Racial and Ethnic Disparities in Health Status and Community Functioning Among Persons with Untreated Mental Illness

Using 6 years of data from the National Survey of Drug Use and Health, the present study investigated ethnic minority-White disparities in self-rated health and community functioning for persons with untreated mental illness. Comparing minority and White persons with untreated severe mental illness (SMI) and mild and moderate mental illness (MMMI), the study sought evidence of “double jeopardy”: that minority persons with mental illness suffer an added burden from being members of ethnic minority groups. For African Americans with SMI and MMMI, results indicated that the odds were greater of living in poverty, being unemployed, and being arrested in the past year, and for African Americans with SMI, the odds were greater of reporting fair/poor health. For Native Americans/Alaska Native persons with MMMI, the odds were greater of living in poverty and being arrested in the past year. For Latinx persons with SMI and MMMI, the odds were greater of living in poverty and for Latinx persons with SMI the odds were greater of reporting fair/poor health. Results indicate that African Americans with mental illness suffer pervasive adversity relative to Whites and Native Americans/Alaska Natives and Latinx persons do so selectively.

Researchers also must clarify the methodological requirements for obtaining clear-cut evidence of double jeopardy. One approach is to identify samples of persons with mental illness-to control for mental illnesses as single jeopardyand demonstrate added jeopardy from race and ethnicity by showing racial and ethnic disparities in health and functioning among persons with mental illness. Only one study of double jeopardy has been published thus far and it follows this approach. There, researchers demonstrated that, for persons with severe mental illness, African Americans and Latinx persons' rates of diabetes were higher than Whites' rates [13], thereby proving added risk of diabetes for ethnic minority persons beyond the risk alone from severe mental illness. Alternative approaches, including those controlling for underlying differences in minority and White persons who are not mentally ill, would further focus inquiry on mental illness-minority disparities.

The Present Study: For Persons with Mental illness, Investigating Health Status, and Community Functioning Disparities Nationwide
The present study assessed double jeopardy-whether persons with mental illness suffer an added, ethnicity-associated jeopardy for less healthy and successful community functioning when they are members of largest ethnic minority groups. The investigators defined double jeopardy to occur when minority persons with mental illness suffer greater health and community functioning adversity than Whites going beyond disparities in health and community functioning in the general population.
The study examined this question in a large multiyear national probability sample of African Americans, Native Americans/Alaska Natives, Latinx, and Asian American/ Pacific Islander/Native Hawaiian (AA/PI/AN), and Whites by asking whether, when predicting poverty, unemployment, self-rated fair or poor health, and being arrested in the past year, there are mental illness-specific racial and ethnic vs. White disparities in health and community functioning. The study's comprehensive approach, featuring the largest ethnic groups and people with diagnosed mental illness, highlights key areas of functioning where mental illness has been associated with considerable adversity: higher poverty [14] and unemployment rates [15], poor health and a shorter life expectancy [6], and criminal justice involvement [7].
Two levels of mental illness were considered: severe mental illness (SMI) and mild and moderate mental illness (MMMI). This differentiation is important because some theories imply that symptoms of SMI-hallucinations, for example-are so prominent and disruptive that they preempt anti-minority prejudice and discrimination [10,[16][17][18]. The present study examines whether disparities are greater for persons with MMMI than with SMI.
Several steps were taken to isolate untreated SMI's and MMMI's impact on disparities in health status and community functioning. To eliminate the influence of White's higher mental illness treatment rates [20], the study selected persons with untreated mental illness. The study controlled for co-occurring substance abuse and for key population demographic differences and, as previously discussed, controlled for disparities in health and community functioning in the population of persons without diagnosed mental illness.

Methods
Utilizing Substance Abuse and Mental Health Services Administration's National Survey of Drug Use and Health's NSDUH, the present study estimated the odds of AI/AN, African Americans', Latinos', versus Whites' detrimental health, economic, and criminal justice experiences nationwide and over several years, while adjusting for population differences in substance abuse, age, gender, and residence (urban vs. rural), and for survey sampling factors. National population estimates assess the magnitude of disparities in the USA for racial/ethnic minorities and Whites with untreated SMI and MMMI beyond disparities among persons without mental illness.

The National Survey of Drug Use and Health
The National Survey of Drug Use and Health (NSDUH) is a nationally representative, annual survey of approximately 67,500 individuals. The NSDUH does not sample persons who are non-sheltered homeless, active-duty military, or institutionalized in jails or hospitals. The present sample aggregated six cross-sectional survey years (2009)(2010)(2011)(2012)(2013)(2014) [21], and the World Health Organization Disability Assessment Schedule for assessing functional impairment [22], and any mental illness (AMI) is scored from statistical models predicting the presence of AMI in survey subsamples completing a Structured Clinical Interview for DSM-IV Axis I Disorders [23].
SMI is having a mental illness as defined above resulting in serious functional impairment. Assignment to the SMI category is based not on direct measures of diagnostic status but on a predictive model. MMMI consists of persons determined to have any mental illness but not SMI.

Living in Poverty
The NSDUH determines poverty status by soliciting family income and subsequently classifying respondents based on number of children and other factors according to national poverty thresholds published by the U.S. Census Bureau. Respondents were classified as living in poverty (family income less than 100% of the poverty threshold) or not living in poverty.
Unemployed Respondents were identified as unemployed if they were not employed in the last week and were looking for a job. Respondents who were employed full time, employed part time, or not seeking employment were identified as not unemployed.
Poor/Fair Health Status Health status was assessed by "This question is about your overall health. Would you say your health in general is excellent, very good, good, fair, or poor?" Respondents who answered fair or poor were classified as such. Respondents not in poor/fair health answered as excellent, very good, or good.

Past-Year Arrest
Survey respondents were identified as having a past-year arrest if they reported having been arrested one or more times in the last 12 months.

Race and Ethnicity
Survey respondents who selected Hispanic as their ethnicity were categorized as Latinx. Non-Hispanic White and Black persons were categorized as White and African American, respectively. Persons selecting American Indian or Alaska Native were classified as such. Persons selecting Non-Hispanic Native Hawaiian, Pacific Islander, Chinese, Filipino, Japanese, Asian Indian, Korean, Vietnamese, Other Asian, and Multiple Asian categories were classified as Asian American/Native Hawaiian/Pacific Islander.
Respondents selecting more than one race or ethnicity were classified by the NSDUH as "other." To focus on people identified most closely with each ethnic group and to forestall justifiable but, for present purposes, overly complex interpretations of ethnicity, we omitted persons whose race or ethnicity was classified as "other" from our sample.

Demographic Controls
We adjusted for differences in population structure. Gender was identified as male or female. Age groups were 18-25, 26-34, 35-49, and 50-64. Respondent's counties of residence, if non-metropolitan, were classified as rural. Respondents living in small or large metropolitan were identified as urban. The year that the respondent was surveyed, 2009 through 2014, also served as a control.

Analysis
To assess living in poverty, unemployed, poor/fair health status, and being arrested in the past year and comparing each racial/ethnic minority group with Whites, the investigators created proportional estimates accounting for the survey's complex sampling design. Condition rates were calculated using SAS Survey means procedure while considering the weighting, clustering, and stratification of the design within each race/ethnic group [24]. The resulting rates consider the representation of survey respondents relative to corresponding national population representations and estimate the rate of each condition in each racial/ ethnic group. Population proportions were estimated by race/ethnicity for all individuals nationally as well as for individuals with untreated mental illness versus those without an identified mental illness or who were treated. All analyses were performed using Statistical Analysis Software (SAS) 9.3.

Odds Ratio Computation
Health and community functioning indicators were regressed on mental illness and race/ethnicity while controlling for gender, age group, rural county of residence, and survey disparities year. Racial and ethnic vs. White disparities were identified as significant interactions between race/ethnicity vs. White status and untreated MMMI or SMI. These interactions demonstrated "double jeopardy": that MMMI and SMI disparities exceeded those found among persons without a mental disorder or undergoing treatment.
The investigators estimated a total of four weighted logistic regression models for SMI and four for MMPI to produce adjusted odds ratios. Odds compared living in poverty, for example, for ethnic/racial minorities as compared to White when afflicted with an untreated mental illness, equalizing on control variables (full results not shown). Weighted logistic regression models were developed using SurveyLogistic in Statistical Analysis Software (SAS) 9.3, Population Proportions Population proportion estimates were created for each racial/ethnic minority group while accounting for the survey's complex sampling design. The proportion of the nationwide population experiencing each outcome was calculated using SAS SurveyMeans procedure while considering the weighting, clustering, and stratification of the survey design within the domains of race/ethnicity [24]. The resulting proportions consider the representation of survey respondents relative to the national population and estimate the proportion of individuals within each racial/ethnic group living in the USA who experience each concern. Results of population proportions are displayed alongside logistic regression results in Tables 2 and 3.

Results
Descriptive statistics are presented in Table 1 Regression results indicating racial and ethnic disparity by SMI and MMMI interactions are presented in Tables 2  and 3. Results for poverty and unemployment are presented in Table 2 and for fair/poor health and past year arrest in Table 3.
Most odds ratios favored Whites over minorities, and several were statistically significant. African Americans with SMI's odds of living in poverty were 2.8 times greater than White's odds (95% CI = 1.9, 3.9); their odds of being unemployed were 1.6 times greater (95% CI = 1.0, 2.5), their odds of self-rated fair/poor health were 1.6 times greater (95% CI = 1.0, 2.4), and their odds of arrest in the past year were 2.1 times greater (95% CI = 1.2, 3.7). Latinx odds of living in poverty were 1.7 times greater than Whites' odds (95% CI = 1.1, 2.5) and their odds of self-rated air/poor health were 1.9 times greater (95% CI = 1.2, 2.8).

Discussion
For African Americans with mental illness especially, prospects were significantly worse than Whites' prospects for healthy and successful community living. African Americans with SMI and MMMI were more likely to be poor, unemployed, and arrested in the past year. Furthermore, African Americans with MMMI were more likely than Whites to report being in fair/ poor health. Vulnerabilities from mental illness were amplified by African Americans' other vulnerabilities stemming from more limited educational opportunities and greater residence in segregated neighborhoods of concentrated poverty, biased policing and excess incarceration, exposure to violence and victimization, lack of opportunities practice healthy eating and exercise habits, and lack of access to health insurance and other structural racism indicators. When combined with mental illness, these and other economic and social disadvantages produced even greater economic, health, and criminal justice adversity.
Native American/Alaska Native persons with MMMI, but not those with SMI, demonstrated considerably higher odds of living in poverty and of arrest: odds of impoverishment were more than three times greater than Whites' odds and Native American/Alaska Natives' odds of arrest more than four times greater. In absent prominent symptoms and disability from SMI, Native American/Alaska Natives people with MMMI were challenged considerably by mental illness more than Whites. Native American/ Alaska Natives' greater social and economic vulnerability and greater exposure to bias and discrimination became formidable obstacles when mental illness' disability was less; with less disabling mental illness came greater challenges to earning capacity and more scrutiny and intervention by law enforcement officials. Mild and moderate mental illness intensifies these adversities especially for Native American/ Alaska Native people.
Neither for SMI nor MMMI did Asian American/Pacific Islander/Native Hawaiian people show greater adversity than Whites in poverty, unemployment, fair/poor health, or arrest. Individual Asian American/Pacific Islander/ Native Hawaiian subgroups vary widely in economic and social standing, and some are markedly disadvantaged; all face prejudice and discrimination. More personal and family financing resources, on average, may provide a better cushion against the challenges of mental illness. Research is needed to understand personal and community coping strategies permitting Asian American/Pacific Islander/ Native Hawaiian people with mental illness not to economic and social adversity at levels characterizing other ethnic minority groups.
SMI and MMMI were associated with poverty disparities for Latinx persons and with fair/poor health for Latinx persons with SMI. Latinx persons' labor market disadvantages and economically marginal position may cause them more readily to slip into poverty when mental illness interferes with their ability to meet customary job-related responsibilities. Lack of access to publicly supported programs for undocumented persons and, whether they are documented or not, concern about mistreatment by immigration officials may limit a willingness to express health-related concerns or exposure to police or other authority figures who might challenge Latinx people over their immigration status.    The present findings argue for a differentiated approach when formulating questions to address mental illnesses and ethnic minority status's impact on adversity. While marginalization from race and ethnicity and mental illness is a legitimate source of universal concern, whether their impact is additive varies with the group, mental illness severity, and outcome under consideration. Theorists and researchers should focus on identifying specific pathway of influence by which ethnic identities and community experiences of minority-based and stigma introduce barriers to community well-being and successful living. Conceivably, disparities in individual and family living conditions and resources, labor market positioning, family and network resources, and local community characteristics-as well as immigration status, English language proficiency, and community and institutional stigma-all can be influential. Sweeping characterizations should give way to group-specific accounts applied to less and more severe forms of mental illness.

Improving Behavioral and Physical Health and Promoting Community Adjustment
More effort is warranted to address past deficiencies that have left too many minority persons untreated and otherwise prevented disproportionately many minority persons with mental illness from reaching their potential for healthy and productive living. Outreach to minority communities must be increased to identify persons with mental illness and link them with culturally informed treatment resources. Culturally attuned media campaigns targeting minority communities should be implemented, and community opinion leaders enlisted who can reach persons with mental illness and their families. Greater use should be made of community health workers [25] by health plans and community clinics for reaching out to reduce mental illness stigma and to identify persons with mental illness, referring them for appropriate treatment and navigating complex treatment bureaucracies. Social services bureaucracies are equally complex and, serving as navigators, community health workers can facilitate successful community functioning by bringing to minority persons with mental illness income and employment assistance and other sources of needed support.
Not-for-profit community-based organizations-nongovernmental, civil society, or other grassroots organizations with a community service mission-can also play meaningful roles in reducing barriers to mental health treatment by reaching out to minority communities and reducing mental health treatment disparities. Ethnic minority people are overrepresented in Federally Qualified Health Centers (FQHCs) [26], which deliver a large and growing volume of mental health care. FQHCs are well-positioned to screen minority patients for mental health problems and undertake wide-scale stigma reduction efforts. Thousands of nonprofit hospitals have also become community hubs in return for state, federal, and local tax relief [27]. All not-for-profit health plans and hospitals should assess mental health needs in ethnic minority communities in their mandated community health needs assessments [28].
Ethnic minority persons with mental illness may be doubly discriminated against, and Federal, state, and local antidiscrimination policies should be examined to address this possibility. Fair employment and fair housing policies must recognize discrimination against minority people with mental illness. Policies requiring language assistance for persons with Limited English Proficiency in mental health settings-the Americans with Disabilities Act-may be a major leverage point for preventing discrimination against people with mental illness. Especially for persons with SMI who are disproportionately homeless and ethnic minority persons, Housing First policies improve residential stability [29]. Housing First can be indispensable, providing a foundation for achieving better health and successful community functioning. Vigilance is needed to insure that people with SMI are not discriminated against due to either SMI [30] or ethnic minority status.

Limitations
Several limitations deserve mention. The NSDUH does not collect surveys from individuals who are non-sheltered homeless, active-duty military, or institutionalized in jails or hospitals. African and Native Americans and Latinos are overrepresented in several of these categories and their omission might bias the findings proportionately. Critics have challenged the cross-cultural validity of diagnostic assessment procedures, and sometimes of diagnosis itself [31,32] introducing another possible source of bias.
Another limitation arises from the reciprocal influences between mental illness on the one hand and poverty, unemployment, health, and criminal justice involvement on the health and criminal justice involvement cause more minority's than Whites' mental illness rather than minorities' and White's mental illness causing more minority persons to suffer poverty, unemployment, poor health, and criminal justice involvement.
Despite these limitations, the study provides clear-cut evidence that for some groups and some disorders, race and ethnicity are associated with disparities in health, economic, and criminal justice involvement. Double jeopardy is selective, but it does exist, doubly disadvantaging some minority persons with mental illness. Only from a wide-ranging and vigorous effort can the special burden of impaired health and community functioning be reduced for ethnic minority persons.
Author Contribution The first author formulated the research questions, oversaw the data analysis, interpreted the findings, and drafted the manuscript. The second author assisted in formulating research questions, performed the data analysis, interpreted the findings, and contributed in the preparation of the manuscript. The third author contributed to formulating the research question, interpreting the findings, and preparing the manuscript.
Funding The analysis described in this manuscript was funded by a contract from the US Department of Health and Human Services Substance Abuse and Mental health Services Administration (SAMHSA). The authors alone are responsible for manuscript contents.

Consent to Participate and Ethics Approval
The data are deidentified and publicly available. According to the University of California at Berkeley Committee for the protection of human Subjects, such data are exempt from review.

Competing Interests
The authors declare no competing interests.
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