Mental health care among marginalized populations in the United States

Abstract

The public faces many barriers when accessing mental health resources. Economic barriers can include a lack of health insurance or ability to pay (including premiums and copays). Another barrier is minimal awareness of or education about mental health conditions, available treatments, and services that improve access. The stigma associated with mental illness—a sense of shame or embarrassment that some feel or are made to feel by others—can prevent people from seeking mental health treatment. Other individuals may not have the time or related supports, such as taking leave from work, securing child care, or accessing timely transportation. There is a known lack of appropriate intervention strategies, including integration of mental health and primary health care services and opportunities to engage patients or refer them for psychiatric services or counseling support. In addition to these barriers, many individuals who are members of marginalized populations encounter tremendous burdens that affect their ability to access mental health care, such as racism, homophobia, or misogyny. These offenses may originate from the public, community organizations, large institutions, governments, historical inertia, or long-standing structural bias. It is our collective responsibility as health care professionals to address the marginalization of vulnerable people. This includes, but is not limited to, challenging our own implicit and explicit biases and addressing policies and systems to ensure the equitable treatment of these populations. This article examines the disparities in mental health services provided to marginalized groups in the United States—Asian, Black, LGBTQ (lesbian, gay, bisexual, transgender, and queer/questioning), Middle Eastern, and women—and addresses the unique barriers they face in accessing mental health services, as well as the unique mental health–related challenges they experience. The COVID-19 pandemic has upended our way of life in the United States and worldwide. Yet the impact of the pandemic and the efforts to control it have not been equal across the U.S. population. CDC data show that a disproportionate number of Black Americans have been infected with COVID-19 and have died from the disease.1CDC Coronavirus disease 2019: Racial and ethnic minority groups.www.cdc.gov/coronavirus/2019Date accessed: May 20, 2021Google Scholar Furthermore, decades upon decades of structural racism have influenced unequal access to services and other social determinants of mental health. Adding to the weighted psychological burden of the pandemic on access to health care, abrupt lifestyle changes, and financial challenges for Black Americans, the world was witness to the structural violence that took the life of George Floyd. After his killing, and the killing of many other Black Americans, the population has increasingly demanded that we make structural changes to prevent such violence and protect Black lives. As health care providers, it is important that we examine and challenge our participation in such systems to better serve the mental health needs of this population.2Robles-Ramamurthy B Black children and the pressing need for antiracist child psychiatry.J Am Acad Child Adolesc Psychiatry. 2021; 60: 432-434Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar The effects of structural racism, defined as “a system in which public policies, institutional practices, cultural representatives, and other norms work in various, often reinforcing ways to perpetuate racial group inequity,”3Aspen Institute 11 terms you should know to better understand structural racism.www.aspeninstitute.orgDate: July 11, 2016Date accessed: May 20, 2021Google Scholar are widespread. The system has traumatized Black Americans in many ways, from housing policies promoting racial wealth disparities to overrepresentation in the criminal justice system through profiling and increased surveillance.4Rothstein R The color of law: A forgotten history of how our government segregated America.1st ed. Livelight Publishing, New York2017Google Scholar Such traumas erode the safety, security, and sense of connection that is essential to the healthy development of children and the sustainable wellness of adults. Without such critical elements, there is an increased risk of familial instability, troubles within communities, and the perpetuation of trauma across generations. Learning objectivesAt the conclusion of this knowledge-based activity, pharmacists will be able to▪Describe the difficulties in accessing mental health services among marginalized populations.▪Outline the various mental health–related problems that face marginalized populations.▪Discuss the various roles individuals, institutions, and systems play in propagating disparities in mental health services among marginalized populations.▪Discuss pharmacist roles in addressing mental health disparities among marginalized populations. Preassessment QuestionsBefore participating in this activity, test your knowledge by answering the following questions. These questions will also be part of the CPE assessment.1Which of the following is an appropriate strategy to reduce inequities in mental health services across marginalized populations?aUse technical terminology when providing education.bSolicit staff to volunteer their time to provide special services that address inequities.cHire and promote staff solely on the basis of merit to avoid favoritism.dEncourage staff to challenge their conscious and subconscious biases at every level.2Which statement is true?aBlack Americans are less likely to use emergency departments to receive mental health services.bBlack Americans are equally represented in mental health research.cOne in two Black Americans who are in need of mental health services receive it.dBlack Americans are less likely to receive guideline-based care. At the conclusion of this knowledge-based activity, pharmacists will be able to ▪Describe the difficulties in accessing mental health services among marginalized populations.▪Outline the various mental health–related problems that face marginalized populations.▪Discuss the various roles individuals, institutions, and systems play in propagating disparities in mental health services among marginalized populations.▪Discuss pharmacist roles in addressing mental health disparities among marginalized populations. Before participating in this activity, test your knowledge by answering the following questions. These questions will also be part of the CPE assessment. 1Which of the following is an appropriate strategy to reduce inequities in mental health services across marginalized populations?aUse technical terminology when providing education.bSolicit staff to volunteer their time to provide special services that address inequities.cHire and promote staff solely on the basis of merit to avoid favoritism.dEncourage staff to challenge their conscious and subconscious biases at every level.2Which statement is true?aBlack Americans are less likely to use emergency departments to receive mental health services.bBlack Americans are equally represented in mental health research.cOne in two Black Americans who are in need of mental health services receive it.dBlack Americans are less likely to receive guideline-based care. As health care providers, we are well aware of the vital role safety and security play in mental health. We must do our part to ensure that systems prevent trauma and increase Black Americans’ access to mental health–related resources. With limited access to necessary resources, coupled with a distrust in the system, Black Americans may not feel safe asking for help and support.2Robles-Ramamurthy B Black children and the pressing need for antiracist child psychiatry.J Am Acad Child Adolesc Psychiatry. 2021; 60: 432-434Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar There is significant variation in how Black Americans experience mental health services. Many shared cultural values among Black Americans encourage resilience and strength. These may include family connections, expression through spirituality or music, reliance on community support, and religious networks. However, the shared experience of racism, discrimination, and inequity has substantial adverse effects on mental health. Data from the U.S. Health and Human Services’s Office of Minority Health show that Black adults in the United States are more likely than white adults to report persistent symptoms of emotional distress, including sadness, hopelessness, and feeling overwhelmed.5U.S. Department of Health and Human Services Office of Minority Health.https://minorityhealth.hhs.gov/omhDate accessed: May 20, 2021Google Scholar Black adults living in poverty are more likely to report severe psychological distress than those with relatively greater financial security.5U.S. Department of Health and Human Services Office of Minority Health.https://minorityhealth.hhs.gov/omhDate accessed: May 20, 2021Google Scholar Despite these issues, only one in three Black adults who need psychiatric services receive it. According to the American Psychiatric Association’s Mental Health Facts for African Americans guide, Black Americans are also less likely to receive guideline-consistent care, are less frequently included in research, and are more likely to use emergency departments for primary care instead of receiving care from mental health services.6American Psychiatric Association Diversity & health equity education: African Americans.www.psychiatry.org/psychiatrists/cultural-competency/education/african-american-patientsDate accessed: May 20, 2021Google Scholar Black people have a long history of experiencing prejudice and discrimination in the U.S. health care system and continue to experience these issues when they attempt to seek treatment. They face provider bias, both conscious and unconscious, with research showing that a lack of cultural competency among providers can result in misdiagnosis and inadequate treatment.6American Psychiatric Association Diversity & health equity education: African Americans.www.psychiatry.org/psychiatrists/cultural-competency/education/african-american-patientsDate accessed: May 20, 2021Google Scholar Black men are more likely to be misdiagnosed with schizophrenia when describing symptoms related to mood disorders or PTSD.5U.S. Department of Health and Human Services Office of Minority Health.https://minorityhealth.hhs.gov/omhDate accessed: May 20, 2021Google Scholar, 6American Psychiatric Association Diversity & health equity education: African Americans.www.psychiatry.org/psychiatrists/cultural-competency/education/african-american-patientsDate accessed: May 20, 2021Google Scholar, 7National Alliance on Mental Illness Black/African American.https://nami.org/Your-Journey/Identity-and-Cultural-Dimensions/Black-African-AmericanDate accessed: May 20, 2021Google Scholar These factors have led to a mistrust of mental health professionals among Black Americans, presenting yet another barrier to seeking mental health treatment. Black Americans also may be more likely to somaticize, thus will often report physical symptoms related to mental health problems instead of describing psychiatric symptoms. They may report pain instead of depression. Therefore, cultural competence may help clinicians recognize when mental health treatment could be of benefit. Data from the National Latino and Asian American Study show that Asian Americans have a 17.3% overall lifetime incidence rate of any psychiatric disorder.8National Latino and Asian American Study (NLAAS) www.massgeneral.org/mongan-institute/centers/dru/research/past/nlaasDate accessed: May 20, 2021Google Scholar On a monthly basis, the rate of any such disorder in this population is 9.2%.8National Latino and Asian American Study (NLAAS) www.massgeneral.org/mongan-institute/centers/dru/research/past/nlaasDate accessed: May 20, 2021Google Scholar However, Asian Americans are three times less likely than white Americans to pursue any type of mental health support or treatment. Furthermore, national data show that only 8.6% of Asian Americans seek any type of mental health services or resource, compared with nearly 18% of the general population.9Spencer M Discrimination and mental health–related service use in a national study of Asian Americans.Am J Public Health. 2010; 100 (201): 2410-2417Crossref PubMed Scopus (90) Google Scholar Similar results have been found by other studies, some of which also examined the specific mental health–related needs and issues faced by Asian Americans from a variety of communities (Asian Indian, Cambodian, Chinese, Indonesian, Korean, Taiwanese, Thai, and Vietnamese). In 2007, the Health Needs Assessment project reviewed the various mental health concerns that were most important within Asian American communities in Maryland. In interviews of 174 Asian Americans, 19 focus groups identified several common sources of stress that affected the mental health of Asian Americans and specific barriers to care.8National Latino and Asian American Study (NLAAS) www.massgeneral.org/mongan-institute/centers/dru/research/past/nlaasDate accessed: May 20, 2021Google Scholar One source is significant parental and familial pressure to excel in academics. Another is the difficulty in talking about mental health issues, which is often considered taboo in many Asian cultures. Research conducted by Spencer and colleagues found that many young Asian Americans most often seek out support from personal contacts, such as close friends, family members, and religious community members, rather than pursuing professional assistance to address their mental health issues and challenges.9Spencer M Discrimination and mental health–related service use in a national study of Asian Americans.Am J Public Health. 2010; 100 (201): 2410-2417Crossref PubMed Scopus (90) Google Scholar Their research showed that the biggest deterrents to seeking professional help were the negative stigma surrounding mental health issues and lack of awareness of resources and services available to them. As a result, many Asian Americans may minimize, dismiss, neglect, or deny their symptoms. Further adding pressure to this trend is the strong emphasis on family obligations, which includes strict adherence to traditional and cultural values. Researchers have noted the difficulty for many Asian Americans in finding balance between two different cultures and thus developing a sense of self. Language barriers were another significant factor in accessing mental health services. Collaboration between service systems and community resources has been lacking, and there is a significant need for more translators to address the language barrier.10Lee S 2009. J Community Health. 2009; 34: 144-152Google Scholar The researchers also described the burden to live up to the “model minority” stereotype, which falsely represents Asian Americans as having successfully integrated into mainstream culture and having moved beyond the difficulties of racial discrimination. Yet discrimination due to racial or cultural background continues to plague Asian Americans. Though federal data on hate crimes for 2020 has not yet been released, hate crimes data from 2019 showed the highest level in over a decade. The FBI has been concerned about a surge in hate crimes against individuals of Asian descent in the United States as a result of the COVID-19 pandemic. Late in 2020, the United Nations issued a statement that described “an alarming level” of racially motivated violence and other hate crimes directed at Asian Americans.11BBC News Covid ‘hate crimes’ against Asian Americans on rise.www.bbc.com/news/world-us-canada-56218684Date: May 21, 2021Date accessed: May 21, 2021Google Scholar In March of 2021, a devastating shooting at spas and massage parlors in Atlanta left eight Asian Americans dead, which many felt could in part be related to the fetishization of Asian women.13Chang A For Asian American women, misogyny and racism are inseparable, sociologist says. NPR, March 19, 2021www.npr.org/2021/03/19/979336512/for-asian-american-women-misogyny-and-racism-are-inseparable-sociologist-saysDate accessed: May 20, 2021Google Scholar Data on the incidence of such crimes and discrimination are difficult to determine because of the lack of long-term data tracking and differences in the way such instances are reported. A national advocacy group, Stop Asian American Pacific Islander (AAPI) Hate, designed an online self-reporting tool at the beginning of the pandemic to track instances of violence and discrimination. During 2020, the organization reported more than 2,800 such acts directed at Asian Americans and Pacific Islanders nationwide. In New York City, the hate crimes task force was called to investigate 27 incidents in 2020, a ninefold increase from the previous year. Police in Oakland, CA, have added patrols and set up a command station in Chinatown.8National Latino and Asian American Study (NLAAS) www.massgeneral.org/mongan-institute/centers/dru/research/past/nlaasDate accessed: May 20, 2021Google Scholar, 11BBC News Covid ‘hate crimes’ against Asian Americans on rise.www.bbc.com/news/world-us-canada-56218684Date: May 21, 2021Date accessed: May 21, 2021Google Scholar, 12Yam K Racism, sexism must be considered in Atlanta case involving killing of six Asian women, experts say. NBC News.www.nbcnews.com/news/asian-america/racism-sexism-must-be-considered-atlanta-case-involving-killing-six-n1261347Date: March 17, 2021Date accessed: May 20, 2021Google Scholar, 13Chang A For Asian American women, misogyny and racism are inseparable, sociologist says. NPR, March 19, 2021www.npr.org/2021/03/19/979336512/for-asian-american-women-misogyny-and-racism-are-inseparable-sociologist-saysDate accessed: May 20, 2021Google Scholar, 14Kaur H Fetishized, sexualized and marginalized, Asian women are uniquely vulnerable to violence. CNN, March 17, 2021www.cnn.com/2021/03/17/us/asian-women-misogyny-spa-shootings-trnd/index.htmlDate accessed: May 20, 2021Google Scholar It’s important to note that the terms Middle Eastern and Muslim should not be used interchangeably. Not all Middle Easterners are Muslim, and not all Muslims are Middle Eastern. Middle Eastern Americans come from many different countries, and there is not a single religious identity shared within these communities. Many other unique differences exist among Middle Eastern Americans as well, such as immigrant and refugee status. Some immigrants may have come from countries at war, while others may be struggling with substantial economic and social instability. Despite significant disparities in health care services received by Middle Eastern Americans, there is a paucity of data examining their health care needs. The available research shows that Middle Eastern Americans who moved to the United States to escape political violence and religious persecution in their home countries have an increased risk for anxiety and depression.15Winerman L Reaching out to Muslim and Arab Americans.Monitor on Psychology. 2006; 37: 54www.apa.org/monitor/oct06/reachingDate accessed: May 20, 2021Google Scholar This is due in part to the discrimination and anger their respective communities have faced since September 11, 2001. It is also due to the difficulties of adjusting to life in the United States. Many young Middle Eastern Americans may struggle with the balance between the pressure from the cultural values of their home country and their life as an American. Some often feel as if they must lead two lives. Independent of age, many Middle Eastern Americans also struggle with the sociopolitical tensions between the United States and the Middle East. Muslim women face particular stressors. For example, the U.S. media often portrays Muslim women as being oppressed by their home country, but many Muslim American women choose to wear a veil and say they find it empowering. Yet the identifiable dress increases the possibility that they are targets of discrimination and harassment. COVID-19 presents unique stressors for this population, as well. There may be increased worry about family in their home country, changes to immigration status, and access to resources as a result of the pandemic. Middle Eastern refugees have increased difficulty in utilizing social and economic support compared with U.S.-born Americans. Despite these increased stressors and a great need for psychological services, many Middle Eastern and Muslim Americans often avoid accessing mental health services because of the shame and stigma associated with seeking such help, as well as other cultural barriers. Research shows that Middle Eastern Americans are more likely to seek help from their families than to engage with mental health services when they are in need. This stigma may be reduced by engaging this population in comfortable community settings and not being overly technical when providing information.16Michigan Medicine Department of Psychiatry Middle Eastern American communities.https://medicine.umich.edu/dept/psychiatryDate accessed: May 20, 2021Google Scholar Focusing on general topics, such as adjustment to a different culture or parenting strategies, can encourage interest without eliciting defenses. Mental health clinicians may also consult with Imams, Muslim religious leaders who many Muslims first reach out to for help, to learn better approaches to helping such communities.16Michigan Medicine Department of Psychiatry Middle Eastern American communities.https://medicine.umich.edu/dept/psychiatryDate accessed: May 20, 2021Google Scholar There is also a described tendency to think of their symptoms in a biological framework instead of a psychological one. Middle Eastern Americans often seek treatment from a primary care physician instead of a mental health professional. Middle Eastern Americans experiencing psychological difficulties might present with somatic symptoms such as aches, pain, and fatigue rather than DSM diagnostic criteria of anxiety or depression. It may be helpful for clinicians to relate physical symptoms to psychological ones and to consider the unique stressors Middle Eastern Americans face because of the pandemic, such as access to resources, concern about family in their home country, and impact on immigration status.15Winerman L Reaching out to Muslim and Arab Americans.Monitor on Psychology. 2006; 37: 54www.apa.org/monitor/oct06/reachingDate accessed: May 20, 2021Google Scholar Being LGBTQ is not a mental illness. However, many LGBTQ people experience mental health conditions and difficulties to a greater degree than their heterosexual cisgender counterparts. They are 2.5 times more likely to seek mental health services, as well. The bisexual and transgender communities have the greatest degree of mental health problems within the LGBTQ spectrum. Younger individuals have the highest rates of psychiatric problems of all age groups within the LGBTQ community. All members of this population are at higher risk for experiencing shame, fear, discrimination, and traumatic events. Many LGBTQ individuals are also members of other marginalized groups. They may be Black, indigenous, or people of color (BIPOC), have a physical disability, belong to a minority religious group, or have a low socioeconomic status. The complexity of their experiences cannot be accounted for by examining just one aspect of their life. Because of negative stereotypes, it may be difficult for LGBTQ individuals to reveal to others this important part of their identity. And when they do express themselves, there is the potential to face rejection from peers, colleagues, and friends, leading to feelings of loneliness.17National Alliance on Mental Illness LGBTQI (I stands for Intersex) Americans.www.nami.org/Your-Journey/Identity-and-Cultural-Dimensions/LGBTQIDate accessed: May 20, 2021Google Scholar The LGBTQ population is at an increased risk for a variety of mental health–related problems. LGBTQ youth have significantly higher rates of anxiety, depression, and substance use disorders.18Kann L McManus T Harris WA et al.Youth Risk Behavior Surveillance (YRBSS) United States, 2015.MMWR Surveill Summ. 2016; 65: 1-174doi:10.15585/mmwr.ss6506a1Crossref Scopus (844) Google Scholar, 19Safren SA Heimberg RG Depression, hopelessness, suicidality, and related factors in sexual minority and heterosexual adolescents.J Consult Clin Psychol. 1999; 67: 859-866doi:10.1037//0022-006x.67.6.859Date accessed: March 22, 2018Crossref PubMed Scopus (253) Google Scholar Compared with the general population, LGBTQ adults have higher tobacco, alcohol, and other drug use, as well as higher rates of cancer, HIV, and obesity.20Institute of Medicine Lesbian health: Current assessment and directions for the future. The National Academies Press, Washington, DC1999doi:10.17226/6109Google Scholar, 21Struble CB Lindley LL Montgomery K Hardin J Burcin M Overweight and obesity in lesbian and bisexual college women.J Am Coll Heal. 2010; 59: 51-56doi:10.1080/07448481.2010.483703Crossref PubMed Scopus (49) Google Scholar, 22Institute of Medicine The health of lesbian, gay, bisexual, and transgender people. The National Academies Press, Washington, DC2011doi:10.17226/13128tGoogle Scholar Research suggest that LGBTQ adults also have higher rates of mood and anxiety disorders and are at a higher risk for suicidal behavior than heterosexual adults. LGBTQ adults are more than twice as likely as heterosexual adults to experience a mental health condition. Transgender individuals are nearly four times as likely as cisgender individuals to experience a mental health condition. The health disparities seen within the LGBTQ population are significantly related to stigma, stress, and structural discrimination.32Haas A Suicide and suicide risk in lesbian, gay, bisexual, and transgender populations: Review and recommendations.J Homosexuality. 2011; 58: 10-51Crossref PubMed Scopus (670) Google Scholar Approximately 8% of LGBTQ individuals and nearly 27% of transgender individuals report being denied health care because of their identify. With respect to mental health care, it has been found that stigma, lack of cultural sensitivity, and unconscious and conscious reluctance to address the identity of a patient may have a negative impact on care. Evidence suggests that implicit preferences for heterosexual people versus LGBTQ people are pervasive among heterosexual health care providers.23Hudiasa H Health care disparities among lesbian, gay, bisexual, and transgender youth: A literature review.Cureus. 2017; 9e1184doi: 10.7759/cureus.1184PubMed Google Scholar It is known that stigma, when experienced on a long-term basis, can lead to adverse effects on physical and mental health. Furthermore, research has shown that environmental factors such as experiencing discrimination often lead to the expectation of experiencing future discrimination. This form of chronic stress and stigma sensitizes individuals to always be on guard. The resulting hyperawareness has the potential to lead to internalization of the traumatic experiences related to being discriminated against, which in turn can lead to a negative sense of self.24Meyer IH Minority stress and mental health in gay men.J Health Soc Behav. 1995; 36: 38-56doi:10.2307/2137286Crossref PubMed Scopus (2063) Google Scholar, 25Meyer IH Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence.Psychol Bull. 2003; 129: 674-697doi:10.1016/j.micinf.2011.07.011.InnateCrossref PubMed Scopus (6367) Google Scholar This is of significant concern when large systems are not sensitive to issues affecting the LGBTQ population, or are even offenders. Data have shown that the degree of structural stigma is directly proportional to physical and mental health problems that such individuals experience.26Hatzenbuehler ML Social attitudes regarding same-sex marriage and LGBT health disparities: Results from a national probability sample.J Soc Issues. 2017; 73: 443-681doi:10.1111/josi.12229Crossref Scopus (43) Google Scholar, 27Hatzenbuehler ML State-level policies and psychiatric morbidity in lesbian, gay, and bisexual populations.Am J Public Health. 2009; 99: 2275-2281doi:10.2105/AJPH.2008.153510Crossref PubMed Scopus (344) Google Scholar, 28Hatzenbuehler ML Inclusive anti-bullying policies and reduced risk of suicide attempts in lesbian and gay youth.J Adolesc Health. 2013; 53: S21-S26doi:10.1016/j.jadohealth.2012.08.010Abstract Full Text Full Text PDF PubMed Scopus (171) Google Scholar The perception of social rejection was found to be as influential as actual experiences on health outcomes.29Ross MW Actual and anticipated societal reaction to homosexuality and adjustment in two societies.J Sex Res. 1985; 21: 40-55doi:10.1080/00224498509551243Crossref Scopus (36) Google Scholar However, there is a reduction in health problems in LGBTQ individuals when such structural stigma is mitigated.30Hatzenbuehler M Bellatorre A Lee Y Finch BK Muennig P Fiscella K Structural stigma and all-cause mortality in sexual minority populations.Soc Sci Med. 2014; 103: 33-41doi:10.1016/j.socscimed.2013.06.005Crossref PubMed Scopus (228) Google Scholar, 31Hatzenbuehler ML The impact of institutional discrimination on psychiatric disorders in lesbian, gay, and bisexual populations: A prospective study.Am J Public Health. 2010; 100: 452-459doi:10.2105/AJPH.2009.168815Crossref PubMed Scopus (601) Google Scholar Given our understanding that health disparities among this population stem from public treatment and discrimination, health care professionals must be aware and attentive to the unique issues LGBTQ people face, and how to create a safe treatment experience for them. Significant disparities exist between women and men in the risk, prevalence, presentation, course, and treatment of a variety of mental health disorders. Depression is the most common mental health disorder diagnosed in women. Women are twice as likely as men to develop depression during their life.33Desai HD Jann MS Major depression in women: A review of the literature.J Am Pharm Assoc. 2000; 40: 525-537Google Scholar Compared with men, they also have double the likelihood of experiencing generalized anxiety disorder, panic disorder, and PTSD.34National Center for PTSD Women, trauma, and PTSD.www.ptsd.va.gov/public/PTSD-overview/women/women-trauma-and-ptsd.aspDate: 2015Date accessed: May 20, 2021Google Scholar The rates of schizophrenia between men and women are very similar.35National Institute of Mental Health Mental health information: Schizophrenia.www.nimh.nih.gov/health/topics/schizophrenia/index.shtmlDate: 2015Date accessed: May 20, 2021Google Scholar When considered alongside the barriers to mental health services that disproportionately affect women, one must pause to examine potential explanations for such disparities. Women disproportionately experience a number of risk factors for common mental health disorders. One is economic—women earn less than men in equivalent jobs. Compared with their male counterparts in a given year, women who are full-time workers earn about one-fourth less. Women aged 18 to 64 have a poverty rate of 14.2%, whereas men within the same age range have a poverty rate of 10.5%. The poverty rate for women aged 65 and older is 10.3% percent, compared with 7% for men in the same age range.36US Census Bureau 2016. Income, poverty and health insurance coverage in the United States.https://www.census.gov/library/publications/2016/demo/p60-256.htmlDate: 2015Date accessed: May 20, 2021Google Scholar Women are more affected by violence, with about one in three women having experienced sexual violence, physical violence, and/or stalking by an intimate partner in their lifetime.37CDC National intimate partner and sexual violence survey—state report.www.cdc.gov/violenceprevention/nisvs/summaryreports.html3Date accessed: May 20, 2021Google Scholar Women often take on greater roles as caregivers, and it is estimated that 65% of caregivers are women. Compared with male caregivers, female caregivers may spend as much as 50% more time providing care and other supports.38Family Caregivers Alliance Women and caregiving: Facts and figures.https://caregiver.org/women-and-caregiving-facts-and-figuresDate: 2015Date accessed: May 20, 2021Google Scholar According to a WHO study, there are differences in the way women and men seek and use mental health services39WHO Women’s mental health: An evidence-based review.www.who.int/mental_health/media/en/67.pdfDate accessed: May 20, 2021Google Scholar as well as differences in the treatment they receive. Women are more likely to seek help from and disclose mental health problems to their primary health care physician, while men are more likely to see a mental health specialist. Women are less likely than men to disclose problems with alcohol use to their health care provider and are reluctant to disclose a history of violent victimization unless physicians ask about it directly. Women are more likely to be prescribed psychotropic medications than men. Physicians are more likely to diagnose depression in women compared with men, even when both genders have identical symptoms or similar scores on standardized measures of depression.39WHO Women’s mental health: An evidence-based review.www.who.int/mental_health/media/en/67.pdfDate accessed: May 20, 2021Google Scholar ▪Develop an understanding of social structures that affect our patients’ health and well-being. Humility is also important, as there are limitations in how much we can truly appreciate about the unique experiences of the patients we serve. To best provide mental health treatment to these populations, we may require training to develop competency.▪Provide training about how structural discrimination creates and strengthens inequities in mental health. Think about how such issues directly affect the communities you serve. Get the perspective of local voices and stakeholders to share these experiences when thinking about what training is needed.▪As health care providers, it is essential that we recognize our own biases. Such biases can be conscious or subconscious, yet all of them can influence how we practice. When working directly with patients, keep an open mind and practice humility. Foster a relationship with patients, caregivers, and family members that encourages them to tell you about their lives.▪Make efforts to understand the structural traumas experienced by the communities we serve. This will help us to understand how such traumas have impacted their mental health and what barriers they face in accessing such services. Our treatments and interventions should be informed with an awareness of these structural traumas.▪Build a diverse staff. This means taking active efforts to mentor, recruit, promote, and retain health care providers, administrators, and staff from diverse populations at every level of the organization.▪Seek out and use feedback from patients who are members of vulnerable groups and communities about the health care services that you and the organization you belong to provide. Be willing to make changes based on this feedback.▪Support work that counters discrimination by health care providers, administrators, and staff with protected time and/or additional compensation. It is important to highlight the value of such practices.▪Collaborate with local and national advocacy groups that represent such populations to address inequities and discrimination. Engage educational systems and policymakers in such collaborations as well.▪Encourage mobile crisis response teams to seek input from clinical staff and community leaders about what is needed by the local people they serve. In many circumstances, crisis intervention, rather than police intervention, may be more appropriate to help support individuals, youth, and families.▪Bring attention to and take action on the school-to-prison pipeline, which disproportionately affects Black youth and has great influence on their life trajectories. Support efforts to maintain funding for school resource officers and encourage engagement with school partnerships that may prevent youth from being routed into the juvenile legal system.▪Create a culture of sharing pronouns, including sharing your personal pronouns on identification badges and e-mail signatures. If we create a culture where everyone shares their pronouns by default, it removes some of the stigma of sharing one’s pronouns and reduces accidental misgendering in the workplace.▪Have translators available to address potential language barriers that might deter those in need from seeking mental health services.▪Provide the option for patients to request a mental health provider of a specific gender. For a variety of reasons, a patient may have a strong preference that can significantly impact their participation in treatment.▪Implement strategies to reduce stigma and increase comfort for populations that are resistant to seeking mental health services. Provide education in community settings that are comfortable for the target audience. Avoid technical terms and mental health jargon when speaking with individuals or providing information to larger groups. As health care providers, administrators, and staff serving marginalized populations within our communities, it is our duty to recognize the unique challenges such individuals face, address structural issues that stand in their way, and create a safe place when providing them mental health, and general health, services. This assessment must be taken online; please see “CPE Information” in the sidebar below for further instructions. The online system will present these questions in random order to help reinforce the learning opportunity. There is only one correct answer to each question. 1Which of the following is an appropriate strategy to reduce inequities in mental health services across marginalized populations?aUse technical terminology when providing education.bSolicit staff to volunteer their time to provide special services that address inequities.cHire and promote staff solely on the basis of merit to avoid favoritism.dEncourage staff to challenge their conscious and subconscious biases at every level.2Which statement is true?aBlack Americans are less likely to use emergency departments to receive mental health services.bBlack Americans are equally represented in mental health research.cOne in two Black Americans who are in need of mental health services receive it.dBlack Americans are less likely to receive guideline-based care.3Individuals from which group are most likely to seek psychiatric services for a mental health–related difficulty?aBlack AmericansbLGBTQ AmericanscMiddle Eastern AmericansdAsian Americans4Which group has experienced an increase in stress since September 11, 2001?aMiddle Eastern AmericansbBlack AmericanscAsian AmericansdLGBTQ Americans5Which member of the LGBTQ community is at highest risk for mental health difficulties, based on their demographic information alone?a78-year-old gay maleb14-year-old lesbian femalec17-year-old transgender femaled27-year-old bisexual male6Which statement is true?aWomen have an equivalent poverty rate to that of men.bOne in three women has experienced sexual violence, physical violence, and/or stalking by an intimate partner.cWomen have higher rates of schizophrenia than men.dAn estimated 80% of caregivers are women. CPE informationTo obtain 1 hour of CPE credit for this activity, complete the CPE exam and submit it online at www.pharmacist.com/education. A Statement of Credit will be awarded for a passing grade of 70% or better. You have two opportunities to successfully complete the CPE exam. Pharmacists and technicians who successfully complete this activity before July 1, 2024, can receive credit.Your Statement of Credit will be available online immediately upon successful completion of the CPE exam.This policy is intended to maintain the integrity of the CPE activity. Learners who successfully complete this activity by the expiration date can receive CPE credit. Please visit CPE Monitor for your statement of credit/transcript.To claim credit1.Go to http://apha.us/CPE0721.2.Log in to your APhA account, or register as anew user.3.Select “Enroll Now” or “Add to Cart” (click “View Cart” and “Check Out”).4.Complete the assessment and evaluation.5.Click “Claim Credit.” You will need to provide your NABP e-profile ID number to obtain and print your statement of credit.Assistance is available Monday through Friday from 8:30 am to 5:00 pm ET at APhA InfoCenterby calling 800-237-APhA (2742) or by e-mailing [email protected] . To obtain 1 hour of CPE credit for this activity, complete the CPE exam and submit it online at www.pharmacist.com/education. A Statement of Credit will be awarded for a passing grade of 70% or better. You have two opportunities to successfully complete the CPE exam. Pharmacists and technicians who successfully complete this activity before July 1, 2024, can receive credit. Your Statement of Credit will be available online immediately upon successful completion of the CPE exam. This policy is intended to maintain the integrity of the CPE activity. Learners who successfully complete this activity by the expiration date can receive CPE credit. Please visit CPE Monitor for your statement of credit/transcript. To claim credit 1.Go to http://apha.us/CPE0721.2.Log in to your APhA account, or register as anew user.3.Select “Enroll Now” or “Add to Cart” (click “View Cart” and “Check Out”).4.Complete the assessment and evaluation.5.Click “Claim Credit.” You will need to provide your NABP e-profile ID number to obtain and print your statement of credit. Assistance is available Monday through Friday from 8:30 am to 5:00 pm ET at APhA InfoCenterby calling 800-237-APhA (2742) or by e-mailing [email protected] .