During the COVID-19 pandemic, mental health issues, like anxiety and depression, increased for many individuals, especially for persons of color. According to the 2020 National Survey on Drug Use and Health, more than five million (17.3 percent) African American adults reported having a mental illness. Among those with a mental illness, 1.4 million (27 percent) had a serious mental illness. A serious mental illness is a mental illness that impacts an individual’s ability to function. Nearly five million (15.4 percent) African American adults had a substance use disorder. Of these, 2.1 million (44.7 percent) used illicit drugs and 3.3 million (70.1 percent) drank alcohol.
Inequity in Behavioral Health Research
Patients are often encouraged to seek evidence-based treatments for their behavioral health needs. Evidence-based treatments have been through multiple peer-reviewed research studies using randomized controlled trials. These studies are generally large-scale and involve many patients. Cognitive behavioral therapy is a commonly used evidence-based treatment.
Findings from research studies are ideally generalizable and can be useful in other settings. However, there are often research gaps and limitations that prevent applicability to certain groups. Black, Indigenous, and Persons of Color are often underrepresented in research studies. The National Institutes of Health (NIH), the lead federal agency for healthcare research, reported a median of 10 percent African American participants in its mental health studies. In its substance abuse prevention studies, the median participation decreased to seven percent for African Americans. However, African Americans account for 13.4 percent of the U.S. population.
Factors Impacting Representation
A common rationale for African American underrepresentation in research is the unwillingness to participate. Distrust of participation in research, driven by historical abuses, is a persistent concern for African American communities. The majority of African American adults (61 percent) felt medical research misconduct was as likely to occur today as it did in the past. Yet, despite these barriers, research shows African Americans are no less likely than other racial groups to participate in studies when asked.
It is imperative that behavioral health researchers address issues of distrust to increase African American participation in studies. This requires intentionality and investment to build trustworthiness through increased diversity, equity, inclusion, and accessibility (DEIA) in research.
Improving DEIA in Research
The behavioral health field has started its journey of improving equity for African Americans, Indigenous, and other Persons of Color in the provision of care. However, it is of equal importance that we advocate for equity in behavioral health research. In October 2021, the American Psychological Association published its resolution, Advancing Health Equity in Psychology, noting that “people of color are significantly underserved by research and health equity research continues to be undervalued by funding agencies, academic audiences, and community settings.”
Building trust in behavioral health research begins with diversity in the research workforce. Racial concordance, or the shared racial identity between patient and provider, is an important factor in healthcare. The Journal of Black Psychology found that the relationship between African American patients and their African American provider displayed a “distinct sense of solidarity … as evidenced by having a better understanding of the context of Black clients’ lives.” Racial concordance translates to higher levels of trust in the patient-provider relationship, and more willingness to engage in and continue treatment.
More diverse research teams could yield similar results for African American research participants. Even so, for 2021, NIH reported only three percent of its research grants were awarded to African American Principal Investigators (PIs) compared to 72 percent White PIs. Improving participation and applicability of research findings for African Americans requires an investment in African American researchers.
Strengthening the Workforce
Several organizations have committed to increasing diversity in behavioral health research through various programs. SAMHSA’s Minority Fellowship Program (MFP) aims “to improve behavioral health care outcomes for racial and ethnic populations by growing the number of racial and ethnic minorities in the nation’s behavioral health workforce.” Each year, approximately 200 MFP fellows receive scholarships, tuition assistance, and professional development training through the program. The MFP Alumni often serve in key leadership roles in behavioral health treatment services, policy and program development, and clinical research. Though smaller in scale, NIH’s Distinguished Scholars Program (DSP) “aims to build a more inclusive community within the NIH Intramural Research Program by reducing the barriers to the recruitment and success of principal investigators from groups underrepresented in biomedical research.” The DSP supports up to 15 diverse investigators each year with mentoring and other professional development activities to build research and career success. Scholars represent various races and ethnicities, individuals with disabilities, individuals from disadvantaged backgrounds, and women.
Building the Evidence
In recent years, various expert panels have convened and issued recommendations to address DEIA in clinical research. The National Academies of Sciences, Engineering, and Medicine recently published a comprehensive report titled, Improving Representation in Clinical Trials and Research: Building Research Equity for Women and Underrepresented Groups. The report includes 17 recommendations related to reporting and accountability, federal incentives, remuneration, education, workforce, and partnerships.
In a field driven by science and evidence, it is important to study the feasibility and impact of such recommendations. The Association of Public and Land-grant Universities, joined by the Coalition of Urban Serving Universities and the Association of American Medical Colleges, outlined specific actions to build scientific evidence for interventions aimed at increasing access to science careers. Actions include developing pilots, cross-institutional studies, and analysis of national datasets.
Implementation and continuous evaluation of these recommendations and strategies are essential to achieving DEIA in behavioral health research. Failing to do so can have significant consequences on health outcomes. For instance, the National Standards for Culturally and Linguistically Appropriate Services (PDF | 408 KB) (CLAS) in Health and Health Care have the potential to expedite our journey to behavioral health equity. However, few mental health agencies have adopted all 15 National CLAS Standards into their policies. Nearly one-quarter of agencies reported no policies related to National CLAS Standards. For any policies implemented, reporting on outcomes is necessary to ensure continuous evaluation and improvement.
Efforts to increase DEIA in behavioral health research should not solely rely on African American researchers. Dismantling years of discrimination and inequity requires buy-in and support from the entire research community. There is strength in solidarity as evidenced by the widespread support for current behavioral health equity initiatives.
All behavioral health researchers have a responsibility to build their knowledge and understanding of how to best serve African American patients. SAMHSA’s African American Behavioral Health Center of Excellence (AABH-CoE) is transforming behavioral health services for African Americans through collaboration, training, technical assistance, and a variety of curated resources. The breadth of the AABH-CoE’s work ranges from addressing stigma within African American communities to identifying emerging best practices to improve behavioral health outcomes. The AABH-CoE strengthens the capacity of the entire behavioral health workforce, not just African American providers and researchers.
Eliminating disparities in behavioral health research is critical for achieving equitable outcomes for African Americans and other underrepresented groups. Building trustworthiness in research depends on diversifying the research workforce, studying DEIA recommendations and strategies, and transforming evidence into practice. Though this work will take considerable time and effort, the load is lighter when we carry it together.