Persistent Black-White disparities in mental healthcare needs during the COVID-19 pandemic: A call for action

Respected Editor,

Mental illnesses are a leading cause of disability and premature mortality worldwide that most profoundly affect marginalized and disadvantaged populations (Price et al., 2016; World Health Organization [WHO], 2021). Before the COVID-19 pandemic, in the United States (U.S.), nearly a fifth of the adults had any mental illness (AMI) in a given year, but less than half of these individuals received mental health services (Price et al., 2016; Substance Abuse and Mental Health Services Administration [SAMSHA], 2020). In relation to disparities before the pandemic, while non-Hispanic Whites (NHWs) were more likely to report having AMI, non-Hispanic Blacks (NHBs) were significantly less likely to receive mental health services (Cook et al., 2019; SAMSHA, 2020; Snowden & Graaf, 2021). During the pandemic, there was a major increase in AMI burden reported in the U.S. Specifically, during the early phases of the pandemic, the rates of depression and anxiety more than doubled according to some estimates (Blanchflower & Bryson, 2022; Czeisler et al., 2020; Khubchandani et al., 2021). Unfortunately, racial and ethnic minority groups, such as Black Americans suffered a disproportionate burden of COVID-19-related hospitalizations, deaths, and were more likely to report mental health issues ranging from anxiety/depression to substance abuse and suicidal ideation (Blanchflower & Bryson, 2022; Czeisler et al., 2020; Khubchandani et al., 2021). While Black-White disparities in the burden of mental disorders were well established during the pandemic, little is known about the mental health care received during the pandemic among these two groups.

To address this knowledge gap, we analyzed the Household Pulse Survey data from phase 2 (August 19, 2020) to phase 3.4 (May 9, 2022) that included observations for more than two million adult Americans (Blanchflower & Bryson, 2022; United States Census Bureau, 2022). The data files are publicly available at https://www.census.gov/householdpulse. We investigated the trends in the proportion of NH-Black and NH-White adults who needed but did not receive mental health care in the 4 weeks preceding the survey date. We used Joinpoint regression to test for trends over time by identifying slope and intercept (Kim et al., 2000). For the entire study period (August 2020–May 2022), NHBs {11.5% (95% CI [11.1, 11.9])} were statistically significantly more likely to report that they needed but did not get mental healthcare compared to NHWs {10.6% (95% CI [10.3, 10.8])} (p < .001; Figure 1). Breaking down by the phases of data collection, in phase 2 (August–October 2020), 10.3% (95% CI [9.4, 11.1]) of NHBs and 9.6% (95% CI [9.4, 9.8]) NHWs who needed mental health care did not receive it (p = .20). However, in phase 3 (November 2020–May 2022), NHBs {11.7% (95% CI [11.6, 12.0])} were statistically significantly more likely to report that they did not receive mental health care when needed than NHWs {10.7% (95% CI [10.5, 10.9])}. During the entire study period (August 2020 to May 2022), there was a significant upward trend in the percentage of NHBs who needed but did not receive mental health care (average percentage change of 1.4% (95% CI [0.7, 2.2], p < .001). There was no such significant change for NHWs in the study period.

Figure 1.

Time trends in the proportion of non-Hispanic Blacks and non-Hispanic Whites who needed mental health counseling or therapy but did not receive during past 4 weeks from August 9, 2020 to May 9, 2022. Solid lines represent the observed trends and dotted lines represent the modeled trends for each group.

Note. APC = average percentage change expressed as the point estimate (95% confidence interval). Statistically significant trends denoted with an asterisk (*).

Two years since the beginning of the COVID-19 pandemic, NHB Americans continue to suffer the disproportionate health and economic burdens of the pandemic (Khubchandani et al., 2021; Lopez et al., 2021). Racial/ethnic health disparities existed even before the COVID-19 pandemic, but have worsened now. Even before the COVID-19 pandemic, NHBs had a much lower life expectancy and quality of life than NHWs (Price et al., 2013; Snowden & Graaf, 2021). Continued unmet mental healthcare needs among NHBs may further reduce their life expectancy and wellbeing. Urgent and decisive public health actions are needed to meet the growing and persistent mental healthcare needs of NHBs. These actions should target the expansion of healthcare services, increase the quality and reduce the cost of mental health services, focus on lifestyle modification and health promotion, and also, address the social determinants of poor mental health among NHBs and other vulnerable ethnic groups (Centers for Disease Control and Prevention [CDC], 2022; Cook et al., 2019; Khubchandani et al., 2022; Lopez et al., 2021; Price et al., 2016; Snowden & Graaf, 2021).

In conclusion, the results of our analysis indicate continued and widening racial disparities in the need for mental healthcare services for non-Hispanic Blacks. These disparities can be reduced by actions at three levels (i.e. education, policy, and research; CDC, 2022; Khubchandani et al., 2022; Price et al., 2013; Snowden & Graaf, 2021; WHO, 2021). First, at the education level, sustained and widespread public health awareness campaigns need to be implemented to improve NHBs’ knowledge of mental health issues, medical information, and health literacy. These initiatives are needed to destigmatize mental illness, help-seeking, and uptake of mental healthcare services among NHB populations. Educational initiatives are also needed for the providers’ side; mental healthcare professionals should be sensitized to the unique needs of NHB populations so that they can provide culturally and linguistically appropriate care. Second, for policy-based interventions, greater allocation of resources is needed to improve healthcare coverage, infrastructure, and social services for NHBs with mental healthcare needs (e.g. to increase community capacity for screening/treatment, mental health promotion activities, telehealth/web-based services, training of minority mental health professionals, and for the deployment of family and community-based interventions). Third, for research priorities, focus on existing and new initiatives is imperative. For example, the existing policies and interventions need to be evaluated rigorously for their coverage, impact, and scalability to determine their efficacy and efficiency in helping reduce mental healthcare disparities. For new initiatives, research is needed on community-based, culturally appropriate, and technology-driven low-cost mental healthcare services to ensure a broader reach of mental health services for racial and ethnic minorities. Finally, public health organizations should implement continuous data collection and surveillance measures in their respective territories to monitor the mental health status and needs of racial/ethnic minority populations; this will help guide the formulation of tailored policies and targeted interventions to improve mental health (CDC, 2022; Cook et al., 2019; Lopez et al., 2021; Price et al., 2013; Snowden & Graaf, 2021; WHO, 2021).