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President's New Freedom
Commission on Mental Health

Achieving the Promise: Transforming Mental Health Care in America

Goal 3: Disparities in Mental Health Services Are Eliminated


    3.1 Improve access to quality care that is culturally competent.

    3.2 Improve access to quality care in rural and geographically remote areas.

Understanding the Goal

Minority Populations Are Underserved in the Current Mental Health System

Racial and ethnic minority Americans comprise a substantial and vibrant segment of the U.S. population, enriching our society with many unique strengths, cultural traditions, and important contributions. As a segment of the overall population, these groups are growing rapidly; current projections show that by 2025, they will account for more than 40% of all Americans.102

Unfortunately, the mental health system has not kept pace with the diverse needs of racial and ethnic minorities, often underserving or inappropriately serving them. Specifically, the system has neglected to incorporate respect or understanding of the histories, traditions, beliefs, languages, and value systems of culturally diverse groups. Misunderstanding and misinterpreting behaviors have led to tragic consequences, including inappropriately placing minorities in the criminal and juvenile justice systems.

While bold efforts to improve services for culturally diverse populations currently are underway, significant barriers still remain in access, quality, and outcomes of care for minorities. As a result, American Indians, Alaska Natives, African Americans, Asian Americans, Pacific Islanders, and Hispanic Americans bear a disproportionately high burden of disability from mental disorders. This higher burden does not arise from a greater prevalence or severity of illnesses in these populations. Rather it stems from receiving less care and poorer quality of care.16

The mental health system has not kept pace with the diverse needs of racial and ethnic minorities, often underserving or inappropriately serving them.

Receiving appropriate mental health care depends on accurate diagnosis. Racial and ethnic minorities' higher rates of misdiagnosis may contribute to their greater burden of disability. For instance, African Americans are more likely to be overdiagnosed for schizophrenia and under-diagnosed for depression.16 To compound this problem, physicians are less likely to prescribe newer generation antidepressant or antipsychotic medications to African American consumers who need them.103

The report, Mental Health: Culture, Race and Ethnicity, A Supplement to Mental Health: A Report of the Surgeon General, highlighted striking disparities in mental health services for racial and ethnic minority populations. For example, these populations:

Minorities Face Barriers to Receiving Appropriate Mental Health Care

Cultural Issues Also Affect Service Providers

Rural America Needs Improved Access to Mental Health Services

For rural racial and ethnic minorities, these problems are compounded by their minority status and the dearth of culturally competent or bilingual providers in these medically underserved areas.

Compounding the problems of availability and access is the fact that rural Americans have lower family incomes and are less likely to have private health insurance benefits for mental health care than their urban counterparts.109 Lack of coverage often occurs because small groups and individual purchasers dominate the rural health insurance marketplace, so insurance policies are more likely to have large deductibles and limited or no mental health coverage.109

Rural residents also have longer periods without insurance coverage than their urban peers and are less likely to seek services when they cannot pay for them.110 For many rural Americans, the cost of mental health services - particularly prescription drugs - may be too high.

Rural areas also suffer from chronic shortages of mental health professionals. Virtually all of the rural counties in this country have a shortage of practicing psychiatrists, psychologists, and social workers.111 Of the 1,669 Federally designated mental health professional shortage areas, more than 85% are rural.112 These professional shortage problems are even worse for children and older adults.111

In addition, many primary care providers who work in rural areas are unprepared to diagnose or treat mental illnesses. Where general health providers in rural areas often use physician extenders, mental health extenders are not yet widely used. Where they are available, their services are frequently not reimbursed by insurance.

Another problem is that suicide rates are significantly higher among older men and Native American youth who live in rural areas. The rate of suicide appears to increase as the population becomes more rural.21; 108; 113 While several factors may contribute to this phenomenon, researchers have yet to conduct in-depth analyses and studies across different geographic settings.

However, one certainty is that access to mental health care, attitudes toward mental illnesses, and cultural issues that influence whether people seek and receive care differ profoundly between rural and urban areas.

Achieving the Goal


3.1 Improve access to quality care that is culturally competent

Culturally Competent Services Are Essential to Improve the Mental Health System

      Culturally competent services - the delivery of services that are responsive to the cultural concerns of racial and ethnic minority groups, including their language, histories, traditions, beliefs, and values.

In addition, State plans should promote increased opportunities to include individuals from diverse cultural backgrounds in the mental health workforce. These opportunities should reflect the changing demographics and needs of communities for culturally and linguistically competent providers.

Figure 3.1. Model Program: A Culturally Competent School-Based Mental Health Program


Dallas School-based Youth and Family Centers


To establish the first comprehensive, culturally competent, school-based program in mental health care in the 12th largest school system in the Nation. The program overcomes stigma and inadequate access to care for underserved minority populations.


Annually serves the physical and mental health care needs of 3,000 low-income children and their families. The mental health component features partnerships with parents and families, treatment (typically 6 sessions), and follow-up with teachers. The well-qualified staff, who reflect the racial and ethnic composition of the population they serve (more than 70% Latino and African American), train school nurses, counselors, and principals to identify problems and create solutions tailored to meet each child's needs.


Improvements in attendance, discipline referrals, and teacher evaluation of child performance. 114 Preliminary findings reveal improvement in children's standardized test scores in relation to national and local norms.

Biggest challenge

To sustain financial and organizational support of collaborative partners despite resistance to change or jurisdictional barriers. Program's $3.5 million funding comes from the school district and an additional $1.5 million from Parkland Hospital.

How other
can adopt

Recognize the importance of mental health for the school success of all children, regardless of race or ethnicity. Rethink how school systems can more efficiently partner with and use State and Federal funds to deliver culturally competent school-based mental health services.


Dallas and Fort Worth, Texas

Finally, emerging evidence shows that collaborative efforts to bridge community health and mental health services are effective in the outreach, identification, engagement, and treatment for racial and ethnic minorities with mental illnesses.16 Accordingly, national leadership is needed to improve the training of general medical practitioners and specialty mental health practitioners in caring for consumers at the intersection of these two parts of our overall health care system.

Therefore, the Commission recommends making strong efforts to recruit, retain, and enhance an ethnically, culturally, and linguistically competent mental health workforce throughout the country.

The Commission encourages government agencies, colleges, universities, professional associations, and minority advocacy groups to work together to address the workforce crisis in mental health services for racial and ethnic minority populations, especially for youth and their families. These efforts could include:

The Commission recommends forming public-private partnerships for pre-service and in-service training. All Federally funded health and mental health training programs should explicitly include cultural competence in their curricula and training experiences. (See Goal 5 for a broader recommendation on the mental health workforce.)

The Commission recommends making strong efforts to recruit, retain, and enhance an ethnically, culturally, and linguistically competent mental health workforce throughout the country.

Given the significant role of faith-based organizations and leaders in the lives of many people, including ethnic and racial minorities, the Commission recommends enlisting their support and partnership in mental health care. This effort would involve working with the faith communities and leaders to help:

These faith-based leaders also may be critical in helping the mental health system and providers better understand the community.


3.2 Improve access to quality care in rural and geographically remote areas.

Rural Needs Must Be Met

To address the specific needs of the rural and geographically remote communities, the Commission encourages the U.S. Department of Health and Human Services (HHS) to convene a cross-agency workgroup to examine rural workforce issues to:

The Commission recommends that the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources and Services Administration (HRSA) collaborate to support the training, deployment, and continuing education of rural mental health professionals. Such efforts should focus on strengthening the capacity and competency of the workforce to sustain an evidence-based service delivery system. (Also see Goals 5 and 6.)

In addition, the Commission recommends developing a Rural Mental Health Plan with specific, measurable targets and benchmarks. An important goal for this plan would be to fully integrate mental health into the existing infrastructure for rural public health. SAMHSA and HRSA should fully participate in developing this plan and should carefully consider the recommendations of the HHS Rural Task Force and the Initiative on Rural America. This national plan should closely align with States' Comprehensive Mental Health Plans. (See Recommendation 2.4.)

The Commission recommends that rural Americans receive increased access to mental health emergency response, early identification and screening, diagnosis, treatment and recovery services.

The Commission recognizes that affordable mental health care is a critical issue for rural communities and residents. Federal and State agencies should explore policy options that enable rural individuals and small businesses to enter pools to purchase insurance so that they gain access to more affordable, high quality, health insurance. In addition, Federal agencies should ensure that new funding announcements do not place unrealistic non-Federal matching fund requirements on rural entities.

The emergence of telehealth offers access to care. Telehealth is using electronic information and telecommunications technologies to provide long-distance clinical health care, patient and professional health-related education, public health, and health administration. (See Goal 6.)

The Commission recommends that SAMHSA, HRSA, and the National Institutes of Health fund demonstration grants in rural areas to provide and evaluate the effectiveness of mental health services delivered by distant providers through new technologies. Enhanced coordination between funded telehealth systems and public mental health systems must be promoted.

The Commission supports this technology as one of the most promising means of improving access to specialty mental health care in underserved rural areas.

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