A larger proportion of African American public housing residents suffered from anxiety and substance use disorders than African American non-public housing residents, which is consistent with previous studies reporting that public housing residents are less healthy than non-public housing residents [15
]. Sociodemographic differences were present that may contribute to the observed mental illness disparity. Compared to non-public housing residents, public housing residents had higher unemployment levels, larger proportions of females and unmarried residents, and less educational achievement, all of which may either impact mental health or treatment of mental illness [26
]. Low income, a qualification for public housing, is another possible risk factor for anxiety and depression [31
], and serious mental illness is associated with decreased annual earnings of approximately $16,000 [32
]. This reduction in income may enable more mentally ill African Americans to qualify for public housing than non-mentally ill individuals, which would subsequently increase mental illness levels among public housing residents. After controlling for sociodemographics and chronic medical illness, however, the association of public housing residency with increased likelihood of having a 12-month or lifetime psychiatric (i.e., anxiety, mood, and/or substance use) disorder persisted. Although non-Hispanic blacks may have less risk for anxiety, mood, and substance use disorders than whites [30
], this trend was not present in African American public housing residents who had similar levels of anxiety and mood disorders, as well as more substance use disorders than a national largely white adult population [33
]. For comparison, among US English-speaking adult household residents the estimated 12-month prevalence of anxiety, mood, and substance use disorder levels were 18.1%, 9.5%, and 3.8% [33
] (African American public housing residents had levels of 19.8%, 9.2% and 6.0%).
We did not find statistically significant differences in utilization of mental health assistance from medical providers with 30.2%, 26.7%, and 16.4% of public and 23.7%, 39.1%, and 26.8% of non-public housing residents with a 12-month history of an anxiety, mood, or substance use disorder receiving care. These findings are indicative of mental healthcare disparities because among a national primarily white population of community-dwelling adults, 36.9%, 50.9%, and 34.5% of those with a 12-month history of an anxiety, mood, or substance use disorder utilized health services for mental healthcare [34
], which are higher than our utilization estimates. Such racial and ethnic disparities may result because depressed Latinos, Asians, and African Americans are less likely to access mental health services than non-Latino whites [35
], and depressed African Americans may have a more severe and chronic course and receive less treatment than non-Hispanic whites [36
African American public (and non-public) housing residents may have great need for mental health treatment as only 26% of residents with a 12-month history of an anxiety, mood, and/or substance use disorder received mental health services from general or mental health providers. These illnesses can have serious consequences [33
] and anxiety and depression often have chronic courses [37
]. Many residents may never recover from their mental illness without appropriate medical care and psychosocial interventions. The public housing setting may offer opportunities to improve services for detection and treatment of mental illnesses such as substance use disorders due to the relatively high prevalence of mental illness and low levels of service utilization. One such public housing intervention has had some success [39
]. Many public housing residents may also benefit from multi-disciplinary services, and service providers such as social service agencies may be well positioned to educate residents about mental illness, help with screening, and be involved with treatment management. Specifically, some public housing apartment complexes have social workers or other potential gatekeepers that could help with mental illness education, screening, referral to appropriate care, and follow-up. Nevertheless, our data suggest that African American public housing residents do not receive or benefit from these potential opportunities to deliver improved care.
A limitation of these analyses is that the public housing residents were a small subsample of the NSAL’s nationally representative African American population. The NSAL African American public housing subgroup was estimated to represent 2.5 million adults, whereas the US Department of Housing and Urban Development estimated that 1.1 million African Americans lived in public housing in 2000 [12
]; thus, the NSAL sample of public housing residents is likely not entirely representative of public housing residents nationally. Also, mental health professionals did not conduct the research interviews, and reliance on non-mental health professionals for data collection may lead to inaccuracies in psychiatric illness prevalence estimates. Another limitation is that the classification of public housing status relied on a single self-report question that may be inaccurately reported. Many African Americans are also overrepresented in disadvantaged groups not examined by the NSAL (e.g., prison [11
] and homeless [10
] populations), exclusion of which may lead to underestimation of the true burden of mental illness among African Americans.