There is accumulating evidence of rural-urban disparities in mental health treatment. Data from the National Comorbidity Survey Replication (NCS-R) for example, that residents of small towns not adjacent to larger metropolitan areas reported significantly less treatment for their stated mental health disorders than did residents of rural areas adjacent to a metropolitan area, suburban areas, and central cities.1
Similar rural-urban treatment disparities were detected using data from the Medical Expenditure Panel Survey (MEPS).2
Like the NCS-R data, the MEPS data revealed that respondents residing in rural areas with low population density, regardless of adjacency, obtained less mental health treatment than residents of metropolitan areas and more urbanized rural areas. Other studies have confirmed rural-urban differences in mental health treatment rates using less precise measures of rurality.3–6
There are also reports of racial and ethnic disparities in receipt of health care in general and mental health care in particular.3,8–11
Specifically, African Americans and Hispanics receive less mental health treatment even when such factors as age, gender, and insurance status are controlled for in the analysis.12–15
For instance, results from the Mexican American Prevalence and Services Survey (MAPSS) indicate that 71% of Mexican Americans with DSM-III-R defined disorders received no mental health services in the past 12 months.16
Using MEPS data, Harman, Edlund and Fortney17
showed that African Americans and Latinos were about half as likely as non-Hispanic Whites to fill a prescription for an antidepressant. Hans and Liu,14
also using the MEPS showed that African Americans were 8.3% less likely than non-Hispanic Whites to fill a prescription for psychotropic medications used to treat mental illness, which cost, on average, $600 less annually.
Considerably less is known about racial disparities in mental health treatment in rural areas. Vega and colleagues16
found that the pattern of services use was different for Mexican Americans living in rural areas when compared to those of urban users. Specifically, rural Mexican Americans were more likely to use general practitioners or informal service providers for their mental health problems. Using data from the National Comorbidity Survey, another study showed that rural residence was associated with less mental health treatment for African Americans and Latinos. Results from the same study conclude that African Americans who were not poor also had lower odds of receiving specialty care than Whites who were not poor.18
Other studies have shown that both race and rurality are associated with fewer mental health treatment visits.1–3,19
Frieman and Zuvekas,3
for example, showed that African Americans and Latinos received fewer mental health specialty visits and were prescribed fewer psychotropic medications but rural residents received no fewer psychotropic prescriptions than did urban residents. Rural residents in this study did receive fewer specialty visits than their urban counterparts. Zimmerman19
showed that rural and Latino children, but not African American children, received fewer mental health specialty visits than urban residents and non-Hispanic Whites.
There are multiple factors that combine with both race and rurality to affect mental health treatment. For example, rural residents, African Americans, Latinos, and members of other minority groups are more likely to be impoverished than are non-Hispanic Whites. Poverty rates for Latinos, African Americans, and Native Americans ranged from 21.8 to 26.8% during 2004; the poverty rate for residents of non-metropolitan areas during the same time frame was 14.5%.21
Insurance, both public and private, increases the likelihood of mental health services use, but both rural residents and members of minority groups are less likely to have it.2,11,18,22,23
Others have shown that neighborhood factors, gender, insurance eligibility group, and personal attitudes contribute to both ethnic and rural-urban treatment disparities.9,11,15,19,25–27
The findings also suggest that urban non-Hispanic Whites are more likely to receive mental health treatment than are rural residents of any other race/ethnicity. This inference is supported by the findings of Alegria and colleagues18
who showed that urban non-Latino Whites were more likely to receive specialty mental health treatment than were Latinos or African Americans regardless of income status, but that race was not a significant factor in receiving treatment in rural areas among those classified as non-poor. One potential explanation for the finding of these investigators is that access to care is restricted for all people in rural areas and that non-Hispanic Whites’ relative advantage in obtaining care in urban areas disappears in areas where few mental health professionals and facilities exist. Another suggestion is that ethnicity and race may be components of a more complex construct of social position that requires further research.
The present research examines the extent to which mental health treatment rates differ across level of rurality and by race and ethnicity. Our primary database includes 4 panels of the MEPS (1996–1999) which were aggregated to increase the number of rural minority respondents available for analysis. Building on Alegria’s argument, we expect that non-Hispanic Whites residing in metropolitan areas will receive more mental health treatment than members of racial/ethnic minority groups. We expand on this argument, by hypothesizing that this relative treatment advantage for non-Hispanic Whites will not be evident in non-metropolitan areas because of the absence of services.