Most studies to date on mental health service use among ethnic groups of youth in the United States suggest that Black youth receive less treatment than Whites.1–5
These findings apply to both children and adolescents and control for age, sex, socioeconomic status, and severity of illness. Research to improve mental health services for minority youth is important because mental disorders often begin in youth6
and early onset is correlated with worse education, employment, and socioeconomic achievement in adulthood, particularly for Black youth (Fergusson BJP 2007; Turnbull JCCP 1990; Kessler Educational Attainment AJP 1995).7,8,9
However, none of these studies distinguishes among the various ethnicities contained within the designation Black
, making it difficult to ascertain intra-ethnic differences in mental health service use. We present an analysis of mental health service use among Haitian youth, an under-studied but sizeable community in the United States.
The most recent US census counts over 400,000 Haitians, but this number is widely viewed as an underestimate.10
There are large Haitian communities in the cities of Miami, New York, Boston, and Montreal. While studies have documented differential rates of disorders and use of mental health services between African American, English-speaking African Caribbean, and Haitian adults,11,12
few studies have examined such differences among Black youth in the United States. Intra-ethnic comparisons may identify important cultural differences within broad groups that have historically been clustered together for historical or political reasons, such as individuals of African descent. US Census categories, long the traditional unit of comparison in health disparities research, do not reflect the heterogeneity found among certain urban Black communities in the United States, listed above, and the diversity of health beliefs and behaviors contained therein. White youth, admittedly a diverse group as well, are a useful comparison because research shows them to receive the highest levels of mental health services.1–5
There is a scant research base on the mental health of Haitian youth who immigrated to the United States and or were born or naturalized in the United States (to whom we collectively refer as “Haitian youth”). Increasing rates of suicidality have been found among girls of Caribbean descent in the United States.13
Anecdotal evidence suggests that Haitian families may not readily engage in standard psychopharmacological or long-term psychotherapeutic approaches used in mental health treatments. Rather, some have observed a primary care model of service use among Haitian American families, where attendance in care decreases once symptoms decline.14
Prior research suggests that Haitian immigrant families have among the lowest rates of health insurance in the U.S., which could lead them to be underserved by mental health services.15,16
Although not studied in Haitian American families, under-recognition by parents of their children’s mental health problems also may account for underutilization of mental health services by Black families in the United States.17
Indeed, such parents are less likely than White parents to identify their children’s behavior as a mental health problem requiring intervention,18,19
and these perceptions may be moderated by family income level.20
Beyond patient-specific variables, there are social determinants that affect mental health and service use and may be important mediators of disparities between white, African American and Haitian youth. For example, the effects of low income, lack of education, single parenthood, and being uninsured on psychological distress in minority youth are well-documented.7, 21,22
Neighborhood disadvantage may moderate family effects on conduct-disordered behavior in Black youth.23
Higher levels of mental health need have been found among uninsured and publicly-insured youth.24
Youth from ethnic minorities may experience an exaggerated impact of these social determinants on mental health due to their disproportionate exposure to social adversity and ambient hazards such as crime, violence, or physical disorder.24–27
Other studies have identified correlations between neighborhood poverty and symptoms of depression, anxiety, oppositional defiance, and conduct disorder in diverse groups of adolescents.28
It is possible that the negative effects of these individual-level and neighborhood-level socioeconomic disadvantages may be exacerbated among Haitian and African American youth given that these populations may be additionally burdened with societal influences such as discrimination and acculturative stress.
The present study considers the impact of social determinants on three important indicators of mental health service quality: treatment adequacy, emergency room (ER) use, and early dropout of care for Haitian, African American, and non-Latino White youth. We use a unique health care system dataset that includes patients from 69 ZIP codes in Boston, a metropolitan area with large African American and Haitian communities. The dataset includes mental health visits from specialty mental health, primary care, and emergency settings, all delivered within the same health system by the same providers. It is well documented that youth receive treatment for mental disorders across service sectors, and primarily in school and outpatient mental health settings;29
this dataset includes both outpatient mental health and school-based mental health clinic data.
To determine adequacy of youth mental health treatment, datasets must be able to account for differences in treatment modality (e.g., psychotherapy or psychopharmacology) and in total number of visits. Evidence-based treatment of mental illness in youth sets certain expectations in these areas to meet a basic level of quality. Research datasets that can provide this level of detail may help identify important barriers to the delivery of evidence-based care to ethnic minority youth, which is the care most likely to produce benefits. We hypothesize that Haitians and African Americans will have fewer psychotherapy visits and psychopharmacology visits compared to whites. We further hypothesize that lower rates of adequate care will be seen among families living in areas of more poverty, less education, more single parents, more foreign-born, or more non-citizens, and that these differences will be greater for Haitians and African Americans than for whites.
Because Black youth served in the public health sector use crisis psychiatric services disproportionately, emergency room visits can be seen as a negative indicator of treatment adequacy.30
This overuse is more prevalent in geographic areas of high poverty.31
Previous studies have shown that the majority of ER use is for non-emergent care and could be treated more efficiently in other outpatient settings, which may be due to decreased access to outpatient mental health care by Black youth. We hypothesize that Haitian and African American youth will use more emergency services, and that this relationship will have a positive association with social determinants.
Early dropout from mental health services in the United States is more common among Black families than white families.32
Risk factors for termination are poverty, parental stress, child antisocial behavior, and adverse child-rearing practices. There is also evidence that certain cultural groups, such as Black patients, might use services in brief episodes of engagement and disengagement.33
Because these risk factors are known to be more common among those living in social adversity, and Black families are more likely to live in such conditions, we hypothesize they will be more likely to end care prematurely.
In this paper, we test the hypotheses that African American and Haitian youth without insurance and living in areas of poverty, lower levels of education, and single parent households will have less adequate care and greater ER use than white youth in similar circumstances. We also assess the risk of dropout of mental health care for the different racial/ethnic groups by area-level characteristics and insurance status, accounting for multiple episodes of care.