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Taking Issue   |    
The Persistence of Disparities in Mental Health Care
Pedro Ruiz, M.D.
Psychiatric Services 2008; doi: 10.1176/appi.ps.59.11.1239
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A major paradox in 21st century America is the existence of very serious inequalities in health and mental health in the wealthiest society in the world. This issue of Psychiatric Services includes three articles that focus on racial-ethnic disparities in treatment.

In the past 20 years many worthy initiatives have been implemented to eliminate disparities. However, the study by Alegria and colleagues shows that significant disparities persist into the 21st century. These authors analyzed pooled data for nearly 9,000 adults from three national surveys. They found significant differences in access to and quality of depression treatments among those with a past-year depressive disorder: 40% of non-Latino whites did not access any treatment, compared with 69% of Asians, 64% of Latinos, and 59% of African Americans. Receipt of adequate treatment was less likely for individuals from minority groups who obtained care. These disparities were evident even when the analyses controlled for socioeconomic variables.

The second study examined disparities within a racial-ethnic group. Lesser and colleagues focused on treatment response in two groups of Hispanic patients—those for whom English was the preferred language and those who spoke Spanish by preference. They analyzed data from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial, in which participants with depression received citalopram for up to 14 weeks. The Spanish-speaking patients had lower rates of and slower times to remission and response, a difference that appeared to be explained by their greater social disadvantage. As the authors note, clinicians need to be aware of the role that socioeconomic factors play in disparities and ensure that treatment addresses the difficulties patients face when they struggle with poverty, poor education, and lack of insurance.

Much research on disparities looks at whether individuals are able to access care, but in the third study Elwy and colleagues looked for differences between those who had already gained access—these individuals had completed an intake for outpatient treatment. The authors found no racial-ethnic differences in the number of subsequent treatment visits. They conclude that disparities may result from racial and ethnic differences in treatment-seeking rates and that more emphasis should be placed on ensuring that treatment is available and accessible and that those who need it are activated to initiate it.

These three studies underline the persistence of racial and ethnic disparities in the mental health system and also suggest lines of inquiry that may help refine our understanding of them. As the national election ushers in a new administration, let us work to ensure that initiatives to eradicate disparities—and the research that informs them—continue to receive a high priority.

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