CHAPTER 1 · Introduction

Racial/Ethnic 

Differences in 

Mental Health 

Service Use 

among Adults

RacePrevalence

Treatment

Mental Health Adults

Mental Health Care

Ethnicity

Outpatient Services Inpatient Services

Services
iiSubstance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

Acknowledgments

This chartbook was prepared by the Center for Behavioral Health 

Statistics and Quality (CBHSQ), Substance Abuse and Mental Health 

Services Administration (SAMHSA), U.S. Department of Health 

and Human Services (HHS), the National Institute of Mental Health 

(NIMH), National Institutes of Health (NIH), and RTI International 

(a registered trademark and a trade name of Research Triangle Institute), 

Research Triangle Park, North Carolina. Work by RTI was performed 

under Contract No. HHSS283201000003C and Task Order No. 

HHSS283200700002I/HHS28342005T.

Public Domain Notice

All material appearing in this publication is in the public domain and may 

be reproduced or copied without permission from SAMHSA. However, 

this publication may not be reproduced or distributed for a fee without the 

specific, written authorization of the Office of Communications, SAMHSA, 

HHS. When using estimates and quotations from this publication, citation 

of the source is appreciated.

Recommended Citation

Substance Abuse and Mental Health Services Administration, Racial/

Ethnic Differences in Mental Health Service Use among Adults. HHS 

Publication No. SMA-15-4906. Rockville, MD: Substance Abuse and 

Mental Health Services Administration, 2015.

Electronic Access and Copies of Publication

This publication may be downloaded from http://www.samhsa.gov/data/.

Originating Office

Substance Abuse and Mental Health Services Administration 

Center for Behavioral Health Statistics and Quality 

1 Choke Cherry Road, Room 2-1067 

Rockville, MD 20857

February 2015
Contents

iiiy on Drug Use and Health ev National Sur · tion dministra es Avicerealth S tal Hen buse and M e A Substanc

Highlights                                                       1

1 Introduction                                               3

2 Methods                                                    5

21 Data Sources                                           5

22 Chartbook Methodology                                6

Sample                                                 6

Measures                                               7

Analyses                                                9

3 Racial/Ethnic Differences in Mental Health Service Use

among Adults                                             11

31 Introduction                                           11

32 Racial/Ethnic Differences in Past Year Mental Health 

Service Utilization among Adults                       12

33 Racial/Ethnic Differences in Reasons for Not Using 

Mental Health Services among Adults Who Reported 

an Unmet Need for Services                            18

34 Summary                                              19

4 Differences in Mental Health Service Use among 

Adults with Any Mental Illness                            21

41 Introduction                                           21

42 Racial/Ethnic Differences in Past Year Mental Health 

Service Use among Adults with Any Mental Illness      23

43 Racial/Ethnic Differences in Reasons for Not Using 

Mental Health Services among Adults with Any Mental 

Illness Who Reported an Unmet Need for Services       28

44 Summary                                              29

5 Differences in Mental Health Service Use among 

Adults with Serious Mental Illness                        31

51 Introduction                                           31

52 Racial/Ethnic Differences in Past Year Mental Health 

Service Use among Adults with Serious Mental Illness  33

53 Racial/Ethnic Differences in Reasons for Not Using 

Mental Health Services among Adults with Serious 

Mental Illness Who Reported an Unmet Need for 

Services                                               38

54 Summary                                              39

End Notes                                                      41

List of Figures                                                  43

List of Tables                                                   44
Contents (continued)

ivSubstance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

Appendix

A Mental Health Service Use among Adults: 

Detailed Tables                                      A-1

B Mental Health Service Use among Adults with 

Any Mental Illness: Detailed Tables                  B-1

C Mental Health Service Use among Adults with 

Serious Mental Illness: Detailed Tables              C-1

D List of Contributors                                  D-1
Highlights

1

This chartbook uses combined 2008 to 2012 data from the National Survey on Drug Use and Health (NSDUH) to present 

nationally representative estimates of mental health service utilization among adults aged 18 or older within different racial/ethnic 

groups in the United States. The percentages are annual averages.

● The highest estimates of past year mental health 

service use were for adults reporting two or more races 

(17.1 percent), white adults (16.6 percent), and American 

Indian or Alaska Native adults (15.6 percent), followed 

by black (8.6 percent), Hispanic (7.3 percent), and Asian 

(4.9 percent) adults.

● Estimates of prescription psychiatric medication use in 

the past year were highest for white adults (14.4 percent), 

adults reporting two or more races (14.1 percent), and 

American Indian or Alaska Native adults (13.6 percent), 

followed by black (6.5 percent), Hispanic (5.7 percent), 

and Asian (3.1 percent) adults.

● Outpatient mental health service use in the past year was 

highest for adults reporting two or more races (8.8 percent), 

white adults (7.8 percent), and American Indian or Alaska 

Native adults (7.7 percent), followed by black (4.7 percent), 

Hispanic (3.8 percent), and Asian (2.5 percent) adults.

● Past year inpatient mental health service use was more 

prevalent among black adults (1.4 percent) than white 

adults (0.7 percent).

● Racial/ethnic differences in the estimates of any past year 

mental health service use were similar among all adults, 

adults with any mental illness (AMI), and adults with 

serious mental illness (SMI).

● Estimates of past year mental health service use increased 

with the severity of mental illness across all racial/ethnic 

groups.

● Few racial/ethnic differences were found among the reasons 

for not using mental health services among all adults, adults 

with AMI, and adults with SMI.

● Service cost or lack of insurance coverage was the most 

frequently cited reason for not using mental health services 

across all racial/ethnic groups. The belief that use of mental 

health services would not help was the least frequently cited 

reason for not using mental health services across all racial/

ethnic groups. Among all adults and adults with AMI or 

SMI, white adults were generally the most likely to cite cost 

or insurance and believing that services would not help as 

reasons for not using mental health services compared with 

other racial/ethnic groups.
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2
1 Introduction

3Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

CHAPTER 1 · Introduction

In 2001, the U.S. Surgeon General released a seminal report, Mental Health: Culture, 

Race, and Ethnicity, that documented substantial differences in mental health service 

utilization between non-Hispanic white adults and other racial/ethnic groups.1

The report also noted racial/ethnic differences in the types of services that are used. 

Moreover, the Surgeon General determined that not all differences in mental health 

service utilization resulted from personal preference. Rather, many of the racial/ethnic 

differences in mental health service utilization resulted from structural barriers, such as 

lack of transportation, low availability of care providers, cost, and insurance barriers.

At the same time, the Surgeon General identified an acute need for additional 

information on racial/ethnic differences in mental health care delivery, as well as ongoing 

national surveillance of mental health service utilization.1 Currently, most national 

estimates of mental health service use among racial/ethnic groups are based on data 

nearing or more than a decade old.1,2,3,4,5,6,7,8,9,10,11 Since the release of the Surgeon 

General’s report, significant policy changes have occurred, such as the Mental Health 

Parity and Addiction Equity Act of 2008.12 These policy changes have affected insurance 

coverage for mental health care and access to care.13 Moreover, with the passage of the 

Affordable Care Act of 2010,14 further changes in access to care are expected.15

1
4Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

CHAPTER 1 · Introduction

The purpose of this chartbook is to provide more recent, 

nationally representative estimates of mental health service 

utilization among adults aged 18 or older across different 

racial/ethnic groups in the United States. These data may 

serve as a benchmark for examining future national-level 

changes in mental health service utilization among adults 

in different racial/ethnic groups in the United States, 

particularly in the context of relevant policy changes.

This chartbook uses combined 2008 to 2012 data from 

the National Survey on Drug Use and Health (NSDUH). 

NSDUH is the primary source of statistical information 

on the use of illegal drugs, alcohol, and tobacco by the 

civilian, noninstitutionalized population of the United 

States aged 12 years old or older. The survey also includes 

several modules of questions that focus on mental health 

issues. Conducted by the Federal Government since 1971, 

the survey collects data through face-to-face interviews 

with a representative sample of the population at the 

respondent’s place of residence. The survey is sponsored 

by the Substance Abuse and Mental Health Services 

Administration (SAMHSA), U.S. Department of Health 

and Human Services, and is planned and managed by 

SAMHSA’s Center for Behavioral Health Statistics and 

Quality (CBHSQ). Data collection and analysis are 

conducted under contract with RTI International.

Methods for this chartbook are presented in Section 2. 

The chartbook presents information on racial/ethnic 

differences in mental health service utilization among 

all adults (Section 3), among adults with any mental 

illness (AMI) (Section 4), and among adults with serious 

mental illness (i.e., mental illness with serious functional 

impairment; SMI) (Section 5). Data on racial/ethnic 

differences in mental health service utilization also are 

examined in the context of other characteristics, such as 

age, gender, and education. Sections 3 to 5 are organized 

uniformly, each with an introduction that describes 

relevant points for interpreting the data presented and 

a variety of figures showing racial/ethnic differences in 

mental health service utilization. All of the figures present 

annual average percentages for the 2008 to 2012 period 

and 95 percent confidence intervals (CIs) to show the 

precision of the estimates. Because of small sample sizes 

for some racial/ethnic groups even with 5 years of data, 

some estimates may be imprecise, as indicated by the 

wide CIs. In these situations, large apparent differences 

between groups may not be statistically significant. In 

cases where the estimates are too imprecise, statistical 

comparisons may not be conducted and/or estimates may 

be suppressed. All unsuppressed estimates are available 

in Appendix A (estimates among all adults), Appendix B 

(estimates among adults with AMI), and Appendix C 

(estimates among adults with SMI).
2 Methods

5Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

2.1 Data Sources

Data in this chartbook come from the 2008 to 2012 National Surveys on Drug Use 

and Health (NSDUHs). Each annual survey is administered to a sample of the civilian, 

noninstitutionalized population of the United States aged 12 or older. Respondents 

include residents of households and noninstitutional group quarters (e.g., shelters, 

rooming houses, dormitories) and civilians living on military bases. The survey excludes 

homeless people who do not use shelters, military personnel on active duty, and residents 

of institutional group quarters, such as jails and hospitals.

NSDUH collects data from a probability sample of the population aged 12 or older in 

all 50 States and the District of Columbia using a multistage design. For the 2008 to 

2012 NSDUHs, States were first stratified into State sampling regions (SSRs). Within 

each SSR, the first stage of selection was census tracts. Within sampled census tracts, 

adjacent census blocks were combined to form the second-stage sampling units, or area 

segments. In each of the area segments, a listing of all addresses was made from which 

national samples of addresses were selected. If a sampled address was determined to be 

an eligible dwelling unit, sample individuals were randomly selected using an automated 

screening procedure programmed in a handheld computer carried by the interviewers. 

Up to two eligible individuals from a dwelling unit could be selected for the interview. 

Adolescents aged 12 to 17 and adults aged 18 to 25 are oversampled at this stage.

2
CHAPTER 2 · Methods

6Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

The NSDUH interview can be completed in English or 

Spanish, and both versions have the same content. If the 

sample individual prefers to complete the interview in 

Spanish, a certified bilingual interviewer is sent to the 

address to conduct the interview. Because the interview 

is not translated into any other language, if a sample 

individual does not speak English or Spanish, the interview 

is not conducted.

Immediately after completion of the household screening, 

interviewers attempt to conduct the NSDUH interview 

with each sample individual in the household. The 

interviewer requests the selected respondent to identify a 

private area in the home to conduct the interview away from 

other household members. The interview averages about an 

hour and collects data on a variety of topics, including drug 

and alcohol use, mental illness, substance use disorders, 

and the use of services for mental disorders and substance 

use disorders. Questions about less sensitive topics, such as 

demographic characteristics, are interviewer administered. 

Questions about sensitive topics—including criminal 

justice contact, substance use, and mental health issues—are 

administered via audio computer-assisted self-interviewing 

(ACASI). ACASI provides maximum privacy for 

respondents in the household setting to promote accurate 

reporting of data on sensitive topics. More information 

on the study design of NSDUH can be found in the 2008 

national findings report and the 2009 to 2012 mental health 

findings reports.16,17,18,19,20

2.2 Chartbook Methodology

Sample

This chartbook presents data on adults aged 18 or older 

(henceforth referred to as “adults”). Data collection for any 

mental illness (AMI) and serious mental illness (SMI) began 

in 2008; therefore, this chartbook combines 2008 through 

2012 NSDUH data. From 2008 to 2012, approximately 

45,900 adults were surveyed annually.

Data are presented for racial/ethnic groups based on Federal 

guidelines for collecting and reporting race/ethnicity data.21

Because respondents could choose more than one racial 

group, a “two or more races” category is included for those 

who reported more than one category (i.e., white, black 

or African American, American Indian or Alaska Native, 

Native Hawaiian, Other Pacific Islander, Asian, Other). 

Respondents choosing both Native Hawaiian and Other 

Pacific Islander but no other categories are classified as being 

in the “Native Hawaiian or Other Pacific Islander” category 

instead of the “two or more races” category. Except for the 

“Hispanic or Latino” group, the racial/ethnic groups include 

only non-Hispanics. The category “Hispanic or Latino” 

includes Hispanics of any race.

Of the total sample of adults in the 2008 through 2012 

NSDUH data, 65.4 percent were white, 11.9 percent were 

black, 1.3 percent were American Indian or Alaska Native, 

3.6 percent were Asian, 2.6 percent reported two or more 

races, and 15.1 percent were Hispanic. Because of the low 
CHAPTER 2 · Methods

7Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

numbers of adults who reported mental health service 

utilization among Native Hawaiian or Other Pacific Islander 

respondents, adults in this category were excluded from 

the sample for the presented analyses (0.4 percent of adults 

reported being Native Hawaiian or Other Pacific Islander). 

The total sample size of adults included in this chartbook 

is approximately 228,600 adults. Characteristics of the 

population of adults for this chartbook are presented in the 

detailed tables in the appendices. Table A.1 presents the 

demographic characteristics of all adults (except for Native 

Hawaiians or Other Pacific Islanders), regardless of mental 

illness status. Tables B.1 and C.1 present the demographic 

characteristics of adults with AMI and SMI, respectively.

Measures

Past Year Mental Health Service Utilization

In NSDUH, questions on past year mental health service 

utilization are asked of adult respondents regardless of 

mental illness status. Respondents are asked whether they 

received treatment or counseling in the past 12 months for 

any problem with emotions, “nerves,” or mental health. 

Respondents are asked about treatment or counseling 

in inpatient or outpatient settings or use of prescription 

medication for a mental illness or emotional condition 

(excluding substance use disorders).

This chartbook presents estimates of any of the three 

types of mental health service utilization (approximately 

31,000 respondents). It also presents estimates for each 

of the individual types of mental health service utilization 

among adults: use of inpatient mental health services 

(approximately 2,100 respondents), use of outpatient 

mental health services (approximately 16,000 respondents), 

and use of prescription medication (approximately 25,400 

respondents).

The measurement of past year mental health service 

utilization that was applied for this chartbook assesses any 

use of services versus no use. It does not assess the quality or 

effectiveness of the mental health services, nor does it assess 

the duration or number of visits for inpatient or outpatient 

services. In addition, NSDUH respondents are asked only 

whether they took any prescribed medication for a mental 

or emotional condition in the past 12 months; they are not 

asked how long or how regularly they took medication or 

the types of prescribed medication that they took. Thus, the 

results in this chartbook do not reflect the total amount or 

quality of services being used by any group.

Past Year Mental Illness

The determination of past year mental illness in NSDUH 

is based on a statistical model developed from clinical 

interviews using the Structured Clinical Interview for 

DSM-IV-TR Axis I Disorders, Research Version, Nonpatient Edition (SCID-I/NP)22 that were administered via 

telephone to a subsample of adult respondents who had 

completed the main NSDUH interview. In the clinical 

interviews, adults were defined as having AMI if they had 

a diagnosable mental disorder, excluding substance use 
CHAPTER 2 · Methods

8Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

disorders and developmental disorders, based on criteria 

in the 4th edition of the Diagnostic and Statistical Manual 

of Mental Disorders (DSM-IV), regardless of the level of 

functional impairment because of these disorders.23 SMI 

in NSDUH is operationalized to reflect the definition of 

serious mental illness defined by SAMHSA in the 1993 

Federal Register.24 Adults were defined as having SMI 

if they had a diagnosable mental disorder in the past 12 

months that resulted in serious functional impairment that 

was assessed using the Global Assessment of Functioning 

(GAF) scale from the DSM-IV.

Based on the results of these clinical interviews, a statistical 

model was developed for the full NSDUH sample of adults 

(i.e., not just those who completed the clinical interviews) 

that included measures of psychological distress and 

functional impairment, as well as additional indicators.25

This model was then used to predict the probabilities that 

adults had SMI or AMI and to estimate the percentages 

of SMI and AMI in the past 12 months among all adults 

based on these predicted probabilities. More information on 

these methods can be found in The NSDUH Report: Revised 

Estimates of Mental Illness from the National Survey on Drug 

Use and Health.

25

Reasons for Not Using Mental Health Services

Reasons for not using mental health services were assessed for 

all adult respondents who reported an unmet need for mental 

health services. “Unmet need” was defined as feeling the need 

for mental health services in the past 12 months but not using 

them. Unmet need could include individuals who did not 

receive any mental health services, but also those who received 

inadequate services, needed additional services, or delayed 

seeking services but received them later.

Adult respondents who reported an unmet need for mental 

health services were asked to report why they did not 

receive these services. Reasons that were presented to adults 

included cost or insurance coverage (could not afford cost, 

health insurance does not cover mental health services, or 

insurance does not pay enough for mental health services), 

a low perceived need (did not feel the need for services or felt 

that they could handle the problem without treatment), a 

concern over prejudice and discrimination (felt that mental 

health service use might cause neighbors/community to 

have a negative opinion, might have a negative effect on 

employment, concerns over confidentiality, did not want 

others to find out, or concerns over being committed or 

having to take medication), structural barriers to service use 

(no transportation, inconvenient, did not know where to go 

for services, or did not have time), and concerns over efficacy 

(i.e., did not think it would help), as well as an open-ended 

response option for other reasons. Respondents could choose 

more than one reason for not using services. Therefore, the 

percentages of adults who reported different barriers to using 

mental health services are not mutually exclusive.
CHAPTER 2 · Methods

9Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

Other Characteristics

This chartbook also presents estimates of racial/ethnic 

differences in mental health service utilization according 

to other characteristics. For brevity, Sections 3 to 5 present 

estimates for selected correlates. However, detailed tables in 

the appendices present estimates of service use by a variety 

of additional correlates. Estimates are presented by gender, 

age in years (18 to 25, 26 to 34, 35 to 49, or 50 or older), 

marital status (married, widowed, divorced or separated, 

or never married), employment status (full time, part time, 

unemployed, or other/not in the labor force), highest level 

of education (less than high school, high school graduate, 

some college, or college graduate), poverty status (below 

the Federal poverty level, 100 to 199 percent of the Federal 

poverty level, or 200 percent or more of the Federal poverty 

level), health insurance status (uninsured, private insurance 

only, Medicaid and/or Medicare only, another type of 

insurance only, or multiple insurance types), overall health 

status (excellent, very good, good, or fair/poor), and the 

presence of a substance use disorder (none, any). Substance 

use disorders include dependence or abuse, which are based 

on definitions found in the DSM-IV.23

Federal poverty level is defined based on family size, number 

of children in the household, and total family income. The 

Federal poverty level is calculated as a percentage of the U.S. 

Census Bureau’s poverty level amount by dividing the total 

family income by the appropriate poverty level amount. 

Federal poverty level thresholds vary by year, but are the same 

for each State. For more information, visit http://www.census.

gov/hhes/www/poverty/index.html. Adults aged 18 to 22 

who were living in a college dormitory were excluded from 

the Federal poverty level calculations.

Analyses

Weighted data were used to make inferences for adults in 

the civilian, noninstitutionalized population of the United 

States. All analyses used a multiprocedure package—

SUDAAN® Software for Statistical Analysis of Correlated 

Data—to account for NSDUH’s complex survey design.26

The detailed tables provide estimates of the percentages of 

past year mental health service use and associated standard 

errors (SEs), while the figures present the percentages and 

the 95 percent confidence intervals (CIs).

All estimates presented in this chartbook have met the 

criteria for statistical reliability. Estimates that do not meet 

these criteria are suppressed and do not appear in tables, 

figures, or text. The suppression criteria for various NSDUH

estimates are described in Section B.2.2 in the 2012 mental 

health findings report and also are summarized in Table B.2

in that same report.20

All significance tests were two-sided and tested at an alpha 

level of .05. In cases of comparisons stratified by a covariate 

(e.g., gender, age, insurance status), an overall chi-square test 

was conducted to evaluate overall racial/ethnic differences in 

mental health service use across the levels of the covariate. 

This was done to control for Type I error due to multiple 
CHAPTER 2 · Methods

10Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

comparisons. If this overall test was not significant, 

comparisons of racial/ethnic differences within each 

covariate group were not conducted. In addition, suppressed 

estimates are not included in statistical tests of comparisons. 

For example, a statement that “whites had the highest 

percentage” means that the estimate among whites was 

higher than the estimate among all nonsuppressed racial/

ethnic subgroups. However, the estimate among whites was 

not necessarily higher than the estimate among a subgroup 

for which the estimate was suppressed.

Unless explicitly stated that a difference is not statistically 

significant, all statements that describe differences are 

significant at the .05 level. Statistically significant differences 

are described using terms such as “higher,” “lower,” “more 

likely,” or “less likely.” Statements that use terms such as 

“similar,” “comparable,” or “no difference” to describe the 

relationship between estimates denote that a difference 

is not statistically significant. When a set of estimates 

is presented for population subgroups or for another 

characteristic of interest without a statement of comparison, 

statistically significant differences among these estimates 

are not implied, and testing may not have been conducted. 

Evaluation of significant differences in estimates based on 

SE or CI overlap should not be used for formal significance 

testing because it can lead either to false-positive or to falsenegative conclusions.27,28
3 Racial/Ethnic Differences in 

Mental Health Service Use 

among Adults

11Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

3.1 Introduction

Numerous national and regional studies have demonstrated racial/ethnic differences in 

the use of mental health services in the United States. However, most of the studies that 

examined these differences in detail used data that are now at least a decade old. This 

section provides more recent national estimates of mental health service utilization by 

race/ethnicity.

First, overall annual average estimates for the 2008 to 2012 National Surveys on Drug 

Use and Health (NSDUHs) are presented for past year use of any mental health services 

and by service type (i.e., prescription medication, outpatient, or inpatient) among all 

adults aged 18 or older. Next, any mental health service utilization within racial/ethnic 

groups is presented by correlates to examine racial/ethnic differences in mental health 

service use by these characteristics. Correlates include gender, poverty status, and health 

insurance status. Finally, reasons are presented for not using mental health services 

among adults with an unmet need for mental health services.

Throughout this section, annual average estimates are presented for white, black, 

American Indian or Alaska Native, Asian, and Hispanic adults and for adults reporting 

two or more races. Detailed estimates, including standard errors (SEs), for the figures in 

this section can be found in Appendix A.

3
3.2 Racial/Ethnic Differences in Past Year Mental Health Service Use among Adults

FIGURE 3.1 Mental Health Service Use in the Past Year among 

Adults, by Race/Ethnicity and Service Type, 2008-201229

CHAPTER 3 Racial/Ethnic Differences in Mental Health Service Use among Adults

12Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

 

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 

2008-2012 (2008-2010 Data – Revised March 2012).

● Estimates of any mental health service utilization 

among adults were similar for adults reporting 

two or more races (17.1 percent), white adults 

(16.6 percent), and American Indian or Alaska 

Native adults (15.6 percent) (Figure 3.1). 

Estimates of mental health service use in the past 

year were higher for these three groups than for 

black (8.6 percent), Hispanic (7.3 percent), and 

Asian (4.9 percent) adults. The estimate of service 

utilization among black adults was higher than the 

estimate for Hispanic and Asian adults.

● Racial/ethnic differences among adults also were 

observed for the utilization of different types of 

mental health services. Estimates of prescription 

medication use were highest among white adults 

(14.4 percent), adults who reported two or more 

races (14.1 percent), and American Indian or Alaska 

Native adults (13.6 percent). (continued on next page)
CHAPTER 3 Racial/Ethnic Differences in Mental Health Service Use among Adults

13Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

FIGURE 3.1 (continued) ● Black adults had a higher estimate of prescription 

medication use compared with Hispanic adults 

(6.5 vs. 5.7 percent).

● Asian adults had the lowest percentage of 

prescription medication use (3.1 percent).

● Estimates of outpatient mental health service 

utilization among adults were highest for those 

reporting two or more races (8.8 percent), white 

adults (7.8 percent), and American Indian or Alaska 

Native adults (7.7 percent). Estimates were higher 

for black adults (4.7 percent) than for Hispanic 

adults (3.8 percent). Asian adults had the lowest 

percentage of outpatient service use (2.5 percent).

● The pattern of inpatient mental health service 

utilization across racial/ethnic groups differed from 

the patterns for prescription medication use and 

outpatient mental health service use. Estimates of 

inpatient mental health service use among adults 

were similar for adults reporting two or more races 

(1.1 percent), Hispanic adults (0.8 percent), white 

adults (0.7 percent), and Asian adults (0.6 percent).

● The percentage of inpatient service use was higher 

among black adults (1.4 percent) than among 

Hispanic, white, and Asian adults.
FIGURE 3.2 Mental Health Service Use in the Past Year among 

Adults, by Race/Ethnicity and Gender, 2008-201229

CHAPTER 3 Racial/Ethnic Differences in Mental Health Service Use among Adults

14Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

 

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 

2008-2012 (2008-2010 Data – Revised March 2012).

● The pattern of past year mental health service 

utilization by race/ethnicity varied for adult 

males and females (Figure 3.2).

● White males (11.3 percent) had higher estimates 

of any mental health service use than black 

(6.6 percent), Hispanic (5.5 percent), and Asian 

(4.4 percent) males.

● Estimates of any mental health service use were 

higher for American Indian or Alaska Native 

males (16.3 percent) than for black, Hispanic, 

and Asian males.

● Estimates of any mental health service utilization 

were highest for white females (21.5 percent) 

and females reporting two or more races 

(21.3 percent).

● Estimates of any mental health service use were 

similar for females who were black (10.3 percent) 

and those who were Hispanic (9.2 percent).

● Asian females (5.3 percent) had the lowest 

percentage of mental health service use compared 

with females in other racial/ethnic groups.
● In each age group, white adults were more 

likely than their black, Asian, and Hispanic 

counterparts to use any mental health services 

(Figure 3.3). For example, among adults aged 26 

to 34, 18.1 percent of white adults used mental 

health services in the past year compared with 

8.5 percent of black adults, 5.1 percent of Asian 

adults, and 6.6 percent of Hispanic adults who 

had used mental health services.

● Among those aged 18 to 25, estimates of mental 

health service utilization were similar among 

black (6.5 percent), Asian (5.7 percent), and 

Hispanic (6.7 percent) adults.

● Among adults aged 50 or older, the estimate 

of past year service use was higher among 

black (8.8 percent) and Hispanic (8.6 percent) 

adults than among their Asian counterparts 

(4.5 percent).

FIGURE 3.3 Mental Health Service Use in the Past Year among 

Adults, by Race/Ethnicity and Age, 2008-201229

 

CHAPTER 3 Racial/Ethnic Differences in Mental Health Service Use among Adults

15Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 

2008-2012 (2008-2010 Data – Revised March 2012).
FIGURE 3.4 Mental Health Service Use in the Past Year among Adults, 

by Race/Ethnicity and Poverty Status, 2008-201229,30

CHAPTER 3 Racial/Ethnic Differences in Mental Health Service Use among Adults

16Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

 

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 

2008-2012 (2008-2010 Data – Revised March 2012).

● White adults and adults reporting two or more 

races had similar estimates of any mental health 

service utilization within each poverty status 

category (Figure 3.4). Within each poverty 

category, white adults had higher estimates of 

mental health service use than black, Asian, and 

Hispanic adults.

● Black adults with a family income below the 

Federal poverty level (12.4 percent) had a higher 

estimate of past year mental health service use 

compared with their Asian (6.1 percent) and 

Hispanic (8.3 percent) counterparts.

● Black adults with a family income between 

100 and 199 percent of the Federal poverty 

level (8.7 percent) had a higher estimate of 

mental health service use compared with their 

Asian (2.0 percent) and Hispanic (6.3 percent) 

counterparts.
● Within each health insurance group, most 

estimates of any past year service utilization were 

similar for white adults, American Indian or 

Alaska Native adults, and adults reporting two or 

more races (Figure 3.5). The exception was that 

American Indian or Alaska Native adults who 

had Medicaid/Medicare only were less likely to 

have used mental health services in the past year 

compared with their white counterparts (18.3 vs. 

26.3 percent, respectively).

● Uninsured black adults had a higher percentage 

of mental health service use compared with 

uninsured Hispanic adults (6.1 vs. 4.1 percent). 

Similarly, estimates of any mental health 

service use were higher among black adults 

with Medicaid/Medicare only compared with 

Hispanic adults with similar coverage (15.8 vs. 

11.5 percent).

● Black adults with private insurance were less 

likely than their Hispanic counterparts to use 

mental health services (5.6 vs. 7.7 percent).

● Within each insurance group, Asian adults had 

the lowest estimate of mental health service use, 

with one exception—Asian and black adults 

with private insurance had similar estimates of 

mental health service use (5.1 and 5.6 percent, 

respectively).

FIGURE 3.5 Mental Health Service Use in the Past Year among 

Adults, by Race/Ethnicity and Insurance Status, 2008-201229,31

CHAPTER 3 Racial/Ethnic Differences in Mental Health Service Use among Adults

17Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

 

* Low precision; no estimate reported.

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 

2008-2012 (2008-2010 Data – Revised March 2012).
3.3 Racial/Ethnic Differences in Reasons for Not Using Mental Health Services among Adults Who Reported an Unmet Need for Services

FIGURE 3.6 Reasons for Not Using Mental Health Services among 

Adults Who Had an Unmet Need for Services in the Past Year, by 

Race/Ethnicity, 2008-201229

CHAPTER 3 Racial/Ethnic Differences in Mental Health Service Use among Adults

18Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

 

* Low precision; no estimate reported.

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 

2008-2012 (2008-2010 Data – Revised March 2012).

● Among adults with an unmet need for mental 

health services in the past year, cost or insurance 

(no coverage or coverage limitations) was the most 

commonly cited reason across racial/ethnic groups 

for not using mental health services (Figure 3.6). 

● Cost or insurance as a reason for not using services 

was more likely to be reported by white adults 

(54.1 percent) with an unmet need for services 

compared with black adults (45.4 percent) 

and adults who reported two or more races 

(41.7 percent).

● White adults with an unmet need for mental 

health services were more likely than their black 

or Hispanic counterparts to have a low perceived 

need for mental health services (28.7 vs. 24.5 

and 21.2 percent, respectively). 

(continued on next page)
CHAPTER 3 Racial/Ethnic Differences in Mental Health Service Use among Adults

19Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

FIGURE 3.6 (continued)

● American Indian or Alaska Native adults (17.8 percent) 

with an unmet need were less likely to report structural 

barriers to mental health service use (e.g., lack of 

transportation, not knowing where or how to access 

mental health services) as reasons that they did not use 

mental health services compared with their counterparts 

in other racial/ethnic groups.

● The belief that mental health services would not help 

was the least frequently cited reason for not using mental 

health services among members of each racial/ethnic 

group. This reason for not using services was more likely 

to be reported by white adults with an unmet need 

(9.7 percent) than among their black (5.3 percent) or 

Hispanic (6.5 percent) counterparts. Asian adults with 

an unmet need for mental health services were more 

likely than their black counterparts to believe that mental 

health services would not help (12.9 vs. 5.3 percent, 

respectively).

3.4 Summary

White adults, American Indian or Alaska Native adults, and 

adults reporting two or more races consistently had a higher 

estimate of any past year mental health service use (ranging 

from 15.6 to 17.1 percent). Asian adults had the lowest 

estimate of mental health service use (4.9 percent), and 

black and Hispanic adults had similar estimates of service 

use that were in between those of white and Asian adults 

(7.3 to 8.6 percent). These patterns in the percentage of 

mental health service use by race/ethnicity did not change, 

regardless of gender, age, poverty status, and insurance 

status.

These findings are similar to the findings from other studies 

of both regional and national samples. Dobalian and Rivers, 

using data from the 1998 and 1999 Community Tracking 

Study to evaluate racial/ethnic differences in past year 

visits to mental health professionals, found that black and 

Hispanic adults had a lower estimate of mental health care 

visits compared with white adults, regardless of gender, age, 

education level, income, and insurance status.4

In a nationally representative study using medical records 

data from the 1997 National Ambulatory Medical Care 

Survey (NAMCS) and National Hospital Ambulatory 

Medical Care Survey (NHAMCS), Lasser and colleagues 

found that while there were only minor differences in 

the use of medical care overall among white, black, and 

Hispanic adults, both black and Hispanic adults had 
CHAPTER 3 Racial/Ethnic Differences in Mental Health Service Use among Adults

20Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

significantly lower estimates of mental health care and

prescription psychiatric medication than white adults.2

The authors concluded that black and Hispanic adults used 

about half as much outpatient care (defined as outpatient 

counseling or medication) as white adults. The NHAMCS 

findings were similar to the estimates in this study for any 

mental health service utilization, where 16.6 percent of 

white adults had used mental health services compared 

with 8.6 and 7.3 percent of black and Hispanic adults, 

respectively.

Comparing the results for mental health service use 

among American Indian or Alaska Native adults and 

Asian adults with the results for adults reporting two or 

more races is more difficult. Few nationally representative 

studies examine mental health service use in these groups. 

Those that do often focus on descriptive measures within 

one racial/ethnic group and do not make comparisons 

with other racial/ethnic groups. Even in NSDUH, the 

smaller sample sizes for some groups—even with 5 years 

of combined data—lead to imprecision in the estimates, 

which results in larger SEs and reduces the ability to detect 

differences.

The overall pattern of differences (e.g., Asian adults having 

the least mental health service use, followed by black adults 

and Hispanic adults) was found in any mental health 

service use, prescription psychiatric medication use, and 

outpatient mental health service use. For inpatient mental 

health service use, however, black adults had a higher 

estimate of service use than white adults.

There may be several reasons for this variation. First, it might 

represent a difference in service use preference. Second, 

these findings could be a result of structural factors. For 

example, Medicaid use is associated with higher inpatient 

service use, and this insurance type is more common among 

certain racial/ethnic groups.32 Third, members of certain 

racial/ethnic groups may be more likely to delay using 

mental health services until the severity necessitates inpatient 

services. Fourth, inpatient mental health service use is 

usually reserved for individuals with acutely serious mental 

illness. The finding that black adults were more likely to use 

inpatient mental health services than adults of other racial/

ethnic groups may be due to an underlying difference in the 

estimates or severity of mental illness across these groups. 

To examine this possibility, the next two sections present 

estimates of mental health service use among adults with any 

mental illness (AMI) and among adults with serious mental 

illness (SMI) by racial/ethnic groups.
4 Differences in Mental Health 

Service Use among Adults with 

Any Mental Illness

21Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

4.1 Introduction

In Section 3, an examination of the estimates of past year mental health service use 

among all adults indicated racial/ethnic differences in service use. However, it is also 

important to consider that the prevalence of mental illness—and therefore the need for 

services—varies across different racial/ethnic groups.

To evaluate racial/ethnic differences in mental health service use among individuals with 

a similar level of need, this section examines mental health service use among individuals 

with AMI. However, restricting the sample to adults with AMI leads to a substantially 

smaller sample size; therefore, only the overall treatment graphic (i.e., Figure 4.2) 

presents data for all six racial/ethnic groups. The remaining figures present estimates for 

the three racial/ethnic groups with the largest sample sizes: white, black, and Hispanic 

adults. The detailed tables in Appendix B contain estimates for the other racial/ethnic 

groups; however, many estimates are suppressed because of small sample sizes.

4
FIGURE 4.1 Any Mental Illness in the Past Year among Adults, by 

Race/Ethnicity, 2008-201229,33

CHAPTER 4 Differences in Mental Health Service Use among Adults with Any Mental Illness

22Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

 

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 

2008-2012 (2008-2011 AMI Data – Revised October 2013).

● Estimates of past year any mental illness (AMI) 

were higher among white adults (19.0 percent) 

than among black (16.8 percent), Hispanic 

(15.3 percent), and Asian (13.4 percent) adults 

(Figure 4.1). 

● Estimates were similar among white adults 

(19.0 percent) and American Indian or Alaska 

Native adults (22.7 percent). 

● Adults who reported two or more races had the 

highest percentage of AMI (24.9 percent).
4.2 Racial/Ethnic Differences in Past Year Mental Health Service Use among Adults with Any Mental Illness

● Among those with AMI, estimates of any mental health 

service utilization in the past year were similar among 

white adults (46.3 percent), adults who reported two 

or more races (44.8 percent), and American Indian 

or Alaska Native adults (41.6 percent) (Figure 4.2). 

Estimates of any past year mental health service use 

were similar among black and Hispanic adults with 

AMI (29.8 and 27.3 percent, respectively).

● White adults with AMI (41.0 percent) were more 

likely to use prescription medication than their 

counterparts who were black (23.4 percent) or 

Hispanic (22.4 percent). Similarly, white adults with 

AMI were more likely to use outpatient services than 

black or Hispanic adults with AMI (25.7 vs. 18.7 and 

16.6 percent, respectively).

● Asian adults with AMI were the least likely to use any 

mental health services (18.1 percent), prescription 

medication (12.2 percent), or outpatient services 

(11.0 percent).

● Estimates of inpatient mental health service use among 

adults with AMI were similar for adults who reported 

two or more races (3.5 percent), Hispanic adults 

(3.2 percent), white adults (2.9 percent), and Asian 

adults (2.5 percent). However, white adults with AMI 

were less likely than black adults with AMI to have used 

inpatient mental health services (2.9 vs. 5.1 percent).

FIGURE 4.2 Mental Health Service Use in the Past Year among 

Adults with Any Mental Illness, by Race/Ethnicity and Service Type, 

2008-201229

CHAPTER 4 Differences in Mental Health Service Use among Adults with Any Mental Illness

23Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

 

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 

2008-2012 (2008-2010 Data – Revised March 2012).
FIGURE 4.3 Mental Health Service Use in the Past Year among 

Adults with Any Mental Illness, by Race/Ethnicity and Gender, 

2008-201229

CHAPTER 4 Differences in Mental Health Service Use among Adults with Any Mental Illness

24Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

 

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 

2008-2012 (2008-2010 Data – Revised March 2012).

● Estimates of any mental health service utilization 

among adults with AMI were lower among 

black and Hispanic adults than among white 

adults, regardless of gender (Figure 4.3). For 

example, estimates of any mental health service 

use among adults with AMI were 24.0 percent 

for Hispanic males, 25.3 percent for black males, 

and 37.7 percent for white males.
● Among adults in each age group who had AMI, 

white adults were more likely than black or 

Hispanic adults to use mental health services in 

the past year (Figure 4.4). For example, among 

those aged 35 to 49 with AMI, 48.9 percent 

of white adults used mental health services 

compared with 34.2 percent of black adults and 

29.3 percent of Hispanic adults.

● Estimates of past year mental health service use 

were similar among black and Hispanic adults 

with AMI within each age group.

FIGURE 4.4 Mental Health Service Use in the Past Year among Adults 

with Any Mental Illness, by Race/Ethnicity and Age, 2008-201229

CHAPTER 4 Differences in Mental Health Service Use among Adults with Any Mental Illness

25Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

 

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 

2008-2012 (2008-2010 Data – Revised March 2012).
FIGURE 4.5 Mental Health Service Use in the Past Year among 

Adults with Any Mental Illness, by Race/Ethnicity and Poverty 

Status, 2008-201229,30

CHAPTER 4 Differences in Mental Health Service Use among Adults with Any Mental Illness

26Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

 

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 

2008-2012 (2008-2010 Data – Revised March 2012).

● White adults with AMI were more likely than 

black and Hispanic adults with AMI to use 

mental health services in the past year, regardless 

of poverty status (Figure 4.5). 

● Black and Hispanic adults with AMI had similar 

estimates of past year service use, regardless 

of poverty status. For example, estimates of 

mental health service utilization for adults 

with AMI who had family incomes below the 

Federal poverty level were 35.3 percent for black 

adults and 28.9 percent for Hispanic adults. In 

comparison, 49.5 percent of white adults with 

AMI who had family incomes below the Federal 

poverty level used mental health services in the 

past year.
● In each insurance status group, white adults with 

AMI were more likely to report using mental 

health services than black or Hispanic adults 

(Figure 4.6). For example, the estimate for 

mental health service use among uninsured white 

adults with AMI (34.0 percent) was higher than 

the estimate for uninsured black or Hispanic 

adults with AMI (21.6 and 18.5 percent, 

respectively).

● The estimate of mental health service utilization 

for black adults with AMI who had private 

insurance coverage only was lower than the 

estimate for their Hispanic counterparts (22.4 vs. 

30.9 percent, respectively).

FIGURE 4.6 Mental Health Service Use in the Past Year among 

Adults with Any Mental Illness, by Race/Ethnicity and Insurance 

Status, 2008-201229,31

CHAPTER 4 Differences in Mental Health Service Use among Adults with Any Mental Illness

27Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

 

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 

2008-2012 (2008-2010 Data – Revised March 2012).
4.3 Racial/Ethnic Differences in Reasons for Not Using Mental Health Services among Adults with Any Mental Illness Who Reported an 

Unmet Need for Services

FIGURE 4.7 Reasons for Not Using Mental Health Services among 

Adults with Any Mental Illness Who Had an Unmet Need for 

Services in the Past Year, by Race/Ethnicity, 2008-201229

CHAPTER 4 Differences in Mental Health Service Use among Adults with Any Mental Illness

28Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

 

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 

2008-2012 (2008-2010 Data – Revised March 2012).

● Among white, black, and Hispanic adults with AMI 

who had an unmet need for services, cost or insurance 

(none or inadequate coverage) was the most frequently 

cited reason for not using mental health services 

(Figure 4.7). Did not think that services would help 

was the least frequently cited reason for not using 

mental health services.

● Among white adults with AMI who reported an 

unmet need for mental health services, 57.6 percent 

cited cost or insurance as a reason for not using 

mental health services. This was higher than the 

estimate among black adults with AMI who 

reported an unmet need for mental health services 

(47.1 percent).

● White adults with AMI who had an unmet need 

for services were more likely than black or Hispanic 

adults with AMI to believe that services would not 

help (10.4 vs. 6.1 and 6.6 percent, respectively).

● Estimates of low perceived need for services, concern 

over prejudice and discrimination, and structural 

barriers as reasons for not using mental health services 

did not differ significantly by race/ethnicity among 

adults with AMI who had an unmet need for services.
CHAPTER 4 Differences in Mental Health Service Use among Adults with Any Mental Illness

29Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

4.4 Summary

Among adults with AMI, estimates of any past year mental 

health service use, prescription medication use, and 

outpatient mental health service use among adults with 

AMI were greater among white adults, American Indian 

or Alaska Native adults, and adults who reported two or 

more races than among black, Asian, and Hispanic adults. 

Moreover, black adults with AMI were more likely than 

white adults with AMI to have used inpatient mental health 

services. These patterns in the estimates of mental health 

service use by race/ethnicity did not change for adults 

within subgroups defined by gender, age, and insurance 

status. These findings are consistent with those among all 

adults reported in Section 3.

NSDUH estimates of mental health service use among 

adults with AMI by racial/ethnic groups can be compared 

with those reported by Lee and colleagues, who utilized data 

from the 2001 to 2002 wave of the National Epidemiologic 

Survey on Alcohol and Related Conditions (NESARC) to 

examine racial/ethnic differences in mental health service 

use among adults with mood disorder.3 However, it should 

be noted that the time frames differ for the published 

NESARC estimates and the NSDUH estimates in this 

chartbook; the NESARC estimates are produced from 

questions that ask about mental health service use in the 

respondents’ lifetime, while the NSDUH estimates are 

based on questions that ask about past year mental health 

service use. NESARC estimates of lifetime service use 

indicate that over 60 percent of white adults with a mood 

disorder had used mental health services in their lifetime, 

while 63.7 percent of American Indian or Alaska Native 

adults, 47.0 percent of Hispanic adults, 42.6 percent of 

black adults, and 32.4 percent of Asian adults with a mood 

disorder had used mental health services in their lifetime. 

Although the NESARC estimates were higher than those in 

NSDUH, both the NESARC and the NSDUH estimates 

indicate that white adults and American Indian or Alaska 

Native adults had similarly high estimates of mental health 

service use, followed by Hispanic and black adults, with the 

lowest estimates among Asian adults.
30

This page intentionally left blank
5 Differences in Mental Health 

Service Use among Adults with 

Serious Mental Illness

31Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

5.1 Introduction

The previous analyses demonstrated that the estimates of 

any mental health service use are consistently higher among 

white adults than among black or Hispanic adults, regardless 

of gender, age, poverty status, insurance status, and the 

presence of any mental illness (AMI). However, service use 

increases with the severity of mental illness. Therefore, it 

is possible that the findings in the previous sections could 

be explained by racial/ethnic differences in the severity of 

mental illness.

To address this possibility, this section presents estimates 

among adults with serious mental illness (SMI). As noted 

in Section 2, SMI is defined as the presence of a Diagnostic 

and Statistical Manual of Mental Disorders, 4th edition 

(DSM-IV), diagnosable mental illness that results in 

serious functional impairment (excluding substance use 

and developmental disorders). Because of greater variability 

in the estimates associated with the smaller sample sizes 

of adults with SMI who are American Indians or Alaska 

Natives, Asians, or reporting two or more races, the 

estimates in this section are restricted to the three largest 

racial/ethnic groups: white, black, and Hispanic adults.

5
FIGURE 5.1 Serious Mental Illness among Adults, by Race/Ethnicity, 

2008-201229,34

CHAPTER 5 Differences in Mental Health Service Use among Adults with Serious Mental Illness

32Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

 

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 

2008-2012 (2008-2011 SMI Data – Revised October 2013).

● Among white, black, and Hispanic adults, the 

estimate of SMI was higher among white adults 

(4.3 percent) than among black or Hispanic 

adults (3.1 percent) (Figure 5.1). 

● Estimates for SMI, including standard errors 

(SEs), are found in Appendix A, Table A.1. 

Detailed estimates for all other figures in this 

section are in Appendix C.
5.2 Racial/Ethnic Differences in Past Year Mental Health Service Use among Adults with Serious Mental Illness

● The estimate for past year mental health service 

utilization among adults with SMI was higher 

among white adults (69.4 percent) than among 

those who were black (57.2 percent) or Hispanic 

(50.5 percent) (Figure 5.2).

● Estimates of the use of different types of mental 

health services by adults with SMI also varied by 

race/ethnicity. White adults with SMI were more 

likely than their black or Hispanic counterparts 

to use prescription medication (64.2 vs. 47.0 

and 44.8 percent, respectively). The estimate for 

outpatient service use among white adults with SMI 

(45.3 percent) was higher than the corresponding 

estimate for Hispanic adults (33.6 percent).

● White adults with SMI were less likely to use 

inpatient mental health services compared with black 

adults with SMI (7.4 vs. 11.3 percent). White and 

Hispanic adults with SMI had similar estimates of 

inpatient mental health service use (7.4 percent).

FIGURE 5.2 Mental Health Service Use in the Past Year among 

Adults with Serious Mental Illness, by Race/Ethnicity and Service 

Type, 2008-201229

CHAPTER 5 Differences in Mental Health Service Use among Adults with Serious Mental Illness

33Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

 

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 

2008-2012 (2008-2010 Data – Revised March 2012).
FIGURE 5.3 Mental Health Service Use in the Past Year among 

Adults with Serious Mental Illness, by Race/Ethnicity and Gender, 

2008-201229

CHAPTER 5 Differences in Mental Health Service Use among Adults with Serious Mental Illness

34Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

 

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 

2008-2012 (2008-2010 Data – Revised March 2012).

● Mental health service use was higher among 

white adults with SMI for both males and 

females compared with their black or Hispanic 

male and female counterparts (Figure 5.3).
● Within each age group, the estimate of past year 

service use was higher among white adults with 

SMI compared with their black or Hispanic 

counterparts (Figure 5.4). For example, among 

adults aged 18 to 25, 57.6 percent of white 

adults with SMI had used mental health services 

in the past year compared with 40.3 percent of 

black adults and 40.2 percent of Hispanic adults 

with SMI.

FIGURE 5.4 Mental Health Service Use in the Past Year among 

Adults with Serious Mental Illness, by Race/Ethnicity and Age, 

2008-201229

CHAPTER 5 Differences in Mental Health Service Use among Adults with Serious Mental Illness

35Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

 

* Low precision; no estimate reported.

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 

2008-2012 (2008-2010 Data – Revised March 2012).
FIGURE 5.5 Mental Health Service Use in the Past Year among 

Adults with Serious Mental Illness, by Race/Ethnicity and Poverty 

Status, 2008-201229,30

CHAPTER 5 Differences in Mental Health Service Use among Adults with Serious Mental Illness

36Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

 

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 

2008-2012 (2008-2010 Data – Revised March 2012).

● White adults with SMI who had a family income 

below the Federal poverty level were more likely 

than their Hispanic counterparts to have used 

mental health services in the past year (69.0 vs. 

52.0 percent, respectively) (Figure 5.5).

● White and black adults with SMI who had a 

family income between 100 and 199 percent of 

the Federal poverty level had similar estimates 

of past year mental health service use (65.9 and 

58.6 percent, respectively). White adults with 

SMI who had a family income between 100 

and 199 percent of the Federal poverty level 

had a higher estimate of mental health service 

use than their Hispanic counterparts (65.9 vs. 

44.0 percent, respectively).

● White adults with SMI who had a family income 

at 200 percent or more of the Federal poverty 

level were more likely to use mental health services 

than black or Hispanic adults with SMI who had 

a similar family income level (71.4 vs. 50.0 and 

53.1 percent, respectively).
● Among uninsured adults with SMI, the estimate 

of past year mental health service utilization 

for white adults (53.1 percent) was higher than 

that for black adults (41.3 percent) or Hispanic 

adults (36.8 percent) (Figure 5.6). Estimates were 

similar for uninsured black and Hispanic adults 

with SMI.

● Among adults with SMI who had only private 

health insurance coverage, the percentage of 

mental health service use was higher among 

white adults (70.5 percent) than among black 

adults (46.6 percent) and Hispanic adults 

(51.9 percent). Estimates were similar for black 

and Hispanic adults with SMI who had only 

private health insurance coverage.

FIGURE 5.6 Mental Health Service Use in the Past Year among 

Adults with Serious Mental Illness, by Race/Ethnicity and Insurance 

Status, 2008-201229,31

CHAPTER 5 Differences in Mental Health Service Use among Adults with Serious Mental Illness

37Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

 

* Low precision; no estimate reported.

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 

2008-2012 (2008-2010 Data – Revised March 2012).
5.3 Racial/Ethnic Differences in Reasons for Not Using Mental Health Services among Adults with Serious Mental Illness Who Reported 

an Unmet Need for Services

FIGURE 5.7 Reasons for Not Using Mental Health Services among 

Adults with Serious Mental Illness Who Had an Unmet Need for 

Services in the Past Year, by Race/Ethnicity, 2008-201229

CHAPTER 5 Differences in Mental Health Service Use among Adults with Serious Mental Illness

38Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

 

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 

2008-2012 (2008-2010 Data – Revised March 2012).

● Similar to the findings among all adults and 

adults with AMI, cost or insurance (none or 

insufficient coverage) was the most commonly 

reported reason for not using mental health 

services among adults with SMI who had 

an unmet need for mental health services 

(Figure 5.7).

● Did not think services would help was the least 

commonly reported reason for not using mental 

health services in the past year among adults with 

SMI who had an unmet need. 

(continued on next page)
CHAPTER 5 Differences in Mental Health Service Use among Adults with Serious Mental Illness

39Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

FIGURE 5.7 (continued)

● Racial/ethnic differences in the reasons for not using 

mental health services were seen only for cost or 

insurance and did not think that services would help. For 

both reasons, the percentage was higher among white 

adults with SMI who had an unmet need than among 

their black or Hispanic counterparts.

● Among white adults with SMI who had an unmet need, 

62.1 percent reported that they did not receive services 

because of cost or insurance, and 10.8 percent thought 

that services would not help.

● Among black adults with SMI who had an unmet need, 

51.7 percent did not receive services because of cost or 

insurance, and 5.5 percent thought that services would 

not help.

● Approximately 58.6 percent of Hispanic adults with SMI 

who had an unmet need did not receive services because 

of cost or insurance, and 8.7 percent thought that 

services would not help.

5.4 Summary

Regardless of race/ethnicity, adults with SMI were more 

likely than adults with AMI to report mental health 

service use in the past year. Among adults with mental 

illness, the patterns of mental health service use by race/

ethnicity were similar among adults with AMI or SMI. The 

estimate of past year use of any mental health services was 

higher among white adults than black or Hispanic adults 

with AMI or SMI. Similarly, estimates of prescription 

psychiatric medication use and outpatient mental health 

service use were higher among white adults than among 

black or Hispanic adults, regardless of the severity of mental 

illness. However, inpatient mental health service use was 

more prevalent among black adults with AMI or SMI 

compared with inpatient white adults with AMI or SMI. 

To the authors’ best knowledge, NSDUH provides the only 

annually published nationally representative estimates of 

past year mental health service use among adults with AMI 

or SMI by race/ethnicity; therefore, the estimates in this 

report cannot be directly compared with estimates from 

other data sources.
40

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End Notes

41

1. U.S. Department of Health and Human Services, Public Health Service, 

Office of the Surgeon General. (2001). Mental health: Culture, race, and 

ethnicity—A supplement to Mental health: A report of the Surgeon General. 

Rockville, MD: Author.

2. Lasser, K. E., Himmelstein, D. U., Woolhandler, S. J., McCormick, 

D., & Bor, D. H. (2002). Do minorities in the United States receive 

fewer mental health services than whites? International Journal of Health 

Services: Planning, Administration, Evaluation, 32, 567-578.

3. Lee, S. Y., Martins, S. S., Keyes, K. M., & Lee, H. B. (2011). Mental 

health service use by persons of Asian ancestry with DSM-IV mental 

disorders in the United States. Psychiatric Services, 62, 1180-1186.

4. Dobalian, A., & Rivers, P. A. (2008). Racial and ethnic disparities in 

the use of mental health services. Journal of Behavioral Health Services & 

Research, 35, 128-141.

5. Harris, K. M., Edlund, M. J., & Larson, S. (2005). Racial and ethnic 

differences in the mental health problems and use of mental health care. 

Medical Care, 43, 775-784.

6. Wang, P. S., Berglund, P., Olfson, M., Pincus, H. A., Wells, K. B., & 

Kessler, R. C. (2005). Failure and delay in initial treatment contact 

after first onset of mental disorders in the National Comorbidity Survey 

Replication. Archives of General Psychiatry, 62, 603-613.

7. Gonzalez, J. M., Alegría, M., Prihoda, T. J., Copeland, L. A., & Zeber, 

J. E. (2011). How the relationship of attitudes toward mental health 

treatment and service use differs by age, gender, ethnicity/race and 

education. Social Psychiatry & Psychiatric Epidemiology, 46(1), 45-57. 

doi:10.1007/s00127-009-0168-4

8. Keyes, K. M., Hatzenbuehler, M. L., Alberti, P., Narrow, W. E., Grant, 

B. F., & Hasin, D. S. (2008). Service utilization differences for Axis-I 

psychiatric and substance use disorders between white and black adults. 

Psychiatric Services, 59, 893-901.

9. McAlpine, D. D., & Mechanic, D. (2000). Utilization of specialty 

mental health care among persons with severe mental illness: The roles 

of demographics, need, insurance, and risk. Health Services Research, 

35(1 Pt 2), 277-292.

10. Neighbors, H. W., Caldwell, C., Williams, D. R., Nesse, R., Taylor, 

R. J., Bullard, K. M. K., Torres, M., & Jackson, J. S. (2007). Race, 

ethnicity, and the use of services for mental disorders: Results from the 

National Survey of American Life. Archives of General Psychiatry, 64, 

485-494.

11. Wang, P. S., Lane, M., Olfson, M., Pincus, H. A., Wells, K. B., & 

Kessler, R. C. (2005). Twelve-month use of mental health services 

in the United States: Results from the National Comorbidity Survey 

Replication. Archives of General Psychiatry, 62, 629-640. doi:10.1001/

archpsyc.62.6.629

12. Mental Health Parity and Addiction Equity Act of 2008, Pub. L. No. 

110-343, Title V, Subtitle B of Division C, §§ 511-512 (2008).

13. Barry, C. L., & Huskamp, H. A. (2011). Moving beyond parity—

Mental health and addiction care under the ACA. New England Journal 

of Medicine, 365, 973-975. doi:10.1056/NEJMp1108649

14. Affordable Care Act of 2010, Pub. L. No. 111-148, Title II, §§ 2001-

2955 (2010).

15. Garfield, R. L., Zuvekas, S. H., Lave, J. R., & Donohue, J. M. (2011). 

The impact of national health care reform on adults with severe mental 

disorders. American Journal of Psychiatry, 168, 486-494.

16. Office of Applied Studies. (2009). Results from the 2008 National Survey 

on Drug Use and Health: National findings (HHS Publication No. SMA 

09-4434, NSDUH Series H-36). Rockville, MD: Substance Abuse and 

Mental Health Services Administration.
42Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

End Notes

17. Center for Behavioral Health Statistics and Quality. (2010). Results 

from the 2009 National Survey on Drug Use and Health: Mental health 

findings (HHS Publication No. SMA 10-4609, NSDUH Series 

H-39). Rockville, MD: Substance Abuse and Mental Health Services 

Administration.

18. Center for Behavioral Health Statistics and Quality. (2012a). Results 

from the 2010 National Survey on Drug Use and Health: Mental health 

findings (HHS Publication No. SMA 11-4667, NSDUH Series 

H-42). Rockville, MD: Substance Abuse and Mental Health Services 

Administration.

19. Center for Behavioral Health Statistics and Quality. (2012b). Results 

from the 2011 National Survey on Drug Use and Health: Mental health 

findings (HHS Publication No. SMA 12-4725, NSDUH Series 

H-45). Rockville, MD: Substance Abuse and Mental Health Services 

Administration.

20. Center for Behavioral Health Statistics and Quality. (2013). Results 

from the 2012 National Survey on Drug Use and Health: Mental health 

findings (HHS Publication No. SMA 13-4805, NSDUH Series 

H-47). Rockville, MD: Substance Abuse and Mental Health Services 

Administration.

21. Office of Management and Budget. (1997). Revisions to the standards 

for the classification of federal data on race and ethnicity. Federal Register, 

62(210), 58781-58790.

22. First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (2002, 

November). Structured Clinical Interview for DSM-IV-TR Axis I 

Disorders, Research Version, Non-patient Edition (SCID-I/NP). New York, 

NY: New York State Psychiatric Institute, Biometrics Research.

23. American Psychiatric Association. (1994). Diagnostic and statistical 

manual of mental disorders (DSM-IV) (4th ed.). Washington, DC: 

Author.

24. Substance Abuse and Mental Health Services Administration. (1993, May 

20). Final notice establishing definitions for (1) Children with a serious 

emotional disturbance and (2) adults with a serious mental illness. Federal 

Register, 58(96), 29422-29425.

25. Substance Abuse and Mental Health Services Administration, Center 

for Behavioral Health Statistics and Quality. (2013, November 19). 

The NSDUH Report: Revised estimates of mental illness from the National 

Survey on Drug Use and Health. Rockville, MD.

26. RTI International. (2008). SUDAAN®, Release 10.0 [computer software]. 

Research Triangle Park, NC: Author.

27. Payton, M. E., Greenstone, M. H., & Schenker, N. (2003). Overlapping 

confidence intervals or standard error intervals: What do they mean in 

terms of statistical significance? Journal of Insect Science, 3, 34.

28. Schenker, N., & Gentleman, J. F. (2001). On judging the significance 

of differences by examining the overlap between confidence intervals. 

American Statistician, 55(3), 182-186.

29. This figure presents the annual average percentages and 95 percent 

confidence intervals for mental health service use from 2008 to 2012. 

The annual average is the average percentage of mental health service use 

per year for 2008 to 2012.

30. Respondents aged 18 to 22 currently living in a college dormitory were 

excluded from the poverty calculation.

31. Other health insurance is defined as having the Civilian Health and 

Medical Program of the Uniformed Services (CHAMPUS), TRICARE, 

Civilian Health and Medical Program of the Department of Veterans 

Affairs (CHAMPVA), the U.S. Department of Veterans Affairs (VA), 

military health care, or any other type of health insurance.

32. Snowden, L. R., & Cheung, F. K. (1990). Use of inpatient mental health 

services by members of ethnic minority groups. American Psychologist, 

45, 347-355.

33. Estimates for AMI presented in this figure may differ from previously 

published AMI estimates because of revised estimation procedures. For 

details, see The NSDUH Report: Revised Estimates of Mental Illness from 

the National Survey on Drug Use and Health.

34. Estimates for SMI presented in this figure may differ from previously 

published SMI estimates because of revised estimation procedures. For 

details, see The NSDUH Report: Revised Estimates of Mental Illness from 

the National Survey on Drug Use and Health.
List of Figures

43

Figure 31 Mental Health Service Use in the Past Year among Adults, by 

Race/Ethnicity and Service Type, 2008-2012                    12

Figure 32 Mental Health Service Use in the Past Year among Adults, by 

Race/Ethnicity and Gender, 2008-2012                         14

Figure 33 Mental Health Service Use in the Past Year among Adults, by 

Race/Ethnicity and Age, 2008-2012                            15

Figure 34 Mental Health Service Use in the Past Year among Adults, by 

Race/Ethnicity and Poverty Status, 2008-2012                  16

Figure 35 Mental Health Service Use in the Past Year among Adults, by 

Race/Ethnicity and Insurance Status, 2008-2012                17

Figure 36 Reasons for Not Using Mental Health Services among Adults 

Who Had an Unmet Need for Services in the Past Year, by 

Race/Ethnicity, 2008-2012                                     18

Figure 41 Any Mental Illness in the Past Year among Adults, by Race/

Ethnicity, 2008-2012                                           22

Figure 42 Mental Health Service Use in the Past Year among Adults 

with Any Mental Illness, by Race/Ethnicity and Service Type, 

2008-2012                                                    23

Figure 43 Mental Health Service Use in the Past Year among Adults 

with Any Mental Illness, by Race/Ethnicity and Gender, 

2008-2012                                                    24

Figure 44 Mental Health Service Use in the Past Year among Adults 

with Any Mental Illness, by Race/Ethnicity and Age, 

2008-2012                                                    25

Figure 45 Mental Health Service Use in the Past Year among Adults 

with Any Mental Illness, by Race/Ethnicity and Poverty 

Status, 2008-2012                                             26

Figure 46 Mental Health Service Use in the Past Year among Adults 

with Any Mental Illness, by Race/Ethnicity and Insurance 

Status, 2008-2012                                             27

Figure 47 Reasons for Not Using Mental Health Services among 

Adults with Any Mental Illness Who Had an Unmet Need for 

Services in the Past Year, by Race/Ethnicity, 2008-2012          28

Figure 51 Serious Mental Illness among Adults, by Race/Ethnicity, 

2008-2012                                                    32

Figure 52 Mental Health Service Use in the Past Year among Adults 

with Serious Mental Illness, by Race/Ethnicity and Service 

Type, 2008-2012                                               33

Figure 53 Mental Health Service Use in the Past Year among Adults 

with Serious Mental Illness, by Race/Ethnicity and Gender, 

2008-2012                                                    34

Figure 54 Mental Health Service Use in the Past Year among Adults 

with Serious Mental Illness, by Race/Ethnicity and Age, 

2008-2012                                                    35

Figure 55 Mental Health Service Use in the Past Year among Adults 

with Serious Mental Illness, by Race/Ethnicity and Poverty 

Status, 2008-2012                                             36

Figure 56 Mental Health Service Use in the Past Year among Adults 

with Serious Mental Illness, by Race/Ethnicity and Insurance 

Status, 2008-2012                                             37

Figure 57 Reasons for Not Using Mental Health Services among 

Adults with Serious Mental Illness Who Had an Unmet Need 

for Services in the Past Year, by Race/Ethnicity, 2008-2012      38
List of Tables

44Substance Abuse and Mental Health Services Administration · National Survey on Drug Use and Health

Table A1 Demographic Characteristics of Adults Aged 18 or Older, by 

Race/Ethnicity: Percentages and Standard Errors, 2008-

2012, Annual Averages  A-2

Table A2 Past Year Use of Mental Health Services among Adults Aged 18 

or Older, by Race/Ethnicity and Type of Service: Percentages 

and Standard Errors, 2008-2012, Annual Averages A-4

Table A3 Past Year Use of Any Mental Health Service among 

Adults Aged 18 or Older, by Race/Ethnicity and Selected 

Characteristics: Percentages and Standard Errors, 2008-

2012, Annual Averages  A-5

Table A4 Past Year Use of Prescription Psychiatric Medication among 

Adults Aged 18 or Older, by Race/Ethnicity and Selected 

Characteristics: Percentages and Standard Errors, 2008-

2012, Annual Averages  A-7

Table A5 Past Year Use of Outpatient Mental Health Services among 

Adults Aged 18 or Older, by Race/Ethnicity and Selected 

Characteristics: Percentages and Standard Errors, 2008-

2012, Annual Averages  A-9

Table A6 Past Year Use of Inpatient Mental Health Services among 

Adults Aged 18 or Older, by Race/Ethnicity and Selected 

Characteristics: Percentages and Standard Errors, 2008-

2012, Annual Averages  A-11

Table A7 Reasons for Not Using Mental Health Services among 

Adults with an Unmet Need for Services, Aged 18 or Older, 

by Race/Ethnicity: Percentages and Standard Errors, 2008-

2012, Annual Averages  A-13

Table B1 Demographic Characteristics of Adults with Any Mental 

Illness, Aged 18 or Older, by Race/Ethnicity: Percentages 

and Standard Errors, 2008-2012, Annual Averages B-2

Table B2 Past Year Use of Mental Health Services among Adults with 

Any Mental Illness, Aged 18 or Older, by Race/Ethnicity and 

Type of Service: Percentages and Standard Errors, 2008-

2012, Annual Averages B-4

Table B3 Past Year Use of Any Mental Health Services among Adults 

with Any Mental Illness, Aged 18 or Older, by Race/Ethnicity 

and Selected Characteristics: Percentages and Standard 

Errors, 2008-2012, Annual Averages B-5

Table B4 Reasons for Not Using Mental Health Services among Adults 

with Any Mental Illness, Aged 18 or Older, Who Reported 

an Unmet Need for Services, by Race/Ethnicity: Percentages 

and Standard Errors, 2008-2012, Annual Averages B-7

Table C1 Demographic Characteristics of Adults with Serious Mental 

Illness, Aged 18 or Older, by Race/Ethnicity: Percentages 

and Standard Errors, 2008-2012, Annual Averages C-2

Table C2 Past Year Use of Mental Health Services among Adults with 

Serious Mental Illness, Aged 18 or Older, by Race/Ethnicity 

and Type of Service: Percentages and Standard Errors, 2008-

2012, Annual Averages C-4

Table C3 Past Year Use of Any Mental Health Service among Adults 

with Serious Mental Illness, Aged 18 or Older, by Race/

Ethnicity and Selected Characteristics: Percentages and 

Standard Errors, 2008-2012, Annual AveragesC-5

Table C4 Reasons for Not Using Mental Health Services among 

Adults with Serious Mental Illness, Aged 18 or Older, Who 

Reported an Unmet Need for Mental Health Services, by 

Race/Ethnicity: Percentages and Standard Errors, 2008-

2012, Annual Averages C-7
HHS Publication No. SMA-15-4906

2015

U.S. Department of Health and Human Services

Substance Abuse and Mental Health Services Administration

Center for Behavioral Health Statistics and Quality

www.samhsa.gov