TRANSLATIONS
Eliminating Mental Health Disparities by 2020:
Everyone’s Actions Matter
Regina Bussing, M.D., M.S.H.S., AND Faye A. Gary, Ed.D., M.S., R.N.
T
his article describes current United States
Department of Health and Human Services
(HHS) initiatives to end health disparities
and outlines suggestions about how child and
adolescent psychiatrists can contribute to the
Healthy People 2020 goal of achieving “health
equity, eliminate disparities and improve the
health of all groups.” In the decade since the
Surgeon General’s landmark publication, Men-
tal Health: Culture, Race, and Ethnicity,1 its basic
findings of striking disparities for minorities in
mental health services have not changed. As
shown in the most recent National Healthcare
Quality and Disparities Reports, racial and
ethnic minorities still have less access to mental
health services than whites, and when they
receive care, it is more likely to be of poorer
quality.2 Although the exact HHS definitions
vary, disparities in health care are in general
defined as “racial or ethnic differences in the
quality of healthcare that are not due to access-
related factors or clinical needs, preferences,
and appropriateness of intervention” (Figure
1)3 and consider minority status based on so-
cioeconomic (poverty) or geographic (e.g., ru-
ral) status.4
The underlying roots of health disparities are
complex, have been of national concern for de-
cades, and remain only partly understood.4 Nu-
merous models have been developed to help un-
ravel the complex pathways through which
biological, medical, behavioral, and environmental
determinants of health affect individuals, families,
and communities.4 The Institute of Medicine report
An interview with the author is available by podcast at
www.jaacap.org.
JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY
VOLUME 51 NUMBER 7 JULY 2012
Unequal Treatment distinguished two levels of fac-
tors contributing to disparities, system (health care
operations/legal/regulatory) and individual (pa-
tient/provider).3 Further, under-representation of
health professionals from minority backgrounds is
one important mutable contributor to health care
disparities.5 The diversity of the United States is
increasing rapidly, with nonwhite racial and ethnic
groups expected to constitute a majority of the
American population within the century. Thus, it is
essential to find effective ways to increase diversity
within health professions, because it has been
shown to improve health care access for minorities,
decrease discrimination, improve patient-provider
communication, and improve quality and satisfac-
tion outcomes.5
MENTAL HEALTH DISPARITIES
COMMONLY ENCOUNTERED
BY CHILD AND
ADOLESCENT PSYCHIATRISTS
System Level
Child and adolescent psychiatrists encounter
striking examples of disproportionate minority
representation in the school and juvenile justice
systems. Youth from minority backgrounds
who exhibit or are thought to exhibit behav-
ioral or learning problems in school settings are
less likely to receive high-quality mental health
assessments and treatments. Instead, they are
more likely to be streamlined toward disciplin-
ary responses, including detention and possi-
ble incarceration, with juvenile justice serving
as the “de facto” mental health treatment sys-
tem for minority youth. Youth advocates are
concerned that a “school-to-prison pipeline” is
fed by the increased use of the zero-tolerance
discipline. Through the Office for Civil Rights,
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BUSSING AND GARY
FIGURE 1 Differences, disparities, and discrimination: populations with equal access to health care. Reprinted with
permission from Carla S. Gomes and Thomas G. McGuire, Identifying the Sources of Racial and Ethnic Disparities in
Health Care Use (unpublished manuscript; 2001), as presented by Smedley et al.3
the HHS monitors schools and juvenile justice
facilities for disproportionate minority repre-
sentation. Recently, the Disproportionate Mi-
nority Contact Action Network6 was launched
to unite local jurisdictions with national ex-
perts in their efforts to decrease disproportion-
ate minority contacts through sustained, coor-
dinated, and informed efforts that address the
multiple pathways to detention facilities and,
for many youth, blighted adult lives.3,4
Patient/Provider Level
For complex reasons, families from minority
backgrounds are less likely to seek mental
health treatment or participate in research
studies than nonminority families. In turn, cur-
rent medical knowledge is informed predomi-
nantly by clinical and research data derived from
nonminority patients, limiting professional exper-
tise in understanding and interpreting disease pre-
sentations by patients from minority backgrounds.
In an era that values evidence-based and person-
alized medicine, it is disconcerting that many
psychiatric treatments lack generalizability to
racial and ethnic minority populations.7
The costs of mental health disparities are high
and varied; patients develop increased morbidity
and mortality and a lower quality of life; profes-
sionals face uncertainties in clinical decision
making and moral/ethical dilemmas and a fail-
ure to achieve better outcomes; and society loses
productivity and incurs higher costs associated
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with unsuccessfully managed chronic conditions.
Thus, coordinated efforts on all levels are needed
to achieve the Healthy People 2020 goal of elim-
inating disparities.
CURRENT GOVERNMENT INITIATIVES
TO ELIMINATE DISPARITIES
HHS Disparities Action Plan
The HHS seeks to achieve “a nation free of
disparities in health and health care.”8 The
Disparities Action Plan refers to psychiatric
disorders in the context of “behavioral health”;
it includes behavioral health goals and ad-
dresses the behavioral health workforce, em-
phasizing integrations of primary care and
behavioral health settings for underserved mi-
nority populations.
Substance Abuse and Mental Health Services
Administration Initiatives
Several Substance Abuse and Mental Health Ser-
vices Administration (SAMHSA) initiatives focus
on primary care providers’ capacity to screen,
treat, and refer individuals for behavioral health
issues. Through the newly funded Center for
Integrated Health Solutions that works with
higher-education institutes, SAMHSA seeks to
grow a diverse workforce to provide services in
integrated primary care and behavioral health
settings for vulnerable populations. SAMHSA
OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY
VOLUME 51 NUMBER 7 JULY 2012

also collaborated to develop a National Network
to Eliminate Disparities in Behavioral Health.
National Institute for Minority Health and
Disparities
The United States Congress established the Na-
tional Center on Minority Health and Health
Disparities in 2000; subsequently, the complexi-
ties of the underlying roots of disparities were
perceived as requiring more systemic initiatives,
resulting in the recent elevation of the former
National Center on Minority Health and Health
Disparities to the level of an institute, the Na-
tional Institute for Minority Health and Dispari-
ties (NIMHD). With NIMHD leadership, the next
wave of health disparities research will build on
close collaboration among National Institutes of
Health institutes and centers, the Offices of Edu-
cation and Justice, and private research and ser-
vice entities. The NIMHD also needs to address
the integration of genetic codes in the overarch-
ing plan to eliminate health disparities in chil-
dren and youth, but must complement this with
a better understanding of the influence of “zip
codes” (i.e., economic and environmental factors)
on the health of children and their families. By
focusing on the intersection of genetic and “zip”
codes, the NIMHD can lead pioneering research
that brings transparency to the complex phenom-
ena of health disparities.
HOW CAN CHILD AND ADOLESCENT
PSYCHIATRISTS CONTRIBUTE?
Federal initiatives must be supplemented by com-
mitted personal efforts to finally reach the Health
People 2020 goal of eliminating health disparities.
We offer the following suggestions based on pro-
fessional experience and informed by the relevant
literature attesting that these efforts are not incon-
venient “duties” but privileges to expand horizons.
Continuing Education
Disparities are maintained by a complex web of
contributing factors; it is not enough to be well-
meaning and “nondiscriminatory” because pro-
viders may be influenced by bias, stigma, or
stereotyping without conscious awareness. Reg-
ular continuing education increases cultural com-
petency and psychological comfort in working
with families from various backgrounds.
JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY
VOLUME 51 NUMBER 7 JULY 2012
TRANSLATIONS
Cultivate Diverse Friendships
It is invaluable to befriend colleagues from various
cultural backgrounds to increase one’s repertoire of
understanding cultural nuances and skill level in
conversing about potentially anxiety-producing
topics (e.g., explorations of racism).
Community Presence
It is essential to become knowledgeable about one’s
local community, its various groups, norms, and
practices. Furthermore, child and adolescent psy-
chiatrists must help decrease stigma through vol-
unteer activities or professional community service.
Recruitment Through Mentorship
By serving as mentors and employers for stu-
dents from minority backgrounds, we increase
the recruitment of a diverse workforce. Because
members of underserved racially and ethnically
diverse communities are more likely to seek care
from primary care than from mental health pro-
viders, we must reach out to minority students
interested in primary care to increase their capac-
ity to render mental health services.
Organizational Memberships
We need to stay actively involved with professional
(e.g., American Academy of Child and Adolescent
Psychiatry and the American Psychological Asso-
ciation) and advocacy (e.g., National Alliance on
Mental Illness and Children and Adults with At-
tention Deficit/Hyperactivity Disorder) organiza-
tions committed to eliminating mental health dis-
parities and resourced to offer informed timely
guidance to providers and families alike. &
Accepted April 13, 2012.
Dr. Bussing is with the University of Florida, Gainesville. Dr. Gary is
with the Frances Payne Bolton School of Nursing, Case Western
Reserve University, Cleveland.
Disclosure: Dr. Bussing receives research support from the National
Institute of Mental Health, Pfizer, and Otsuka. She has served as a
consultant and on professional advisory boards for Shire. She serves as
member of the Children and Adults with Attention-Deficit/Hyperactivity
Disorder professional advisory board. Dr. Gary reports no biomedical
financial interests or potential conflicts of interest.
Correspondence to Regina Bussing, M.D., Box 100234 UFHSC,
Gainesville, FL 32610-0234; e-mail: rbussing@ufl.edu
0890-8567/$36.00/©2012 American Academy of Child and
Adolescent Psychiatry
http://dx.doi.org/10.1016/j.jaac.2012.04.005
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BUSSING AND GARY
REFERENCES
1. US Department of Health and Human Services. Mental Health:
Culture, Race, and Ethnicity—A Supplement to Mental Health:
A Report of the Surgeon General. Rockville, MD: US Substance
Abuse and Mental Health Services Administration; 2001.
2. Agency for Healthcare Quality and Research. 2010 National
Healthcare Quality and Disparities Reports. AHRQ Publication
No. 11-0005. Rockville, MD: Agency for Healthcare Research
and Quality; 2011.
3. Smedley BD, Stith A, Nelson A, eds. Unequal Treatment: Confront-
ing Racial and Ethnic Disparities in Health Care. Washington, DC:
National Academies Press; 2003.
4. Thompson GE, Mitchell F, Williams M, eds. Examining the Health
Disparities Research Plan of the National Institutes of Health:
Unfinished Business. Washington, DC, Institute of Medicine, Na-
tional Academies Press; 2006.
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666 www.jaacap.org
5. Smedley BD, Butler AS, Bristow LR, eds. Committee on Institu-
tional and Policy-Level Strategies for Increasing the Diversity of
the US Healthcare Workforce. In the Nation’s Compelling
Interest: Ensuring Diversity in the Health Care Workforce.
Washington, DC: National Academies Press; 2004.
6. Disproportionate Minority Contact (DMC) Action Network. Models
for Change: Systems Reform in Juvenile Justice. http://www.
modelsforchange.net/about/Action-networks/Disproportionate-
minority-contact.html. Accessed December 6, 2011.
7. Ruiz P, Primm A, eds. Disparities in Psychiatric Care. Philadel-
phia, PA: Lippincott, Williams and Wilkins; 2010.
8. US Department of Health and Human Services. HHS Action Plan
to Reduce Racial and Ethnic Disparities: A Nation Free of Dispar-
ities in Health and Health Care. Washington, DC: US Department
of Health and Human Services; 2011.
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