Disparities in Mental Health Service Utilization Among Noncitizens in the United States

Background and Purpose: Significant disparities in mental health service utilization exist between native- and foreign-born individuals. To date, however, few studies have looked at the influence of citizenship status on mental health service use. Since the Welfare Reform Act of 1996, citizenship status has become an important consideration in mental health service utilization due to restrictions of federal healthcare benefits to United States citizens. Thus, among foreign-born individuals, non-naturalized citizens may have lower levels of mental health service use when compared to naturalized citizens. The study addresses the following two questions: 1) To what extent does U.S. citizenship status affect rates of mental health service utilization among immigrant populations? 2) What are the predictors of mental health service utilization among noncitizens in the United States?

Methods: The study examined data from the National Latino and Asian American Study (NLAAS). The NLASS is a nationally representative survey that estimates the prevalence of mental disorders and rates of mental health service utilization by Latinos and Asian Americans in the U.S. The sample consisted of 4,226 Latino and Asian adults (aged 18-64), including U.S.-born citizens (n=1,296), naturalized citizens (n=1,486), and noncitizens (n=1,444). Chi-square tests were conducted to examine the sample characteristics according to citizenship status. Guided by Andersen's behavioral model of health service utilization, logistic regression analyses were employed to examine mental health service utilization among noncitizens in the U.S. while controlling for predisposing, enabling, and need factors.

Results: Bivariate analyses indicated that noncitizens were significantly less educated, poorer, less likely to have insurance or any diagnosis of psychiatric disorder, and to have less contact with relatives and friends than their citizen counterparts. Only 6 percent of noncitizens reported receiving any mental health services, compared to 13 percent of U.S. citizens (p <. 001). Logistic regression models with the entire sample indicated age, English proficiency, a diagnosis of a psychiatric disorder, and insurance status were significantly and positively associated with receiving mental health services. However, citizenship status was not related to mental health service utilization after controlling for predisposing, enabling, and need factors. Among noncitizens, those who were younger, not living in poverty, and who were uninsured were less likely to receive mental health services. Citizenship status also moderated the relationships among gender, English proficiency, poverty and insurance status, and the dependent variable mental health service utilization. Poverty and insurance coverage predicted service use among noncitizens but not among citizens. Being female and having higher English proficiency predicted service use among citizens but not among noncitizens.

Conclusions and Implications: Findings indicate that, overall, noncitizens are less likely to receive mental health services than U.S. citizens. However, inclusive insurance options appear to have reduced this disparity for noncitizens. Extending coverage to those noncitizens who do not fall below the poverty level would reduce this disparity even further. Thus, in the continued absence of federal assistance, policymakers should target their efforts to promote development of employer-based health insurance options for noncitizen workers. Dong so, could increase mental health service utilization among this population.