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SPECIAL REPORT: WOMEN’S MENTAL HEALTH

What are the biggest racial and ethnic disparities in women’s mental health care? Wilsa M.S. Charles Malveaux, MD, MA, FAPA, joins Psychiatric Times® to discuss these disparities and their causes, their effects on women of color, and what the psychiatric field can do to address them.

PT: What are the most significant racial/ethnic disparities in women’s mental
health care?

WCM: One of the biggest, yet often overlooked and disregarded ethnic disparities…is that of insufficient diversity and representation among mental health clinicians. [Data from] multiple studies have demonstrated that patients have a preference for clinicians who look like them, and that patients rate physicians of their same ethnicity higher than other physicians in terms of patient comfort and satisfaction.1

Furthermore, patient outcomes are better for some measures, including mortality, when there is concordance with the patient-doctor gender.2

The problem? Although 55.4% of psychiatrists are women, there is far less diversity when we explore the intersectionality of gender and race.3 When race and ethnicity of psychiatrists were explored as of 2018, 64.3% of psychiatrists were white, followed by 18% Asian, 9.5% Hispanic or Latino, 5.3% Black, 2.8% unknown, and 0.1% Native American and Alaskan Native.

In 2020, however, and according to a Johns Hopkins [University] study, the situation became worse for women in general, but particularly for women of color (WOC). In the study [data], it was found that though 50% of the US population was female, only 38.5% of practicing psychiatrists were female. Additionally, only 10.4% of practicing psychiatrists were Black, Latino, or Native American combined, despite these groups making up 32.6% of the US population.4

In response to this phenomenon, several companies have emerged in recent years that attempt to pair patients with clinicians of similar backgrounds. However, these companies cannot provide what simply is not yet available.

Another significant disparity is in maternal mortality. For women on a chosen journey to motherhood, the usual expectation is a safe delivery and hope for a healthy child as the outcome. However, for Black women more than [for] all other racial groups, the journey to motherhood is haunted by the too-real possibility of death.

According to a CDC report, although maternal deaths across different age and racial groups spiked in 2021, the rate among Black women was much higher than the rate for other racial groups.5 Although many initially speculated that this was due to lower income levels or lack of health insurance, [findings from] several studies have debunked those theories.

When articles about this topic are posted on social media, you will find no dearth, and in actuality a plethora, of frankly racist and ignorant comments such as “It’s probably due to their own poor choices” and “Why don’t they get prenatal care?” as if to suggest that Black mothers are inherently negligent or reckless with their bodies and resources.

Another common, but incorrect, assumption is that all Black women are poor, and that this must explain the discrepancy. Thankfully, research has shed light on the fact that there are other disparities, including clinician bias, that are at the root of the poor outcomes for both Black mothers and their infants.

The New York Times illuminated some of this data in a February 2023 article based on research from the National Bureau of Economic Research. They found that in California, for every 100,000 births, 173 babies born to the richest white mothers die before their first birthday, and 350 babies born to the poorest white mothers die.

Meanwhile, 437 babies born to the richest Black mothers die, and 653 babies born to the poorest Black mothers die. Additionally, [according to the Times] “In childbirth, mothers are treated differently and given different access to interventions. Black infants are more likely to survive if their doctors are Black.”6

It is also no surprise that Black mothers are at a greater risk for peripartum mental health complications,7 given that stress and poor social support are among the most common risk factors for perinatal mental illness, as well as the common experience of racial discrimination in this most vulnerable period.

Childcare-related stress is also an area of disparity for WOC. Any parent who has searched for childcare in this postpandemic era has seen a significant change in the availability and, at times, the quality of caregivers in the selection pool. This search, however, is often more complicated for families of ethnically minoritized people.

Even before the pandemic, childcare was both hard to find and expensive, particularly for Black, Latinx, and Indigenous families, with some families, including Native American and Alaska Native families, living in a “childcare desert.” Not having childcare has been shown to have a larger negative effect on communities of color, as these families are more likely to experience employment disruptions related to childcare, with a significantly negative effect on family finances.8

During the pandemic, women had to take on more childcare responsibilities than men when the shortage of external care providers worsened. For many, these trends led to financial instability and, in turn, have had the effect of increased—and likely underreported—risk for mental health conditions in WOC.9

PT: What factors cause, contribute to, or perpetuate these disparities?

WCM: I propose the factors that most contribute to these disparities can be boiled down to systemic/institutionalized racism and implicit bias. We have discussed some of the effects of implicit bias for WOC in health care. I think it is important to understand what systemic/institutionalized racism is. There are scholars who study this topic and can give a far more detailed explanation for those who care to learn. Still, there are some basic ways we can see the impact of racism on mental health.

Systemic racism is quite insidious and ingrained in our daily experience. At its core, it elevates the dominant culture over the culture of minoritized groups. WOC are doubly minoritized in that they are both women and people of color.

Examples include when they [receive] lesser pay for the same job, are less likely to be chosen for C-suite or board positions, or are receiving subpar care in medical settings or care from clinicians who have antiquated, racialized views of how and why WOC present for treatment.

[They] are more likely to have housing in areas zoned for public transportation, highways, chemical plants, and other negative determinants of health; are less likely to have houses passed down to them at all, let alone in more desirable areas, from older generations due to deeds from only a generation prior that prohibited the selling of houses to minoritized groups; [and] are more likely to live in areas where the public education is underfunded and substandard.

[Also, they] are more likely to live in neighborhoods with poor available food choices or that lack a grocery store; are less likely to be able to receive a bank loan; are more likely to be over surveilled and over policed in their schools and neighborhoods; and are more likely to have arrests and incarcerations for infractions that individuals of the dominant culture get warnings for—if law enforcement chooses to engage at all.10,11 These, and many more, are examples of systemic racism.

How does this relate to mental health? All these experiences are quite interconnected and have deleterious effects. Less renumeration for work means fewer financial resources available to the family, which directly affects the ability to access health care, including mental health care.

Less likelihood to be chosen for higher-level careers despite education and years of experience means less opportunity to provide generational financial stability, thus perpetuating problems and stress associated with financial lack. Inability to own housing from generations before and a lower likelihood of obtaining bank loans means that a cycle of insurmountable debt continues, especially for those who seek to better their station by education.

Those who choose to open their own business or to become homeowners are thwarted by the inability to obtain small business and home ownership loans. Financial stress not only leads to depression and anxiety, but often leads to impulsive decisions to soothe these negative emotions, such as impulse purchasing and substance abuse, which continues the cycle.12 Poorly funded public education means that individuals are less likely to be able to attain careers to sustain themselves and families—and round and round we go.

Some may say, “Well, Dr Charles Malveaux, you are a Black woman and a physician. Why can’t other Black people simply choose to have the same type of lifestyle as you?” The absurdity of that notion, and the irrationality of asking the question without considering confounding factors, would take a long conversation to explain. While we are asking, what is the reason that all white people are not as rich as Bill Gates?

What I will say is this: Only 2.8% of all physicians are Black women, and American Psychiatric Association (APA) data have shown that only 2% of all US psychiatrists are Black.13,14 For many reasons, physicians like me are unicorns… and it is not because so few of us are capable.

PT: How do these disparities affect the patients who are experiencing them?

WCM: There are 4 major areas of impact that come to mind when I consider disparities in mental health.

1. Higher suicide rates in girls and WOC

Between 2007 and 2018 there was a rise in US suicide rates for those between the ages of 10 and 24 years old. The most significant increase discovered was in young girls. A more concerning finding for WOC was that although [data from] studies found a decrease in suicide rates for white females, the converse was found for girls of color.

CDC data on high school girls in 2019 showed a 9% suicide rate for white females, while the rate for Hispanic females was 12% and the rate for Black females was 15%.15 Between 2013 and 2019, suicide rates for Black female youth increased by 59%, and for female youth of Asian and Pacific Islander ethnicity, the rate grew by 42%. This is compared to a decrease in suicide rates for white youth in the same timeframe.16

2. Impaired financial wellness

Impaired financial wellness causes stress and worsened mental health. For anyone, having limited financial resources can lead to an inability to meet financial responsibilities or save for future needs including retirement, resulting in a greater risk of stress, anxiety, and depression.17 For women in particular, financial insecurity and mental health challenges can easily become a revolving door of problems.

Many women fill roles such as caregivers, stay-at-home mothers, and single or divorced mothers, who usually have little to no income of their own. Women in a financially dependent position are more likely to stay in unhealthy and abusive partnerships. This is particularly problematic for women, given that in most cultures, men are the predominant financial providers and are more valued as such. In 2017, even in married or cohabitating American couples involving both men and women, 66% of men outearned the women.18

[Findings from] a newer study in 2023 showed that breadwinning wives were still in the minority. Even when [men and women are] financially equal partners, however, husbands tend to spend much more of their time on leisure activities, while the nonearning hours of wives are more likely to be spent on caregiving, thus contributing to the increased stress and negatively impacted mental health of women.19

3. Association with housing disadvantage and homelessness

Mental health disparities cause disadvantaged groups to be at greater risk for housing insecurity. Even previous housing disadvantages (including overcrowding, housing mobility, evictions, mortgage delinquency, poor physical housing conditions, etc) are related to poorer mental health later in life.17

Since 2019, the 2 groups that have seen the largest increase in homelessness include women (35% increase) and transgender individuals (113% increase).20 Although homelessness affects all communities, the communities most impacted are [minorities] and [those who are] marginalized.21

4. Higher risk for chronic illness

It is known that there is an increased likelihood for chronic illnesses including hypertension and heart disease related to stress, and that stress is corelated with lower life expectancy, as seen in racially minoritized groups.22

PT: What can mental health clinicians—and the field of psychiatry as a whole—do to promote better outcomes for these patients?

WCM: One thing mental health clinicians can do is educate, and not in a performative way. Implicit bias training is usually done to check a box with no follow-through; it has no accountability and has been shown not to work.23,24 Rather, what would be more helpful is antiracism training. The following actions can be taken to promote better outcomes for our patients who are WOC.

1. Acknowledge the problems.

As mental health professionals, we can acknowledge and work to address the issues of systemic racism that affect all aspects of the medical system, from the diversity—or lack thereof—in physicians and treatment team members to inadequate placement of treatment facilities (ie, …[there are] fewer treatment facilities in US counties with higher numbers of Black, rural and uninsured residents), combined with inaccessible cost of treatment programs.25

2. Intentionally end perpetuation of myths regarding WOC.

There should be concerted, intentional efforts to end the perpetuation of myths regarding who does and does not access treatment. These myths largely place the onus on the disenfranchised individuals rather than focusing on the individuals who have the power to bridge those gaps but are not making the effort to do so.

3. Include appropriate training in core curriculums.

Another way that clinicians in academic medicine may help is by including diversity, equity, inclusion, and belonging…and cultural competency training, specifically as it pertains to medicine, as a part of the core curriculum in psychiatric training.

Individuals from ethnically minoritized groups deserve…their physicians and other clinicians [to] have devoted the necessary time to curate the knowledge for care competency. Likewise, education about issues affecting girls and women specifically should be woven into the curriculum, and not solely available as elective education.

4. Listen to your patients and rule out personal biases versus untruths.

For some, it is difficult to accept that persons of color are reporting the truth in their lived experiences. That in itself is a form a racism, and one reason for the popular hashtag #BelieveBlackWomen. In health care, the reports of Black, Indigenous, and people of color (BIPOC) women, and Black women in particular, are often dismissed or treated with suspicion. In our profession, we must remind ourselves to listen.

5. ACT

Finally, in psychiatry we speak about acceptance and commitment therapy (ACT). We know that the goal of ACT “is to be present with what life brings and to “move toward valued behavior.” ACT “invites people to open up to unpleasant feelings, learn not to overreact to them, and not avoid situations where they are invoked.”24

In a way, we need to ACT on racism and health care disparities. Be present in what the patient is telling us. Accept that their experience of racism and disparate treatment is true. Approach these encounters with mindfulness—“…with openness, interest, and receptiveness.”24

Finally, commit to moving toward a system that does not perpetuate these disparities in mental health care. When we ACT on disparities, we all experience a healthier tomorrow.

Dr Charles Malveaux is a sports psychiatrist in Los Angeles, California, and CEO of WCM Sports Psych. She is an advocate and educator on the intersection of mental health, sports, and racial and social justice. Dr Charles Malveaux lends her expertise as a psychiatric consultant to multiple national sport-related agencies, professional sports teams, and organizations. She is also the Western Regional Trustee (region 4) on the Board of Black Psychiatrists of America.

References

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2. Akau K. Does it matter if your doctor looks like you? Yale School of Medicine. March 12, 2021. Accessed May 23, 2023. https://medicine.yale.edu/news-article/does-it-matter-if-your-doctor-looks-like-you/

3. Psychiatrist demographics and statistics in the US. Zippia. Accessed May 20, 2023. https://www.zippia.com/psychiatrist-jobs/demographics/

4. Wyse R, Hwang WT, Ahmed AA, et al. Diversity by race, ethnicity, and sex within the US psychiatry physician workforce. Acad Psychiatry. 2020;44(5):523-530.

5. Simmons-Duffin S, Wroth C. Maternal deaths in the U.S. spiked in 2021, CDC reports. NPR. March 16, 2023. Accessed May 20, 2023. https://www.npr.org/sections/health-shots/2023/03/16/1163786037/maternal-deaths-in-the-u-s-spiked-in-2021-cdc-reports#:~:text=In%202021%2C%20the%20U.S.%20had,increase%20from%20the%20previous%20year

6. Miller CC, Kliff S, Buchanan L. Childbirth is deadlier for Black families even when they’re rich, expansive study finds. New York Times. February 12, 2023. Accessed May 21, 2023. https://www.nytimes.com/interactive/2023/02/12/upshot/child-maternal-mortality-rich-poor.html#:~:text=New%20data%20from%20California%20shows,the%20poorest%20Black%20mothers%20die

7. Rhodes LR. The maternal mental health of Black women. Counseling Today. March 2, 2023. Accessed May 23, 2023. https://ct.counseling.org/2023/03/the-maternal-mental-health-of-black-women/

8. Novoa C. How child care disruptions hurt parents of color most. Center for American Progress. June 29, 2020. November 7, 2021. Accessed May 21, 2023. https://www.americanprogress.org/article/child-care-disruptions-hurt-parents-color/.

9. Devoto A, Himelein-Wachowiak M, Liu T, Curtis B. Women’s substance use and mental health during the COVID-19 pandemic. Womens Health Issues. 2022;32(3):235-240.

10. Systemic racism. Fair Fight Initiative. Accessed May 20, 2023. https://www.fairfightinitiative.org/systemic-racism/

11. Thielen P. The connection between financial well-being and mental health. Forbes. March 14, 2023. Accessed May 20, 2023. https://www.forbes.com/sites/forbesfinancecouncil/2023/03/14/the-connection-between-financial-well-being-and-mental-health/?sh=11ec3d53a630

12. Proportion of Black physicians in U.S. has changed little in 120 years, UCLA research finds. UCLA Health System. April 20, 2021. Accessed May 20, 2023. https://www.uclahealth.org/news/proportion-of-black-physicians-in-us-has-changed-little-in-120-years-ucla-research-finds#:~:text=News%20%26%20Insights-,Proportion%20of%20Black%20physicians%20in%20U.S.%20has%20changed,120%20years%2C%20UCLA%20research%20finds&text=A%20new%20UCLA%20study%20finds,men%20remains%20unchanged%20since%201940

13. O’Malley L. Addressing the lack of Black mental health professionals. INSIGHT Into Diversity. December 17, 2021. Accessed May 21, 2023. https://www.insightintodiversity.com/addressing-the-lack-of-black-mental-health-professionals/.

14. Alessandrini KA. Suicide among Black girls is a hidden mental health crisis hiding in plain sight. Time. May 11, 2021. Accessed May 20, 2023. https://time.com/6046773/black-teenage-girls-suicide/

15. Ramchand R, Gordon JA, Pearson JL. Trends in suicide rates by race and ethnicity in the United States. JAMA Netw Open. 2021;4(5):e2111563.

16. Singh A, Daniel L, Baker E, Bentley R. Housing disadvantage and poor mental health: a systematic review. Am J Prev Med. 2019;57(2):262-272.

17. Increases in individual homelessness: a gender analysis. National Alliance to End Homelessness. June 4, 2020. Accessed May 20, 2023. https://endhomelessness.org/blog/increases-in-individual-homelessness-a-gender-analysis/#:~:text=The%20number%20of%20individual%20unsheltered,growing%20from%2019%2C452%20to%2029%2C190

18. Parker K, Stepler R. Americans see men as the financial providers, even as women’s contributions grow. Pew Research Center. September 20, 2017. Accessed May 20, 2023. https://www.pewresearch.org/short-reads/2017/09/20/americans-see-men-as-the-financial-providers-even-as-womens-contributions-grow

19. Fry R, Aragão C, Hurst K, Parker K. In a growing share of US marriages, husbands and wives earn about the same. Pew Research Center. April 13, 2023. Accessed May 20, 2023. https://www.pewresearch.org/social-trends/2023/04/13/in-a-growing-share-of-u-s-marriages-husbands-and-wives-earn-about-the-same/

20. Sheppard S. An overview of homelessness. Verywell Mind. March 21, 2021. Accessed May 20, 2023. https://www.verywellmind.com/an-overview-of-homelessness-5079448.

21. Charles Malveaux WMS, Bell TL, Lee CM, Reid RE. Psychiatry’s stigma in minority communities: a social media solution. Medscape. February 24, 2017. Accessed February 24, 2017. https://www.medscape.com/viewarticle/876115

22. Emran A, Iqbal N, Dar IA. ‘Silencing the self’ and women’s mental health problems: a narrative review. Asian J Psychiatr. 2020;53:102197.

23. King MP. Unconscious bias training does not work, here’s how to fix it. Forbes. November 10, 2020. Accessed May 20, 2023. https://www.forbes.com/sites/michelleking/2020/11/10/unconcious-bias-training-does-not-work-heres-how-to-fix-it/?sh=76a16c8b63f0

24. Acceptance and commitment therapy. Wikipedia. April 29, 2023. Accessed May 20, 2023. https://en.wikipedia.org/wiki/Acceptance_and_commitment_therapy

25. Cummings JR, Wen H, Ko M, Druss BG. Race/ethnicity and geographic access to Medicaid substance use disorder treatment facilities in the United States. JAMA Psychiatry. 2014;71(2):190-196.