Residential Segregation and Mental Health Service Use By Older Blacks

Background/Purpose: Older Blacks tend to underuse mental health services although they have mental health concerns. Previous research has found that individual (demographics, socioeconomic status, health) and contextual (e.g., neighborhood demographic composition, number of mental health professionals) characteristics affect mental health services use. Yet there has been little attention to the context of residential segregation, which limits educational and employment opportunities and access to health and mental health care in neighborhoods. To our knowledge, the effects of residential segregation on older Blacks’ use of mental health services have yet to be considered. To address this gap in the literature, this study assessed the role of racial segregation in mental health service use by older Blacks.

Method: Using the 2011-2017 Medical Expenditure Panel Survey, we linked residential segregation data from the National Neighborhood Change Database and county-level data from the Area Health Resources Files, using the Federal Information Processing Standard county code. The sample included 611 community-dwelling Black adults aged 65 and older (level 1) and 87 counties (level 2) where older Blacks resided. We used a robust logistic regression accounting for clustering to examine predictors of mental health service use, operationalized as visit(s) to a mental health professional or prescribed medication for mental health (1=yes, 0=no) during the past year. We measured residential segregation using: 1) isolation (level of interaction within the Black population) and 2) dissimilarity (evenness of distribution of racial groups). Indices ranged from 0 (integrated) to 1 (segregated). We included county-level sociodemographic characteristics (e.g., the proportion of older adults, high poverty areas) and healthcare supply such as numbers of mental health professionals, community mental health centers) and Medicare Advantage penetration rates. We adjusted for age, sex, marital status, education, income, attitude toward health care, health insurance, and mental health status.

Results: Robust logistic regression accounting for clustering showed that older Blacks with mental health symptoms living in a highly segregated area (i.e., higher isolation) were more likely to use mental health services (OR=2.33, p=0.012). Living in a high poverty area decreased the odds of using mental health services compared with living in a county with a lower poverty rate ((OR=0.43, p=0.005), adjusting for all other variables. At the individual level, females (OR=1.87, p=0.003) and US-born older adults (OR=2.22, p=0.03) were more likely to use mental health services, whereas better mental health status (OR=0.94, p<.001) was associated with lower odds of using mental health services. Those with only public health insurance were less likely to use a mental health service than those with public and private health insurance (OR=0.52, p=0.009).

Conclusions and Implications: Findings highlight that living in economically disadvantaged areas can limit mental health service use due to fewer healthcare resources. The finding that living in a segregated county (i.e., higher probability of contact between Black populations) is related to more mental health service utilization suggests the potential for culturally competent mental health services and support from the residents. Future research should look into the intersection of area poverty and living in a segregated neighborhood for this population.