Characteristics Sought Treatment from Psychologist in Past Year Satisfaction with Treatment Believed Treatment Helped
Bivariate Multivariate Bivaritae Multivarite
N % N % Beta SE p-value Beta SE p-value N % Beta SE p-value Beta SE p-value
Total 236 186 78.8 191 80.9
Race/Ethnicity
 White (Caucasian) 199 84.3 158 79.4 161 80.9
 African American 14 5.93 9 64.3 0.252 0.319 0.431 −3.69 0.547 p<.001 11 78.6 −0.118 0.587 0.841 −3.35 0.509 p<.001
 Hispanic 8 3.39 8 100 −0.767 0.170 p<.001 11.07 0.406 p<.001 8 100 14.31 0.337 p<.001 10.93 0.385 p<.001
 Other 15 6.36 10 66.7 0.275 0.223 0.218 −3.92 0.373 p<.001 11 73.3 −0.641 −0.641 0.24 −4.1 0.481 p<.001
Gender
 Male 92 19.7 73 79.3 0.021 0.153 0.894 0.019 0.153 0.898 74 80.4 0.079 0.211 0.706 −0.116 0.213 0.585
 Female 143 21.1 113 79.0 117 81.8
Income
 Low 91 20.6 74 81.3 0.134 0.156 0.390 0.314 0.219 0.151 74 81.3 0.077 0.188 0.683 0.081 0.247 0.742
 High 144 20.2 111 77.1 116 80.6
Education
 < = 12 years 69 46.4 56 81.2 0.079 0.167 0.638 0.077 0.195 0.691 55 79.7 5.0E−03 0.174 0.974 −0.018 0.197 0.926
 > 12 years 167 8.6 130 77.8 135 80.8
Employment
 employed 154 18.1 123 79.9 0.117 0.109 0.484 0.183 0.195 0.348 127 82.5 0.093 0.191 0.627 0.129 0.213 0.544
 not employed 81 27.5 63 77.8 63 77.8
Health Insurance
 Yes 86 19.4 66 76.7 0.169 0.165 0.305 0.346 0.254 0.173 69 80.2 −0.0087 0.192 0.964 0.107 0.269 0.689
 No 149 22.8 120 80.5 121 81.2
Social Support
High 74 20.4 58 78.4 0.012 0.179 0.947 0.159 0.236 0.501 61 82.4 −0.084 0.168 0.618 0.149 0.206 0.471
Low 162 20.9 128 79.0 129 79.6
Cultural Identity
High 121 22.4 103 85.1 −0.429 0.154 p<.01 −0.458 0.193 0.017 111 91.7 −0.822 0.219 p<.001 −0.844 0.243 p<.001
Low 114 19.0 83 72.8 79 69.3
Sociodemographic Characteristics Sought Treatment from Counselor in Past year Satisfied with Treatment Believed Treatment Helped
Bivariate Multivariate Bivariate Multivariate
N % N % Beta SE p-value Beta SE p-value N % Beta SE p-value Beta SE p-value
Total 222 173 77.9 182 82.0
Race/Ethnicity
 White (Caucasian) 180 81.1 138 76.7 144 80.0
 African American 23 10.4 18 78.3 −0.082 0.556 0.883 −0.134 0.534 0.802 20 87.0 0.526 0.661 0.426 0.261 0.672 0.698
 Hispanic 6 2.70 5 83.3 0.87 1.16 0.454 0.897 0.913 0.326 5 83.3 0.714 1.156 0.537 0.465 0.975 0.634
 Other 15 6.76 11 73.3 −0.401 0.691 0.562 −0.613 0.598 0.305 13 86.7 0.071 0.922 0.937 −0.332 0.799 0.678
Gender
 Male 91 40.9 73 80.2 0.239 0.224 0.286 0.222 0.193 0.251 73 80.2 −0.044 0.252 0.862 0.088 0.221 0.693
 Female 132 59.5 99 75.0 108 81.8
Income
 Low 96 43.2 27 28.1 −0.243 0.204 0.234 −0.258 0.236 0.275 79 82.3 −0.049 0.209 0.813 0.053 0.259 0.839
 High 127 57.2 101 79.5 102 80.3
Education
 < = 12 years 105 47.3 76 72.4 −0.164 0.174 0.346 −0.330 0.237 0.164 79 75.2 −0.230 0.229 0.316 −0.358 0.265 0.177
 > 12 years 118 53.2 92 78.0 102 86.4
Employment
 employed 143 64.4 106 74.0 −0.224 0.204 0.272 −0.313 0.221 0.157 114 80.0 −0.048 0.248 0.847 −0.086 0.253 0.734
 not employed 80 36.0 67 84.0 67 84.0
Health Insurance
 Yes 139 62.6 105 75.5 −0.049 0.204 0.808 −0.257 0.268 0.337 112 80.6 0.093 0.238 0.698 0.076 0.279 0.786
 No 84 37.8 68 81.0 68 81.0
Social Support
High 173 77.9 136 78.6 0.292 0.242 0.228 0.348 0.291 0.230 142 82.1 0.255 0.237 0.282 0.379 0.300 0.206
Low 51 23.0 36 70.6 39 76.5
Cultural Identity
High 114 51.4 83 72.8 −0.169 0.225 0.454 −0.258 0.301 0.391 86 75.4 −0.251 0.204 0.219 −0.365 0.263 0.166
Low 109 49.1 90 82.6 94 86.2
Sociodemographic Characteristics Sought Treatment from Social Worker in past year Satisfied with Treatment Believed Treatment Helped
Bivariate Multivariate Bivariate Multivariate
N % N % Beta SE p-value Beta SE p-value N % Beta SE p-value Beta SE p-value
Total 101 77 76.2 84 83.2
Race/Ethnicity
 White (Caucasian) 81 80.2 58 71.6 64 79.0
 African American 7 6.93 7 100 −8.34 0.215 p<.001 8.66 0.598 p<.001 7 100 16.55 0.496 p<.001 5.09 0.674 p<.001
 Hispanic 3 2.97 3 100 −8.34 0.411 p<.001 7.75 0.848 p<.001 3 100 16.55 0.622 p<.001 4.37 1.24 p<.001
 Other 10 9.90 9 90.0 −0.654 0.292 0.025 −7.11 0.377 p<.001 10 100 16.55 0.569 p<.001 4.17 0.540 p<.001
Gender
 Male 45 19.7 34 75.6 −0.111 0.215 0.604 −0.358 0.208 0.086 38 84.4 −0.025 0.232 0.914 −0.188 0.248 0.449
 Female 55 33.7 43 78.2 46 83.6
Income
 Low 46 23.4 30 65.2 −0.654 0.358 0.068 −0.858 0.386 0.026 34 73.9 −0.589 0.462 0.202 −0.857 0.553 0.121
 High 54 28.6 47 87.0 49 90.7
Education
 < = 12 years 55 33.5 38 69.1 −0.439 0.221 0.046 −0.037 0.299 0.899 42 76.4 −0.439 0.250 0.064 −0.252 0.346 0.466
 > 12 years 46 20.3 39 84.8 41 89.1
Employment
 employed 53 20.0 41 77.4 0.065 0.287 0.821 −1E-05 0.391 0.100 43 81.1 −0.165 0.337 0.624 −0.279 0.411 0.497
 not employed 47 37.3 35 74.5 40 85.1
Health Insurance
 Yes 68 27.0 59 86.8 0.829 0.272 p<.01 0.742 0.235 0.001 60 88.2 0.507 0.285 0.075 0.162 0.235 0.489
 No 33 23.7 18 54.5 24 72.7
Social Support
High 73 24.8 57 78.1 0.157 0.226 0.486 −0.304 0.329 0.357 61 83.6 0.025 0.327 0.939 −0.496 0.422 0.239
Low 27 26.0 20 74.1 23 85.2
Cultural Identity
High 45 26.8 38 84.4 −0.355 0.139 p<.01 0.158 0.178 0.375 41 91.1 0.642 0.204 p<.01 0.702 0.267 p<.01
Low 55 24.8 39 70.9 42 76.4
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Medical Doctor

In bivariate analyses, satisfaction with treatment received from a medical doctor did not differ among racial/ethnic groups. Respondents with lower education (p=0.05) and higher social support (p=0.03) reported greater satisfaction with treatment from a medical doctor. The results of the multivariate analyses show that when all independent variables were included in the analyses, the observed bivariate differences in treatment satisfaction became non-significant.

Bivariate analyses show that belief in treatment helpfulness did not differ among racial/ethnic groups. Persons of lower income (p=0.01) were associated with less treatment helpfulness. Having health insurance (p<0.01) and reported higher social support (p<0.05) were associated with greater treatment helpfulness. These associations were not statistically significant in the multivariate analyses.

Psychiatrist

Bivariate analyses showed that satisfaction with treatment received from a psychiatrist was higher among African Americans (p=0.01) and among individuals of ‘Other’ backgrounds (p=0.03) when compared to Whites. The differences in treatment satisfaction for racial/ethnic groups were not statistically significant in multivariate model. Multivariate analysis also showed that having lower education (p<0.01) was associated with greater satisfaction, while respondents with lower incomes (p=0.07) reported less satisfaction with treatment services. Bivariate analyses show that African Americans were less likely to find treatment helpful (p=0.03) when compared to Whites. Respondents of lower incomes also were less likely to find treatment helpful (p=0.03). In the multivariate analyses, only the income difference remained statistically significant.

Psychologist

Bivariate analyses showed that satisfaction with treatment received from a psychologist was lower among Hispanics (p<0.01) when compared to Whites. Respondents with higher cultural identity were less likely to be satisfied with treatment (p<0.01) when compared to those with lower cultural identity. In the multivariate analyses, African Americans (p<0.01) and respondents of ‘Other’ backgrounds (p<0.01) were less likely than Whites to be satisfied with treatment. Unlike the bivariate results, in the multivariate analyses, Hispanics were more likely to be satisfied with treatment than Whites (p<0.01). Having higher cultural identity was associated with less satisfaction (p=0.01) when compared to those with lower cultural identity.

In bivariate analyses belief in greater treatment helpfulness was higher among Hispanics (p<0.01) and those with higher cultural identity (p<0.01). In multivariate analyses, African Americans (p<0.01) and ‘Other’ racial/ethnic groups (p<0.01) were less likely to have found the treatment to be helpful when compared to Whites. Hispanics were likely to have found treatment to be helpful (p<0.01) compared to Whites and cultural identity also was inversely associated (p<0.01) with treatment helpfulness. (See table 2: Psychologist).

Counselor

There were no significant bivariate or multivariate associations between the covariates of interest and receipt of services from a counselor. (See table 2: counselor)

Social Worker

Bivariate analyses showed that satisfaction with treatment received from a social worker was lower among African Americans (p=<0.01), Hispanics (p=<0.01), and respondents of ‘Other’ backgrounds (p=0.03) when compared to Whites. Respondents with lower income (p=0.07), education (p=0.05), and higher cultural identity (p<0.01) were less satisfied with treatment than those with higher incomes, higher education, and less cultural identity, respectively. Respondents with health insurance were more satisfied with treatment (p<0.01) than those without health insurance. In multivariate analyses, African Americans and Hispanics were more likely to be satisfied with treatment compared to other respondents and having health insurance and high income were associated with greater satisfaction (see table 2: social worker).

In terms of helpfulness, in bivariate analyses, belief in treatment helpfulness from social workers was higher among African Americans (p<0.01), Hispanics (p<0.01), and individuals of ‘Other’ backgrounds (p<0.01) when compared to Whites. Having higher cultural identity was associated with report of helpfulness of social workers (p<0.01). The multivariate analyses, the race/ethnic differences remained significant, with cultural identity still predicting helpfulness (See table 2).

Discussion

Using data from a nationally representative survey, we found that racial/ethnic minorities varied in terms of which type of provider was more satisfactory and/or helpful. In terms of subjective satisfaction, African Americans in the general population reported more satisfaction with psychiatrists and social workers while Hispanics reported more satisfaction with psychologists. In terms of perceived helpfulness, African Americans viewed social workers as the most helpful provider while Hispanics viewed psychologists as the most helpful. These results suggest that racial/ethnic minority respondents were more likely to be satisfied and had greater perceptions of helpfulness from services received from specialty mental health providers compared with services by generalist providers. Recent studies which examined within group differences also found Hispanics, Asians and Caribbean Blacks to be more satisfied with services from the specialty mental health service sector (Jackson, et al., 2007; Alegria, et al., 2007; Abe-Kim, et al., 2007). Our findings on treatment helpfulness also corroborate previous work. Past research has demonstrated that racial/ethnic minorities tend to find services from any service sector more helpful, which in some instances does include the use of specialty providers such as psychologists and psychiatrists (Jackson, et al., 2007; Alegria, et al., 2007; Abe-Kim, et al., 2007).

It has been amply shown that racial/ethnic minorities generally are referred at lower rates for specialty care services (Alegria et al., 2001). In this study we showed that racial/ethnic minorities found specialty mental health services more satisfactory and helpful then other generalist services. This suggests that racial/ethnic minorities may be referred primarily to mental health services which are considered less satisfying and helpful, possibly contributing to low help-seeking in these groups. This suggests that more attention should be given to the way this population is referred to specialty care and that, in part; the effort to address disparities in mental health help-seeking between racial/ethnic groups should include an effort to make sure that this group is referred to services which are perceived to be helpful and satisfactory.

The help-seeking literature has linked greater client satisfaction of mental health services with quality of life, age, attitudes about help-seeking, and empathy of provider (Diala, et al., 2000; Constantine, 2002; Mitchell, 1998; Blenkiron & Hammill, 2003). We found that being high in cultural identity was linked to less satisfaction and helpfulness, at least with services from a psychologist; however in the adjusted model, being high in cultural identity was a positive predictor of satisfaction for those who saw a social worker. Previous studies which examined within group differences of racial/ethnic minorities found cultural variations such as language, nativity, and generational status can negatively affect satisfaction of treatment experiences; however these studies did not examine cultural identity (Jackson, et al., 2007; Alegria, et al., 2007; Abe-Kim, et al., 2007).

Consistent with our work, previous studies have found culturally sensitive and/or culturally competent treatment services are more likely to elicit greater treatment outcomes for clients compared to non-culturally specific treatment services (Takeuchi, Sue, & Yeh, 1995). These findings suggest that providers and mental health researchers should consider the way cultural identity can influence help-seeking behaviors and treatment experiences.

There are limitations to this study. Although this was a large national sample, the absolute number of racial/ethnic minorities was small. The limited sample size did not allow for the desegregation of African Americans from Caribbean Blacks or other Blacks, or of the various Hispanic populations such as Mexican Americans and Puerto Ricans, as well as Asian populations. Further research is needed to better understand the various within group differences of racial/ethnic minorities. In addition, we had no data available on a range of other factors, including, for example, language ability and experience of discrimination, which may also contribute to differences in help seeking or treatment satisfaction.

In closing, many, including the Surgeon General’s report on mental health11–12 have emphasized the problem of unmet mental health needs for racial/ethnic minorities. Addressing specialty referral rates and cultural barriers to care may be ways of improving the treatment experiences of racial/ethnic minorities in need of mental health services.

Acknowledgments

This research was supported by the National Institute on Drug Abuse grant #T32DA007267 and in part by NIMH Training Grant #T32 MH16806-25. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Drug Abuse, the National Institute on Mental Health or the National Institute of Health”

Footnotes

“The final publication is available at link.springer.com” http://link.springer.com/article/10.1007/s10597-008-9164-5

Contributor Information

Michelle L. Redmond, Email: mredmond@kumc.edu, University of Kansas School of Medicine-Wichita, 1010 N. Kansas, Wichita, KS 67214, 316-293-1813

Sandro Galea, University of Michigan-Ann Arbor, Center for Social Epidemiology & Population Health, 109 Observatory St. Rm 3663, Ann Arbor, MI 48109-2029.

Jorge Delva, University of Michigan-Ann Arbor, School of Social Work, 1080 S. University, Ann Arbor, MI 48109

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