Mental Health Service Use of Older African Americans: Understanding of Role of County Context

Background/Purpose: Older African Americans tend to underuse mental health services compared to their White counterparts. While previous literature suggests older African Americans seek other forms of support (e.g., pastor) for their mental health concerns, they may also experience barriers to accessing formal mental health services. Most previous research has examined primarily the role of individual-level characteristics (e.g., demographic, socioeconomic status, mental health status) to understand mental health service utilization in this population. However, limited attention has been given to the larger community context. For example, older African Americans are more likely to live in economically disadvantaged areas with fewer mental health care services, but the relationship between area characteristics and their mental health service use remains understudied. Using Andersen’s Behavioral Model of Health Services Utilization, our study examined the association between county characteristics and mental health service use among African Americans ages 60 and over.

Method: We used the 2008-2012 Medical Expenditure Panel Study (MEPS) and linked county-level data from the 2013-2014 Area Health Resources Files and the 2008-2012 Chronic Conditions Data Warehouse, using the Federal Information Processing Standard county code. The sample includes 1,567 community-dwelling Blacks ages 60 or older (level 1) and 237 counties (level 2) where the sample resided. We used multilevel logistic regression analyses to examine predictors of mental health service utilization, operationalized by: 1) type of service providers (e.g., psychiatrist), 2) type of services received (e.g., mental health counseling), and 3) type of diagnosis services using International Classification of Diseases, ninth revision codes. We measured county-level predisposing (e.g., proportion of older adults, percent Black population), enabling (e.g., mental health professionals per 100,000, the existence of community mental health center, median home value), and need (e.g., mood disorder rate) characteristics. We adjusted for individual characteristics (e.g., age, gender, marital status, education, income, attitude toward health care, health insurance, and mental health status).

Results: About 5% of older African Americans respondents used mental health services. Living in a county with a higher proportion of African American residents (OR = 0.97, p = 0.006) decreased the odds of using mental health services compared with living in a county with a lower proportion. At the individual-level, higher levels of income (OR = 1.26, p = 0.032) increased the odds of using mental health services, whereas better mental health status (OR = 0.93, p < .001) was associated with lower odds of using mental health services.

Conclusions and Implications: The finding that living in a county with a higher proportion of African American residents is related to less mental health service utilization suggests potential for mistrust in providers, an absence of culturally-appropriate services, and mental health support from sources not identified through the medical claim data. Future research should look into the intersection of income and county health care resources for this population.