Black youth and access to mental health care

A recent article in CMAJ, Mental health service use among Black adolescents in Ontario by sex and stress level: a cross-sectional study, reveals how patterns of mental health service use among Black youth shift with the level of psychological distress. Lead author Mercedes Sobers, a PhD candidate in epidemiology at the Dalla Lana School of Public Health and research coordinator at the Centre for Addiction and Mental Health, joins the podcast to unpack the findings and their implications.

The study found that Black male youth had higher odds of accessing services than white male youth when at low levels of distress but lower odds of accessing services at high levels. Black female youth had lower odds of service use than white female youth at both low and high distress levels. Mercedes explains how these patterns may reflect how behaviour is interpreted: Black boys may be referred to services more often at lower distress levels but steered toward more punitive responses when distress rises. For Black girls, she points to adultification and cultural mismatches in care.

Dr. Amy Gajaria, a psychiatrist at the Centre for Addiction and Mental Health and associate scientist in the Margaret and Wallace McCain Centre for Child, Youth and Family Mental Health, describes how programs like AMANI aim to provide culturally adapted care and build trust with Black youth. She shares how early encounters with the system can shape future engagement with care.

For physicians, the discussion underscores the importance of culturally sensitive care that embraces and reflects the experiences of Black youth, creating more meaningful and effective pathways to support.

Join us as we explore medical solutions that address the urgent need to change healthcare. Reach out to us about this or any episode you hear. Or tell us about something you'd like to hear on the leading Canadian medical podcast.

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Transcript

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Dr. Blair Bigham I'm Blair Bigham. Dr. Mojola Omole I'm Mojola Omole. This is the CMAJ podcast. Dr. Blair Bigham Jola, you flagged this one for us. Tell us what we're going to be talking about today. Dr. Mojola Omole So I flagged this one because this is something that's of great interest to me, because when I saw that when it was published in CMAJ, I was like, wow, this has some relevance to our colleagues' practices. And so we're looking at mental health service use among Black adolescents, young people, both split into men and women and the differences in usage when they're at a high point of stress in their life and when they're at a low point of stress in their life. Dr. Blair Bigham That's right. And the researchers have compared that to how their white peers access services. And not surprisingly, they found discrepancies. But some of those discrepancies did , kind of, pique our interest. Dr. Mojola Omole A hundred percent, because you would assume that when you're having more acute issues, there'll be more usage of mental health services. But that's not what they found in this cross-sectional study. Dr. Blair Bigham So we're going to talk to one of the authors of the study, and then we're going to talk to somebody who runs a pretty innovative program trying to bridge the gap between people who need services and people who receive them. That's up next on the CMAJ podcast. Dr. Blair Bigham Mercedes Sobers is the lead author on the article. She's a PhD candidate in epidemiology at the Dalla Lana School of Public Health at the University of Toronto and a research coordinator at the Center for Addiction and Mental Health. Mercedes, thank you for joining us today. Mercedes Sobers Hi, thank you, Blair. Dr. Blair Bigham Let's start with what might be the most surprising finding in your study. What did you discover about how Black male youth are interacting with mental health services? Mercedes Sobers Yeah, so that was definitely an unexpected finding. And so what I found is that when their distress was low, they were accessing services a lot higher than their peers, about 1.5 times higher odds. But then once their distress increased to significant levels, they were using mental health services much less than their white peers. And so what that seems to indicate is that when there is no apparent distress, for whatever reason, they are being diverted towards mental health services more so than their white male peers. But when there is distress being experienced by these Black boys, for whatever reason, they're no longer accessing the mental health care that it appears that they need. Dr. Blair Bigham So that seems counterintuitive to me. Break it down for me. What are we talking about when we say low stress and high stress? Mercedes Sobers So we assess mental distress using the Kessler, which is a screener, and it screens for things like anxiety and depression. It's not a diagnostic tool. And so based on the screener results, you can then diagnose further. But a lot of surveys use it just to screen what's going on with the population. And so they ask students six different questions about the last 30 days. And it asks questions around things like motivation and ability to get things done. And then based on their responses, it gives students a score from 0 to 24. And so if you get a score of 8 and below, I believe the cutoff is you're considered to have low distress. And then there's moderate distress. And then there's high distress if you score higher and higher on that scale. Dr. Blair Bigham So with everything that we know about institutional racism in medicine, it doesn't surprise me that Black youth males would be less frequently to use the system when they're really distressed. But what are your thoughts on why they would use it more often than white peers when they're less distressed? Help me understand that. Mercedes Sobers Yeah. So I'm not able to say for certain based on the survey or the data that I worked with. But looking through the literature, what we know is that Black boys are more likely to be criminalized for their behaviours to be seen as violent or problematic. And so I suspect what's going on is when Black boys are just acting like Black boys , kind of, baseline behaviour, perhaps that's when they're being diverted to mental health services because their behaviour is being problematized. And so for adolescent age, I think a lot of adolescents when they access mental health care, it's often through referrals through the adults in their lives, the grown-ups, so parents or teachers, things of that nature. And so they might be diverted to services more so than their peers. Dr. Blair Bigham So when they have low distress, other people are getting them into a mental health pathway. But what's happening when there's high distress? Mercedes Sobers Yeah. And so we know that when Black boys and men exhibit mental distress, there's often much more violent interactions with police services. People interpret them more violently than they would somebody else. And so I suspect what's happening is that when Black boys are actually in distress, their behaviour is being interpreted quite negatively, so much so that they might be diverted to just more disciplinary pathways as opposed to the mental health services that they need. And so we also know that Black adolescents are more likely to enter the mental health care system through more aversive pathways. And so police interactions or emergency department visits. Dr. Blair Bigham Okay. I'm just processing that. So people who are highly distressed, who are Black and male and young, are not being sent to the same health care route that maybe when they have a lower level distress they're sent to. Instead, they're sent more through a justice route as opposed to a health care route. Mercedes Sobers That's my understanding based on the literature, yes. Dr. Blair Bigham And then you found something different for Black female youth. What did you see there? Mercedes Sobers Yeah. So for Black girls, we found that generally they just access services less than their peers. There was a slight trend where if they were in higher mental distress, they were less likely or had a lower odds of accessing it relative to their peers. But in general, Black girls just did not access services as often. Dr. Mojola Omole Do we know why that is that they access it less? Mercedes Sobers So the data that I looked at did not, it was purely quantitative. We didn't look at reasons as to why they're not accessing it. So once again, it's based on what we're seeing in the literature. And similarly, we know that Black girls tend to be more adultified than their peers. And so it could be that the adults in their lives or those who might be navigating them towards services might see Black girls perhaps in less need of care. They can also be coming from family backgrounds where family is not as readily accessing mental health care services for a number of reasons. Dr. Mojola Omole If we look overall, are females, biologic females, overall less likely to access care than cis males? Mercedes Sobers No. So females are more likely to access mental health services overall. And so when I say that Black girls are less likely to access it than their peers, we're comparing it to White girls. And so if we look at all girls together, they still do access services more than their male counterparts. But then when we look at girls specifically all together, Black girls then become less likely than their peers to access mental health services. And this is looking at them based on distress level. So they would have the same level of distress and still access services less frequently. Dr. Blair Bigham What are we talking about when we talk about access to care? Is that like a single episode? Is it longitudinal care? Is it in the ER or a crisis center versus in an office setting? Mercedes Sobers Yeah, that's a great question. So I looked at this in two ways. In the survey, they asked if students used mental health services in the last year, and they asked how frequently they use services. And so we looked at if they used free services at all, yes or no, within the last year, and then we asked how frequently they use services. And so when it came to frequency of use, once they began accessing care, Black boys use services just as frequently as their peers, and Black girls still use services less frequently. So even though they were getting in the door, once they started seeing a mental health provider, they did not see them as frequently as their White female peers. Dr. Blair Bigham So how do we take this information about likelihood to access care and overlay it on top of what we already know about the mental health of Black youth compared to White youth? Mercedes Sobers So I think what we're seeing here is that there's clearly a barrier to access at some point. And I think for any public health issue, and so this one being access to mental health care, there's a number of levels that we want to address. And so at baseline, we want to understand what's going on, because if we don't know what's going on with these youth or what the numbers are, then it's hard to really implement anything. And then we want to understand why. And so I think there's still some more nuanced research needed to understand why they're not accessing care. However, we do have a bit of literature within Canada that talks about culturally appropriate care. And so it can often be that mental health care is just not reflective of the community that it's meant to serve when it's serving Black students, or it could be culturally inappropriate. And so when students are entering into a mental health care provider relationship, they may not be having a positive experience. And that can explain why, at least for Black females, we see that they're not using the services as often. Cost is also... Dr. Blair Bigham Before we go into that, before we consider access, is there just a gap or a difference in terms of overall mental health in youth when we dissect it by race? Mercedes Sobers Yeah. So that question, I'd say, is a bit more complicated to answer. And so... Dr. Blair Bigham That's why I asked it that way. Mercedes Sobers Yeah. So in this survey set, they asked about mental health in two different ways. One was using self-rated mental health. And so we just asked students, how would you rate your mental health on a scale of excellent to poor? And then the other one was using the Kessler like I described. So this Kessler is meant to be a bit more of an objective scale. It asked six questions instead of one. And when we asked students to answer this question using the Kessler, we found that initially it seemed like there was no difference for Black and white students. But then when we segregated by sex, we found that Black girls tended to rate their mental health more poorly. And so they had poorer mental health overall. But that wasn't the case for Black boys. Black boys tended to rate their mental health more favorably. And so that's what the Kessler said. But when we asked them in this single self-rated mental health question, it then showed that Black students were actually more likely to say their mental health was good. And so we see this discrepancy between what the Kessler, the screening tool might say their mental health is, where it tends to screen them more negatively and more in need of mental health care. And then when we ask them through a single question, they are saying that their health is actually better than their peers. And so something that I take from that is that we also need to think about how we ask these questions and perhaps validating them to ensure that we're capturing what we mean to capture. And so perhaps these scales might not be capturing the same thing that it's capturing for white students. Students might be normalizing their experiences among their peers and thinking differently when they talk about what mental health looks like for them. Dr. Blair Bigham Interesting. So this rating scale itself may be, people may be downplaying, I guess what I'm hearing, their own experience. And so the scale might not pick that up. But the impact on their life is probably more substantial than the scale is realizing. Mercedes Sobers Yes. And this is referred to as the Black-white paradox. And so there's a lot of literature in the U.S. about this, where when we survey Black and white participants, Black participants, despite more exposure to adversary conditions or poor physical health conditions, will still rate their health better or comparable to their white peers. Dr. Blair Bigham And their access is certainly less common than their white peers. Mercedes Sobers Yes. Yeah. And so access is a bit more of an objective measure, I would say. And so we're seeing a bit more of a difference there. But it's at this point challenging to say exactly what's happening with their mental health based on how we measure it currently. Dr. Blair Bigham So what do you think the takeaway is here for physicians who are in family practice or on the front lines? How can we take this research and put it into context of what needs to happen to improve things? Mercedes Sobers Yeah. So I think that there can be a lot of inherent bias in the way that we interpret behaviours. And that is often unintentional. And so I would say that thinking about there's a lot of so I know the Center for Addiction and Mental Health does culturally adapted CBT, for example, where they think about ways in which we can culturally adapt cognitive behavioural therapy to screen for and be more appropriate towards different ethno-racial communities. And so we know that when Black students come in with anxiety and depression symptoms, they're more likely to be diagnosed with something like oppositional defiance disorder or some sort of serious mental health issue as opposed to the simple anxiety and depression that they might have. And that's because there could be some bias in the way we interpret their behaviours, but also they might demonstrate behaviours differently. And so we know that certain students might internalize behaviours. They may not talk about anxiety and depression in terms of lack of sleep, but maybe it's psychosomatic where they have pain within their body and those can all be culturally mediated as well. And so there are a lot of trainings and ways in which we become better aware of how different communities might express anxiety and depression, but also ways in which we can recognize bias within our own interactions that is culturally trained in us. It's not intentional and we don't realize that we're doing it. Dr. Blair Bigham There's a lot to think about here with your research, Mercedes, and I'm very grateful for your time. Thank you so much for joining us. Mercedes Sobers Thank you. Dr. Blair Bigham Mercedes Sobers is the lead author on the research article, “Mental health service use amongst black adolescents in Ontario by sex and distress level, a cross-sectional study”. She joins us from Toronto. Dr. Mojola Omole As Mercedes mentioned, the Centre for Addiction and Mental Health runs culturally adaptive programming for Black youth. Dr. Amy Gajaria is a psychiatrist at CAMH whose work focuses on Black youth. She's also an associate scientist in the Margaret and Wallace McCain Centre for Child Youth and Family Mental Health. Amy, thanks so much for joining us today. Dr. Amy Gajaria Hi, great to be here. Dr. Mojola Omole So you work with the program at CAMH called AMANI. Can you describe a bit about the program for us? Dr. Amy Gajaria Amy Yeah, AMANI is previously known as SAPACCY. The goal is to provide culturally adapted care for Black youth. Really, the priority is that youth can come into the service, receive care in a way that meets their needs, is flexible, is integrated between hospital and community. Dr. Mojola Omole So how does this differ from other programs for youth who are not Black? Dr. Amy Gajaria A huge one. It's not the only thing that works, but it is an important piece. The majority of our providers are Black. They identify as Black. And youth often talk about how it's really nice to come in and see someone who looks like them, who might have some shared experience, who might understand their lived experience just by coming in the door. We also incorporate family. We have a more flexible approach to engaging with youth. So we understand that youth and families come in and out of care, that they have a lot of mistrust of the system. And we try to be really warm, welcoming, give them time to engage versus come in straight away and say, you need to know what you want. You need to have your goals set up. You need to have all those things because we acknowledge that it takes folks time to feel comfortable. We are also, you know, we try to be responsive to youth. We try to really see them as a whole person. I think that's the goal for all mental health care for youth, but it's something that we really center at AMANI. And then also when SAPACCY was designed, it was designed around Afrocentric principles of care. So thinking about community building, resilience, strength building, and trying to root itself in those practices as well. Dr. Mojola Omole So in our conversation with Mercedes, there was a standout stat in the research paper that young Black males in low distress were more likely to seek support than their white peers. But when they were in higher distress, they were less likely to seek mental health support. What are your thoughts on why this might be? Dr. Amy Gajaria I think there's lots of potential reasons why at lower levels of distress you might see care access. One is that the school has identified it and said, this is a kid who's, you know, having challenges, go see a psychiatrist for ADHD. That's typically what I'm seeing for Black boys is their sent for ADHD. That's the most common reason that I see. That doesn't necessarily... Dr. Mojola Omole Do they actually have ADHD? Dr. Amy Gajaria I mean, there's an overdiagnosis, there's both an over and underdiagnosis, I would say, of ADHD in Black children and youth. There's an overdiagnosis when actually there's problems of anxiety, depression, other things that are driving challenges with focus, attention and behaviour, as well as trauma. And there's also sometimes an underdiagnosis because people say, oh, it's just criminal behaviour, you're just a bad kid. And there's also reluctance on the behalf of families and communities to access care or to acknowledge that diagnosis because of the history of overdiagnosis. So I think there's like a complex picture there. But my guess is that some of that lower distress was school identified or saying, hey, go see a psychiatrist. We're concerned. That's something that I've certainly seen. The other thing I wonder about in the research that we did, so we did the qualitative research project looking at what are the experiences of caregivers and Black youth in terms of trying to navigate the care system. And this is also reflected in my clinical work, which is that you often see multiple attempts to access care when distress is low, or when people are not in crisis, basically, not so much when distress is low, when they're not completely in crisis. And typically, we see a lot of those youth being turned away or minimized, like their , kind of, diagnosis isn't met, their care needs aren't met. Caregivers often feel like their voices are minimized or not heard. And so typically, when I see a young person, there have been some attempts to access care before things got really bad, but it wasn't effective. Dr. Blair Bigham So is that , kind of, like people aren't, people are so accustomed to crisis care that they're not recognizing the opportunity? Not patients, I'm talking about on the health care side of things. We , kind of, like, oh, you're not bad enough for our really constrained resources. We'll talk to you later when you're in crisis. Dr. Amy Gajaria There's some of that because youth mental health care is just generally, we're just so strapped for resources. However, there is also racial bias. We know that in literature from the U.S., largely, there is just, you know, if young people come with a presenting complaint, they typically will, there's a higher likelihood they will not receive the more accurate diagnosis. They will not receive the right care. Their needs will not be met at that first point of contact. So I think it's both. And I think that the racial bias, unconscious bias of providers really plays into that. And so I can imagine that if you are seeking care multiple times, it's not successful, you might then just throw up your hands. And as things get worse, say like, and this is something I hear from youth as well. They never helped me before. Why am I going to go now? And the other thing is this assumption of criminality for Black men, especially young Black men. So as kids get older, depression presents with a lot of irritability and anger in young people. That's like what depressed young people look like. If you're a young Black man who's an adolescent or young adult, you're super irritable because of your depression. You're going to be read differently and maybe moved into the criminal justice system versus a white young man who might be read as someone with mental health difficulties. So I can also see that potentially as you get to higher levels of distress, more visible , kind of, externalizing behaviours that come with that, then people say, oh, that's not mental health, that's criminal justice. Dr. Mojola Omole So on the other hand though, with young Black girls, they were just less likely to access care in both of in the both scenarios than their white peers. From your experience, what are some of the barriers to care that young Black girls are facing, both in low and high distress? Dr. Amy Gajaria So there's the similar , kind of, things that work for Black young men, which is racial bias in health care providers, mistrust of the system, all that , kind of, stuff. There's also this, and I hear this a lot from the Black women, young women that I work with, this idea of having to be tough, having to be strong, having to be resilient, the idea that you can just take so much because you're strong, you've been through it all, and that there's some amazing things in that. And that's a really important thing to carry forward, the idea of strength and resilience. But it gets to a point sometimes where people are not allowed to fall apart. They're not allowed to be, some of the kids will say, I can't be, you can't be soft because you have to be hard to survive. And that softness, sometimes the lack of feeling you can be soft sometimes means you don't seek out help because you're supposed to just keep going. You're supposed to just keep carrying the weight of everything for you. And that's something that I hear from patients and is also reflected in the literature. Dr. Mojola Omole So coming back to the AMANI program, how have young people in the program responded to it? Dr. Amy Gajaria I mean, they tell me they like it, which is, of course, to my face. Dr. Mojola Omole They also think you're cool, Dr. Amy. So there you go. Dr. Amy Gajaria They think I'm super cool. Also, though, I've transitioned to them being like, you're like a mother figure. And I'm like, oh, gosh, no, I'm cool and young and hip. How dare you? Or aunty. One of them referred to me as like, you know, they were like, oh, you saw that ad on Instagram. It reached the aunty network. And I was horrified because I am cool. And I am not part of the aunty network. But anyways, I think youth always talk about, you know, I finally feel like I can have a conversation with someone that understands something about my experience, that I don't feel crazy just for sharing some of the experiences that I've had, that I can show up and just be who I am. I don't have to educate you on the Black experience, the inner city health experience. I can just show up and then I can focus my mental health without having to do all that other stuff. And I can trust that you will hear me and see me as like a person versus my Blackness or my cultural experience. Or if I'm working with kids that are experiencing poverty and getting involvement, like seeing all of that first, that they can just show up as a person, which is not a thing they get to do in most settings. Dr. Mojola Omole So how can the principles of the program be extended beyond CAMH, but also like both Blair and I work in Scarborough. And so there's, everyone has the common denominator when you're youth in Scarborough. So how can this program be extended to other marginalized groups and also beyond CAMH? Dr. Amy Gajaria I think there's a couple of factors. One is the health and human resources. So as a physician, like a lot of the times I was talking about this with a colleague, when I came back into medicine, I feel like I had to like tone down my part about the way I talk, the way I relate, the way I talk about race, just as being a kid from the GTA, from the outer suburbs. There's just like a way that we communicate and talk and relate. And that was seen as unprofessional. It would be seen as unprofessional in medicine. But actually it's what allows me to really connect and be present with my patients. So I think there is something to be said for looking at how we're training medical professionals, how we're allowing folks to show up, how we're recruiting people, because it's not just skin color, but it's also lived experience of understanding what someone's life would be in like this really real way when they experience poverty, when they grow up in these kinds of environments. The other thing is, so some of the work I do is around supporting other mental health providers in working with racialized youth, specifically Black youth. So talking a bit about how do you create the conditions where a young person feels comfortable showing up, even if you're not from that community, even if you don't have any shared experience, how can you de-center yourself and really like uplift that young person's experience and being interested in that young person for just who they are. And the other really thing I tell people when I'm training them is the curiosity is so important. Just be really interested and curious about the young person's experience, because typically Black kids don't get that when they come to a health care provider, especially for mental health. There's assumptions first before there's curiosity about who they are, why they're doing what they're doing, why they're maybe using substances, why they're angry. Like just really, I want to understand you coming from that stance is super, super helpful. And then, trying to think, like teams where I think team-based care is also really important in this work, because people burn out. The work is really hard. And often you see, oh, well, this is like our Black social worker. We'll bring one Black social worker in. We'll have them see all the patients that are really struggling and they'll do it. They'll figure it out without a lot of support, without a team-based approach, without other providers around them to really make sure they're OK and that they're getting the support they need so that the program is sustained. Because another thing you hear with lots of youth is that when they're kids with high needs, they go through workers every year. There's change of worker, of worker. So how do we support those workers to stay within the fields that kids have that consistent provider that can give them a good experience? Dr. Blair Bigham That's a really interesting point. Dr. Mojola Omole This has been amazing, Amy. Thank you so much. Dr. Amy Gajaria Thank you. It's a pleasure. Dr. Mojola Omole Dr. Amy Gajaria is an Associate Scientist in the Margaret and Wallace McCain Center for Children and Youth and Family Mental Health. She's a psychiatrist at the Center for Addiction and Mental Health, CAMH, in Toronto. Dr. Blair Bigham All right, Jola, this has been fascinating. How do you explain what we've seen here in the data? Dr. Mojola Omole Well, I would say that something that stuck to me what Amy had said was that we need to also understand what, you know, what touchstone access to mental health services is in the low distress period. So it'll be interesting to know what exactly that composes of. Is it just, you make a call or you're referred by the guidance counselor, hey, this kid might be, you know, struggling. So that would be interesting to know. But it doesn't surprise me that young Black males that when they're having high distress, that they actually are seeing more of the justice system than they are seeing the mental health services. That compotes with anecdotal evidence that, you know, I've seen and I've heard from other people. Dr. Blair Bigham That's right. And also, it seems like it's, somewhat counterintuitively, when there's low distress, there's almost this maybe racial bias that pushes people into care earlier, maybe, than they're able to accept or earlier than the system's able to really contribute to their care. And then, of course, we have this gap where they become high distress, they become into crisis, and they're funneled not through the health care system, but through the justice system. Dr. Mojola Omole A hundred percent. And I do think that having spent some time with Amy, understanding what was SAPACCY and now what's a AMANI program is, it's a very innovative way of really, truly meeting people where they're at and recognizing that when people are in distress, young adolescents and Black adolescents, what they need is connection, not the justice system. So, you know, it's a very innovative program that they have across Ontario. And I would ask all our listeners to check it out because it has made a huge difference in the lives of many adolescents across Ontario. Dr. Blair Bigham And it's not just meeting people where they're at, it's meeting the system where it's at, right? And recognizing that the current system isn't matching health care providers to patients in a way that is safe and impactful and comfortable. And in mental health, I mean, that's all there is to it. So, it really is acknowledging how crummy the situation is right now. And these programs, I mean, man, they really seem like they just need to be available everywhere. Dr. Mojola Omole 100%. And to other, you know, and, you know, our focus on this episode was on, you know, Black adolescents, but I would urge listeners to also understand that oftentimes when we develop these type of programs in vulnerable and marginalized communities, it has the ability to have applications in other communities that are also marginalized, whether that is lower socioeconomics, other racialized groups. So, that's something that we should all be keeping in mind and working towards basically being able to provide mental health services for all populations in Canada. Dr. Blair Bigham Absolutely. That's it for this episode of the CMAJ Podcast. If you can, subscribe, like, or follow us where you download your audio. Subscribing is one of the greatest ways that we can reach a wider audience. This podcast is produced by Neil Morrison at PodCraft Productions for the CMAJ. The Senior Editor of the podcast is Catherine Varner, Deputy Editor at CMAJ. I'm Blair Bigham. Dr. Mojola Omole I'm Mojola Omole. Until next time, be well.