Disproportionate impact of post-pandemic negative mental health in underrepresented groups

Historically underrepresented populations are more at risk for COVID-19 infection, hospitalization and death compared with white individuals, the CDC reported in November 2022.

There are many possible factors as to why underrepresented groups, including Black, Hispanic, Asian, American Indian and Alaskan Native populations are at higher risk, Daniel C. DeSimone, MD, of the Mayo Clinic, wrote in an FAQ for the institution. DeSimone cited several reasons such as racism, underlying medical conditions, types of occupations, location and health care access.

Matifadza Hlatshwayo Davis, MD, MPH, director of health for the city of St. Louis, said the factors that put underrepresented populations at higher risk for COVID-19, hospitalizations and death also put them at higher risk for negative mental health effects.

“That severe increase in cases, hospitalizations and deaths mean there is a disproportionate impact of strong grief reactions,” Davis told Healio. “[Higher] mortality rates mean that more loved ones are left in grief, exposing more Black and Brown communities to what we call ‘COVID-severe grief reaction.’ That is disproportionate.”

Lisa Hunter Romanelli, PhD, a psychologist based in Princeton, New Jersey, said that these mental health access issues affecting underrepresented populations are prevalent in pediatric populations as well.

“Children who are in rural areas, children who are in economically disadvantaged areas, children of color – all those groups are less likely to be able to access quality mental health services,” Romanelli told Healio.

Higher rates among minorities

Historically underrepresented groups experience trauma and mental health issues at higher rates for many different reasons, Davis said.

“Some of the [reasons] I would highlight are the long-term disparities around structural determinants of health that didn't allow [minorities] to benefit from a lot of the protections that were put in place during the pandemic,” she said. “Anxiety from not being able to follow the stay-at-home recommendations; disproportionately having frontline, low-paying positions that did not afford [minorities] work-from-home status or paid leave; separation from family and friends, especially those that were in the hospital; and then on the opposite side of the spectrum, living in small, multiple-party households.”

Many families from underrepresented groups live in multigenerational households, Davis continued, a situation that prevented them from being able to social distance and protect relatives from contracting SARS-CoV-2 infection.

“You have matriarchs and patriarchs at the grandparent level, all the way down to young kids, sometimes in one-bedroom apartments with five to eight people,” she said. There's no social distancing. There's no being able to protect those that are most sick.”

In addition, individuals in underrepresented communities are less likely to have health insurance and access to a primary care provider, which leads to a lack of access for COVID-19 testing and treatments, Davis said.

Regina James, MD, the chief of diversity and health equity at the American Psychiatric Association, said that barriers to certain things like mental health services and providers can make it appear as if underrepresented communities have reduced access to resources.

“I think the No. 1 issue is around costs, in terms of accessing mental health services,” James told Healio. “Either [people] have insurance that doesn't cover mental health, or they don't have insurance. So, they are either underinsured or uninsured, and I think that's a big piece. Even when they do have coverage, it's actually a long wait trying to get to someone.”

James said that the health care system is difficult to navigate, so trying to identify a mental health provider is a challenge. And once someone does find a provider that fits their needs, there is the question of whether that person and the clinician will mesh, she said.

“There is a sort of cultural reciprocity,” James said. “Do you relate? Do you connect to them? So, it's difficult to potentially get someone you could culturally and linguistically relate to.”

Barriers to mental health services

Davis also spoke about the barriers to mental health services for underrepresented populations. Like James, Davis said it is compounded by a lack of culturally competent care.

“Minoritized communities, if they walk into a predominantly white place that doesn't understand the uniqueness of their identity, it’s difficult,” Davis said. “And then lack of insurance coverage – all of those things come from that access to care issue.”

In addition, James said, the stigma around mental health is still highly prevalent among underrepresented communities, especially for Black Americans.

“In general, we're coming to a point where we're beginning to normalize these conversations around mental health, and it is just as important and as integral to overall health,” she said. “But we're still moving in that direction. I do think that in certain communities, they may have certain perspectives. I think there is some misinformation and misconceptions about mental health and what that means, [and] that really does contribute to this stigma, to this shame, to this emotional hesitation in terms of reaching out [for help].”

Davis cited a study from the National Alliance of Mental Illnesses, which found that 63% of Black Americans considered a mental health illness as a sign of weakness.

“This contributes to delaying treatment or not seeking treatment at all,” Davis said.

Bringing more education and awareness to the fact that mental health is an integral part of overall health is key in rectifying this, which would help destigmatize these issues of looking weak, James said. Wider adoption of a collaborative care model among multiple providers could also help, she said.

“In a collaborative care environment, there can be that warm handoff between the primary care physician and a mental health care provider to really meet the needs of that individual,” James said.

Davis said there needs to be an increase in efforts to integrate behavioral health into primary care facilities, to assure detection and treatment of mental health, as well as provide more data on underrepresented communities.

“We need more data because data is justice, and it informs policy and funding that examines the cultural differences in Black and Brown communities on beliefs about mental health. That will provide some insight into why minoritized communities are hesitant to seek services,” Davis said.

References:

COVID-19 infections by race: What’s behind the health disparities? https://www.mayoclinic.org/diseases-conditions/coronavirus/expert-answers/coronavirus-infection-by-race/faq-20488802. Published Oct. 6, 2022. Accessed Jan. 12, 2023.

Mental health in Black communities: Challenges, resources, community voices. https://namica.org/mental-health-challenges-in-african-american-communities/. Accessed Jan. 12, 2023.

Risk for COVID-19 infection, hospitalization, and death by race/ethnicity. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html. Updated Dec. 28, 2022. Accessed Jan. 12, 2023.