Perspectives From the National Institutes of Health on Multidimensional Mental Health Disparities Research: A Framework for Advancing the Field

As a hypothetical example, suppose researchers and community partners wish to develop an intervention to improve help-seeking to address high rates of depression and posttraumatic stress disorder in a local Hmong population. The team views health literacy as the key feature driving low levels of help-seeking, but they also identify other relevant determinants, including lack of health insurance, food insecurity, lack of transportation, and lack of availability of Hmong-speaking providers. It becomes clear to the team that a health information–focused intervention alone is unlikely to result in improved help-seeking unless these structural barriers to accessing mental health care are also addressed. We are not suggesting that determinants in all cells of the framework must always be included to address health disparities, but we highlight the importance of examining the constellation of determinants relevant to the specific disparities being studied, and the need to intervene at the appropriate levels to have a sustained impact. The availability of a framework that emphasizes multidomain, multilevel determinants of health does not ensure that research approaches and interventions will successfully address mental health disparities—this depends upon how researchers and stakeholders apply and implement the framework.

Based on the concept of generations of health disparities research (11), we describe examples of three types of mental health disparities research in which the adapted framework may be implemented and that address SDOH. Note that research to document mental health disparities is not included here if does not also examine mechanisms or determinants of those disparities, or if SDOH are measured but included only as control variables in analyses. Although this research progression may be a natural evolution, we argue that the highly incremental research that has characterized much of the health disparities field is not necessary to replicate for mental health disparities, given that this foundational work is often relevant across health conditions and outcomes.

First Generation: Understanding How SDOH Cause, Sustain, or Mitigate Mental Health Disparities

This body of research moves beyond individual-level determinants of mental health disparities (e.g., lack of awareness of mental health problems, lack of health insurance) to identify higher-level social and structural factors that contribute to or mitigate health disparities. Factors such as family and community cohesion, population density, neighborhood-level disadvantage, neighborhood safety and community violence, community social climate, and community and national-level racism and discrimination have all been found to be associated with individual and community-level mental health symptoms and distress (12). This work is critical in identifying modifiable intervention targets that have potential to reduce mental health disparities. Because the social and policy landscape is constantly changing with respect to impacts on minoritized and marginalized populations, this work will always be needed. However, the current distribution, where most mental health disparities research reflects observational research to document and understand disparities, needs to be shifted more toward intervention and action. For example, a recent portfolio analysis conducted by the NIH Office of Disease Prevention of new NIH-funded extramural projects from fiscal year 2012 to 2019 (13) found that about two-thirds of prevention projects were observational, while randomized intervention studies accounted for less than one-fifth of projects, and this proportion declined over time. In addition, only 3.5{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of prevention projects included a randomized intervention to address a leading risk factor for death and disability in populations experiencing health disparities. Prevention research specific to mental health outcomes accounted for less than 8{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of projects in fiscal year 2019 and mirrored these overall patterns (13).

Second Generation: Evaluating Interventions That Help Individuals Address SDOH or Mitigate Their Impact

This body of research recognizes that the unique experiences of minoritized and marginalized populations need to be acknowledged and addressed in the context of mental health interventions and care. Examples include 1) coping-focused interventions to help individuals manage or reduce distress associated with racism or other forms of discrimination, poverty, unemployment, family separations, and other challenging life circumstances (14, 15); 2) trauma-informed interventions that tailor services for individuals exposed to early or chronic traumatic events or poverty-related stressors (16–18); and 3) patient navigation or service linkage interventions that connect individuals to needed health and social services and/or address access barriers to facilitate engagement in care (19, 20). Such interventions, although a critical component of health and mental health care, only address the consequences of societal inequities and do not directly affect the systems and structures that cause and sustain mental health disparities. In isolation, these interventions will not be sufficient to reduce or eliminate mental disparities at the population level. However, based on our observation of applications submitted to NIH, interventions to help individuals or populations mitigate the impact of SDOH rather than changing the SDOH directly remain common.

Third Generation: Evaluating Interventions That Directly Impact SDOH to Produce Lasting Changes for Communities and Populations

Notably, this area seems to be characterized by more articles calling for social and structural interventions (21, 22) than articles describing the results from actual social and structural interventions (23), and the latter are particularly rare in the mental health field. To address mental health disparities, interventions must move beyond an individual-level treatment-focused model of mental health to emphasize families, organizations, and communities and encompass prevention and sustainable change. Examples of such interventions include medical-legal partnerships in which clinicians and legal personnel work to address discrimination or unfair practices related to housing, education, criminal justice, or other domains (24); alternatives to incarceration for individuals with severe mental illness charged with minor offenses (25); and the implementation of evidence-based depression treatment in faith-based settings (26). However, many structural interventions addressing SDOH have not been rigorously evaluated, and few studies have examined the impact of interventions on disparities (21). Although critically needed, research evaluating these types of interventions has many challenges. Balancing methodological rigor with feasibility and acceptability of study designs can be an issue that requires thoughtful communication and collaboration between research and community collaborators. Studies can be costly to execute, as testing interventions at organizational, neighborhood, or community levels requires these settings to be the unit of analysis rather than the individual, necessitating the inclusion of multiple sites or locations. Interventions addressing SDOH (e.g., racism and discrimination) are likely to have nonspecific outcomes relevant to a range of health conditions, which may pose a challenge to funders who prefer interventions to address disease-specific determinants of health leading to disease-specific outcomes. Despite these many challenges, such interventions hold the greatest promise for eliminating mental health disparities and achieving mental health equity.

On an encouraging note, NIH is beginning to emphasize the need for interventions that move beyond addressing SDOH at the individual level in recent funding opportunity announcements. Topics have included maternal mortality and morbidity (27), structural racism and discrimination (28), family- and community-level interventions (29, 30), physical activity (31), opioid misuse (32), HIV (33), firearm morbidity and mortality (34), and suicide and suicidal ideation and behaviors (35). Although these funding opportunities may include mental health determinants and outcomes, additional targeted opportunities from NIH and other funders of mental health research and services that are explicitly focused on SDOH and mental health disparities are likely needed to make significant progress in this area.

Taken together, this review suggests several important implications for mental health disparities research and clinical practices aimed at reducing disparities. First, this review highlights the opportunity for researchers to use and build upon the proffered mental health disparities framework to mechanistically explore SDOH that can subsequently inform appropriately framed and tailored interventions to reduce disparities. Second, from a clinical perspective, this review points to the importance of establishing a continuum of care to address mental health disparities, which includes both mental health promotion and prevention interventions among marginalized and minoritized populations. Development of interventions aimed at the promotion and prevention end of the mental health continuum of care would facilitate addressing the social and structural factors that have been identified as significant drivers of mental health disparities, including SDOH, and would increase the ultimate reach and range of intervention.