Racial and ethnic diversity is increasing in the United States; by 2042, racial/ethnic minorities are expected to surpass non-Hispanic whites as the majority population in the United States (1). Nevertheless, racial/ethnic minority populations remain underserved in the mental health care system (2). The Surgeon General advocates a public health approach to eliminate disparities in mental health among racial/ethnic minorities (3). The New Freedom Commission on Mental Health recommends providing access to high-quality and culturally effective care that includes underserved, remote, and rural areas of the country and recommends that states monitor mental health service disparities through their comprehensive state mental health plans (2).

We describe mental health disparities among racial/ethnic minority populations, such as differences in prevalence rates, diagnoses, access to care, and sources of care. We propose a model that illustrates the relationships between the social determinants of mental health, the necessary public health interventions, and the expected positive outcomes resulting from these interventions in racial/ethnic minority populations. Finally, we offer additional public health recommendations for consideration.

Health disparities are defined as "differences in the overall rate of disease incidence, prevalence, morbidity, mortality, or survival" (4). The Surgeon General's report on mental health noted that mental health and mental illness are not polar opposites (5). Mental health is the successful performance of mental function, resulting in productive activities, fulfilling relationships, and the ability to adapt to change and adversity. Mental illness refers to mental disorders characterized by alterations in thinking, mood, or behavior associated with distress or impaired functioning. The evolution and nuances of definitions of mental health and mental illness are discussed in depth elsewhere in this issue of Preventing Chronic Disease (6).

The prevalence of mental illness differs between whites and racial/ethnic minority populations. For example, among American Indian tribes, the lifetime prevalence of any psychiatric disorder is higher (50%-54% for men, 41%-46% for women) than among the overall US population (44% for men, 38% for women) (7). The prevalence of any psychiatric disorder in the past 12 months is 15% for African Americans, 9% for Asian Americans, 16% for Hispanics, and 21% for non-Hispanic whites (8). Although African Americans and Hispanics have a lower risk of lifetime prevalence of mental disorders than do whites (9), they have a higher risk of persistence (longer course of illness) (10) and disability from mental illness (2). Furthermore, despite similarities in the measured prevalence of mental illnesses, racial/ethnic minority populations are disproportionately represented in vulnerable populations, such as the homeless and incarcerated, whose responses are not typically recorded for community surveys (3).

Racial/ethnic minorities who meet criteria for a mental disorder diagnosis may be undiagnosed or misdiagnosed. African Americans with an affective disorder are more likely to be diagnosed with schizophrenia than are white patients (11). Similarly, Hispanics are more likely to be diagnosed with affective disorders than are whites, although the difference is attenuated by adjusting for sociodemographic, care setting, and payment characteristics (12). Another issue of concern is the quality of care received by racial/ethnic minorities (13). African Americans and Hispanics are less likely than whites to receive guideline-based care for depression and anxiety (13), and African Americans are less likely than whites to be treated with atypical antipsychotic drugs and other newer agents (14).

Racial/ethnic minorities face barriers in accessing mental health care, particularly cost of care and fragmented services (3). Only 20% of American Indians report that they access care through the Indian Health Service (3). Furthermore, limited English proficiency and health literacy pose barriers for immigrant populations. In a 2007 study, only 8% of Hispanics who did not speak English, who reported a need for mental health services, received services. Likewise, of the non-English speaking Asian/Pacific Islander population who reported a need for mental health services, only 11% received services (15). Geographic accessibility is another barrier to care (2). People who live in rural areas have less access to mental health services than do their more urban counterparts (16). Even in rural areas where mental health services are available, some populations may not receive culturally appropriate services because of language barriers.

Medical insurance coverage is also a barrier to mental health care access among some racial/ethnic minorities. Sixteen percent of the overall US population is uninsured, compared with 25% of African Americans and 40% of Hispanics (3). Immigrants are 2.7 times more likely to be without health insurance than are US-born residents (17).

White and racial/ethnic minority populations have different sources of care. African Americans are more likely than whites to use emergency services, primary care physicians, and alternative treatments rather than specialists for diagnosis or treatment of mental disorders. African Americans are also overrepresented in inpatient treatment and underrepresented in outpatient treatment (3). A study of Southwest and Northern Plains tribal members living on or near reservations found that they are less likely than the overall population to seek help for mental illness (from specialists, other medical providers, or traditional or spiritual healers) (7). Asian Americans are less likely than whites to visit community mental health centers, emergency departments, self-help groups, or a psychiatric clinic in a general hospital (18).

We propose a model in which social determinants, interventions, and outcomes influence disparities in mental health and mental illness and are in turn subject to influence. The model illustrates the interactions of these factors to promote mental health and prevent mental illness (Figure).

For nearly a decade, federal reports have called for a public health approach that addresses the social determinants of mental illness to eliminate disparities in diagnosis and treatment. A successful approach must consider racial/ethnic minorities in their social contexts because these social determinants influence health outcomes.

As the US population grows increasingly diverse, providers must become more culturally sensitive in the treatment of mental illness. Provider training in the unique barriers to mental health among racial/ethnic minorities may be achieved by mandating such training in medical school and continuing education. Increases in the number of racial/ethnic minority health care providers could also increase the availability of culturally sensitive mental health care. However, the stigma of mental illness diagnosis and treatment among some groups may delay or prevent mental health care; social marketing campaigns may help alleviate such stigma.

To establish mental health in the public health arena, prevention should be emphasized. An example of universal prevention is the early identification of women with postpartum depression to reduce long-term risks for themselves and their infants (30). The need to recognize symptoms and provide early screening and treatment for common mental illnesses should be emphasized to racial/ethnic minority populations, the general public, and health care practitioners.

Collaborative efforts to eliminate health disparities are under way among several federal agencies. One example is the Federal Executive Steering Committee on Mental Health, an interagency group representing 9 federal agencies, led by the Department of Health and Human Services. This group was formed as a result of the New Freedom Commission on Mental Health (2), which called for a fundamental transformation of the US mental health care delivery system to one driven by consumer and family needs that focuses on building resilience, facilitating recovery, and eliminating disparities in mental health services. Among the steering committee's initial priorities are chronic disease and mental illness comorbidities.

We suggest the following strategies to address the disparities in mental health services and prevalence of mental illness in racial/ethnic minority populations:

A public health approach that promotes mental health among racial/ethnic minority populations and eliminates treatment disparities requires public policies that track and reduce disparities and seek solutions for these diverse communities. These goals will not be fulfilled quickly. They start with improving service programs, overcoming barriers to care, and building public health capacity.