Gender and Race/Ethnicity Differencesin Mental Health Care Use beforeand during the Great Recession

Jie Chen, PhDRada Dagher, PhD

Abstract

This study examines the changes in health care utilization for mental health disorders amongpatients who were diagnosed with depressive and/or anxiety disorders during the Great Recession2007–2009 in the USA. Negative binomial regressions are used to estimate the association of theeconomic recession and mental health care use for females and males separately. Results show thatprescription drug utilization (e.g., antidepressants, psychotropic medications) increased significantlyduring the economic recession 2007–2009 for both females and males. Physician visits for mentalhealth disorders decreased during the same period. Results show that racial disparities in mentalhealth care might have increased, while ethnic disparities persisted during the Great Recession. Futureresearch should separately examine mental health care utilization by gender and race/ethnicity.

Introduction

According to the National Bureau of Economic Research, the Great Economic Recession of theUSA 2007–2009 was marked by a significant decline in production and employment.1 Theunemployment rate increased from 4.5% in 2006 to 9.5% in 2009.1 Substantial reductions inhousehold income were observed during the same period.2

The impact of the economic recession on mental health care utilization is a double-edged sword.On one hand, the demand for mental health care increases substantially during economic hardships.The literature shows consistent adverse effects of job loss on the risk of depression and heavydrinking, and a moderate positive association between economic contraction and suicide and

Address correspondence to Jie Chen, PhD, Department of Health Services Administration, School of Public Health,University of Maryland, 3310A School of Public Health Building, College Park, MD 20742-2611, USA. Phone: +1-301-4059053; Fax: +1-301-4052542; Email: jichen@umd.edu.

Rada Dagher, PhD, Department of Health Services Administration, School of Public Health, University of Maryland,3310B School of Public Health Building, College Park, MD, 20742-2611, USA. Phone: +1-301-4051210; Email:rdagher1@umd.edu

Journal of Behavioral Health Services & Research, 2014. 1–12. c) 2014 National Council for Behavioral Health. DOI10.1007/s11414-014-9403-1

Mental Health Care during the Recession

antisocial behavior.3 Meanwhile, economic hardship can also result in perceptions of insecurity andstress, and an increase in the risk of mental disorders4,5 and mental health care utilization.6–9 Onthe other hand, mental health coverage deteriorates during the same time. State and localgovernments are likely to cut back mental health care coverage during the recession budget cuts.The loss of employment-based private health insurance adds another barrier to have mental healthcare. A recent report shows that the annual spending on mental health care by private healthinsurance decreased from 7.0% in 2004–2007 to 2.1% in 2007–2009.10

Mental health care utilization patterns might differ by gender during the economic recession. Ingeneral, the literature shows that females have higher medical care utilization rates than males in avariety of health services (primary care, specialty care, emergency treatment, etc.),11,12 includingmental health care utilization.13 Lower rates of mental health treatment among men compared towomen is a consistent finding in the literature.14,15 This is possibly due to a greater perceivedstigma of seeking mental health care among men in comparison with women and greater abilityamong women than men to identify nonspecific feelings of distress and recognize the presence of amental health problem.16,17 In addition, the Great Economic Recession caused disproportionatelymore job losses for males than for females because more jobs were lost in the construction andmanufacturing sectors than in the service sector.18 Thus, it is likely that males were more likelythan females to encounter barriers to mental health care during the recession.

It has been well documented that African Americans and Latinos have worse access to mentalhealth services than whites.19,20 During the recent economic recession, racial/ethnic minoritiesexperienced more job losses and housing foreclosures, and hence, were exposed to a higherlikelihood of losses in health insurance coverage and reductions in wealth.21–23 Inflation-adjustedmedian wealth fell 66% among Latino households, 53% among African American households, and16% among white households.2 Unemployment rates were also higher among African Americansand Latinos than whites, with 25% of African Americans and Latinos losing their jobs during 2008and 2010, compared to 15% of whites.24,25 Thus, racial and ethnic minorities may haveencountered more access barriers to mental health care during the Great Recession.

This study examines the utilization of two major cost-effective treatments for depressive andanxiety disorders, prescription drug utilization and physician office visits,26–28 during the recenteconomic recession 2007–2009 in the USA. Depression and anxiety are two highly prevalentmental disorders that are often comorbid and cause substantial disability if not treated.29 Moreover,both disorders are associated with increased health care expenditures and high economic costs tosociety.30,31These mental disorders are highly undertreated in the USA due to poor health insurancecoverage and financial barriers.32

This study adds to the literature on the relationship between economic downturns and mentalhealth by examining the different associations of the 2007–2009 economic recession and mentalhealth care utilization by gender and race/ethnicity. The hypotheses are (1) gender disparities in theutilization of mental health care during the recession may have increased and (2) racial/ethnicdisparities in the utilization of mental health care may also have increased during the recession.

Methods

Data

This study uses the nationally representative dataset of Medical Expenditure Panel Survey(MEPS) of 2000–2009.32 The MEPS has several sub-files. The MEPS consolidated file containsdetailed information on patients’ demographics and socioeconomic characteristics. The MEPSmedical condition files collect data on respondents’ chronic diseases and the associated health careutilization for each of these diseases. The medical condition files provide synthesized data fromdifferent MEPS sub-files including drug utilization and physician visits for each primary disease

The Journal of Behavioral Health Services & Research 2014

reported by the respondent. The prescription drugs identified in this study include antidepressants,anti-anxiety medications, and psychotropic medications that are used to treat depressive and anxietydisorders. Physician visits are also calculated if patients visit the physicians to treat depression oranxiety as their primary disorder. Chronic diseases are self-reported by the patients, and then are codedby professional coders to fully specified International Classification of Diseases, 9th Revision ( ICD9)codes. As documented in the MEPS, medical providers and pharmacies are contacted to validate dataon ICD9 codes and services the respondents have used. TheMEPSmedical condition files are linked tothe consolidated files to get comprehensive information on patients’ demographics (e.g., gender, race/ethnicity) and socioeconomic status (e.g. education, income).

This dataset enables the authors to identify patients who were primarily diagnosed withdepressive (ICD9=311) or anxiety (ICD9=300) disorders, and observe the correspondingprescription drug utilization and physician visits specific to depression and anxiety treatmentduring the survey years. The outcome variables are the annual utilization of prescription drugs andphysician visits that treat primary depressive and anxiety disorders.

The analyses include adults aged 18 to 64 years old, who are diagnosed with depressive oranxiety disorders as the primary disorders. The sample of females totals 16,482, including 11,569non-Hispanic whites (whites), 2,943 Latinos, and 1,970 non-Hispanic African Americans (AfricanAmericans), and the sample of males totals to 6,835, including 5,164 whites, 1,068 Latinos, and603 African Americans.

Independent variables

Recession year indicators The objective of this study is to examine the changes in mental health careutilization during the Great Economic Recession 2007–2009. The longitudinal survey years from2000–2009 provide the analysis capacity to observe the trends of utilization during the last decade. It isworth noting that in the past decade, there was another economic recession in 2001 (from March 2001to November 2001) in the USA.33 The duration of the 2001 recession was short, and the consequenceswere relatively mild (e.g. the unemployment rate was 4%–6% during 2001 recession) compared to therecent Great Recession. Nevertheless, it is also interesting to see the changes of utilization by genderand race/ethnicity during the 2001 recession. Hence, the authors consider 2001, 2007, 2008, and 2009as the recession years and construct the interaction terms of each of these recession years with race andethnicity. The interaction terms are included to examine the different utilization patterns among theraces and ethnicities during the recessions. To capture the gender differences, the analyses examinemental health care utilization for females and males separately.

Other covariates The analyses comprise a number of independent variables that are associated withmental health care utilization.34,35 These variables include respondents’ age, marital status (marriedor not), educational attainment (no high school degree, high school degree, college degree,advanced degree), family income (less than 100% federal poverty line (FPL), 100%–200% FPL,more than 200% FPL), health insurance coverage (no health insurance coverage, public healthinsurance, private health insurance), health care access (having a usual source of care), employmentstatus (employed, unemployed), Metropolitan Statistics Area (urban, rural), and US Census Region(North East, Midwest, South, West).

Health outcome measures are controlled as proxies to the severity of mental health status. Thesevariables include self-reported physical health (excellent/very good, good, fair/poor), self-reportedmental health (excellent/very good, good, fair/poor), and the SF short-form 12 (SF12): physicalcomponent summary (PCS) and mental component summary (MCS) scores.36–38 These measuresare considered as valid instruments for measuring health-related quality of life and mental healthstatus, and have been widely adopted in the literature.39

Mental Health Care during the Recession

Analysis

The study first presents the trends of utilization of prescription drugs and physician visits amongpatients with depression and anxiety using nationally representative statistics from 2000–2009.These statistics are calculated and weighted using the sampling weights provided by the MEPS.Authors then show the sample summary statistics by gender and race/ethnicity. Means tests areconducted to compare the racial and ethnic differences in each covariate by gender, with whites asthe reference group. Negative binomial models are used to estimate the association between theeconomic recession and mental health care utilization.40,41 The model specification is as follows:

Number of prescription drugs used

¼ f β0 þ β1Latinoþ β2African Americanþ β3year indicatorþ β4Latino*�

Recession Year Indicatorþ β5African American*Recession Year Indicatorþ β6X Þwhere f() represents the negative binomial function. X includes other demographic andsocioeconomic variables. βs represent the coefficients to be estimated in the model. The abovemodel is estimated separately by gender. The incidence rate ratios (IRRs) are reported from thenegative binomial regressions. The IRRs indicate the estimated incidence ratio relative to itsreference group. The same model specification is used to examine the association of the economicrecessions with physician visits that treat mental disorders.

Finally, based on the negative binomial models, the frequency of prescription drug utilizationand physician visits are estimated by gender and race/ethnicity across the years, adjusted by all theother covariates. All regressions are adjusted for sampling weights provided in the MEPS to ensurethat the results are nationally representative. All statistical analyses are conducted using Stata 12.

Results

Table 1 presents the trends of utilization of prescription drugs and physician visits from 2000 to2009 by gender and race/ethnicity. The prescription drug utilization increased in the recession years2007–2009 among white females, Latinas, and white males. The rates of prescription drugutilization among African American females and males decreased in 2008 and 2009 compared tosurvey years before the Great Recession. African American females had relatively high rates ofprescription drug utilization in 2007 compared to any other survey year. The prescription drugutilization of Latino males was lower in 2007–2009 compared to 2005. The rates of prescriptiondrug utilization were generally lower in 2001 compared to the years preceding or after the 2001economic recession, except among Latino males. The differences between whites versus Latinoswere more pronounced compared to the differences between whites versus African Americans.Racial and ethnic disparities were also more pronounced among females compared to males.

Compared to 2005–2006, statistics show that the utilization of physician visits was relativelyhigher in 2007–2008 among whites and Latinos. African Americans (both males and females) hadlower rates of physician visits during 2007. Trends of physician visits were relatively similar acrossrace and ethnicity. The only racial difference was observed in 2008 and 2001, with AfricanAmericans (both females and males) using significantly fewer physician visits compared to whites.

Table 2 presents the sample summary statistics of patients diagnosed with depressive and anxietydisorders by gender and race/ethnicity. Compared to white females, Latinas and African Americanfemales reported worse physical and mental health, lower education, and family income, and weremore likely to be uninsured. Similar trends were observed among males.

Table 3 presents the results of the negative binomial regressions, treating the count ofprescription drug utilization and physicians visits as the outcome variables separately. Compared towhite females, Latinas and African American females used significantly fewer prescription drugs(IRR=0.75, pG0.001; IRR=0.71, pG0.001), and African American females had significantly fewer

The Journal of Behavioral Health Services & Research 2014

physician visits (IRR=0.71, p=0.01). Compared to white males, Latino males had significantlylower rates of prescription drug utilization (IRR=0.72, pG0.001) and physician visits (IRR=0.72,pG0.05).

Year indicators show that prescription drug utilization of females was stable from 2000–2007,but increased significantly in 2008 (IRRs=1.20, pG0.001) and 2009 (IRRs=1.20, pG0.001).Physician visits among females demonstrated a similar trend. Year indicators are generally notsignificant in the regressions among the male population. Results show that only males hadsignificantly lower physician visits in 2009 (IRR=0.55, pG0.001).

The interaction terms between the recession year indicators and races/ethnicities among femalesshow that compared to white females, African American females used more prescription drugs in2007 (IRR=1.26, pG0.05) and fewer physician visits in 2008 (IRR=0.54, pG0.05). The interactionterms between the recession year indicators and races/ethnicities of males indicate that AfricanAmerican males utilized fewer prescription drugs in 2008 (IRR=0.61, pG0.05), and fewerphysician visits in 2008 (IRR=0.42, pG0.05) and 2001 (IRR=0.28, pG0.001).

Table 1Prescription drug utilization and physician visits among patients with depression and/or anxiety by

gender and race/ethnicity from 2000–2009

Prescription drug utilization

Females Males

Whites Latinos African Americans Whites Latinos African Americans

2000 1.82 1.29* 1.23* 1.82 0.87*** 1.672001 1.83 1.22*** 1.26** 1.57 1.15 1.142002 1.88 1.25*** 1.43* 1.60 0.94*** 1.252003 1.84 1.24*** 1.34** 1.61 1.02** 1.742004 1.82 1.24*** 1.42* 1.71 1.13** 1.512005 1.86 1.43** 1.85 1.68 1.59 1.562006 1.92 1.31*** 1.67 1.65 1.00*** 1.612007 1.95 1.44*** 1.99 1.72 0.82*** 1.132008 2.24 1.57*** 1.38*** 2.07 1.16*** 1.04***2009 2.21 1.73** 1.53*** 2.02 1.23*** 1.42*Physician visits2000 2.72 2.55 1.58 3.32 5.49 3.482001 2.97 2.26 2.15 3.86 2.58 0.87***2002 3.02 2.71 2.09 2.43 2.46 1.32*2003 3.16 2.57 2.68 2.81 2.31 3.512004 2.48 3.37 3.65 2.79 1.95 1.972005 2.49 3.01 3.49 3.74 3.11 2.732006 2.32 3.05 2.74 2.88 2.72 2.672007 2.76 2.03 3.03 2.19 2.90 2.342008 3.91 2.77 1.74** 2.41 3.11 0.87***2009 3.01 3.50 2.87 1.87 2.44 1.36

Estimates are nationally representative by adjusting the sampling weights provided by the MedicalExpenditure Panel Survey***pG0.001; **pG0.01; *pG0.05, the reference groups are the White females/males in each survey year

Mental Health Care during the Recession

Table 2Sample summary statistics of patients with depression and/or anxiety by gender and race/ethnicity

Females Males

Whites LatinosAfricanAmericans Whites Latinos

AfricanAmericans

n=12,639 n=3,207 n=2,227 n=5,679 n=1,173 n=673

Mean Mean Mean Mean Mean Mean

Age18–24 0.08 0.08* 0.07 0.08 0.13*** 0.1025–34 0.16 0.22*** 0.18 0.14 0.19*** 0.1435–44 0.24 0.27** 0.23 0.23 0.25 0.2345–54 0.29 0.27*** 0.32 0.29 0.26 0.3155–64 0.23 0.17*** 0.21* 0.25 0.17*** 0.22*

Married 0.48 0.46*** 0.20*** 0.51 0.47* 0.33***Self-reported health status

Poor/Fair 0.30 0.43*** 0.45*** 0.33 0.38*** 0.45***Good 0.30 0.30 0.29 0.30 0.28 0.28Very good/excellent 0.40 0.28*** 0.26*** 0.37 0.34** 0.27***

Self-reported mental health statusPoor/Fair 0.25 0.31*** 0.37*** 0.29 0.33** 0.40***Good 0.36 0.34** 0.30*** 0.34 0.33 0.29**Very good/excellent 0.39 0.35*** 0.32*** 0.37 0.34 0.31**

SF12-PCS 0.46 0.45** 0.42*** 0.46 0.46 0.43***SF12-MCS 0.41 0.40*** 0.39*** 0.41 0.41 0.41Education

No high school degree 0.20 0.52*** 0.33*** 0.22 0.50*** 0.32***High school degree 0.48 0.32*** 0.48 0.46 0.39*** 0.48College degree 0.14 0.07*** 0.07*** 0.15 0.06*** 0.09***Advanced degree 0.18 0.09*** 0.12*** 0.16 0.05*** 0.11***

Family incomeG100% Federal povertyline (FPL)

0.19 0.33*** 0.42*** 0.16 0.26*** 0.34***

100%–200% FPL 0.18 0.31*** 0.26*** 0.19 0.29*** 0.26***9200% FPL 0.63 0.35*** 0.32*** 0.65 0.44*** 0.40***

Unemployed 0.33 0.46*** 0.48*** 0.30 0.34*** 0.53***Having usual source of care 0.90 0.80*** 0.86*** 0.85 0.72*** 0.83Health insurance

Uninsured 0.10 0.25*** 0.12*** 0.14 0.28*** 0.16Private health insurance 0.69 0.38*** 0.41*** 0.66 0.43*** 0.42***Public health insurance 0.21 0.37*** 0.47*** 0.19 0.29*** 0.41***

Urban 0.76 0.90*** 0.84*** 0.77 0.92*** 0.87***US region

Northeast 0.15 0.17*** 0.14*** 0.16 0.16 0.13*Midwest 0.28 0.08*** 0.21*** 0.27 0.08*** 0.21***South 0.37 0.30*** 0.55*** 0.35 0.29*** 0.53***West 0.21 0.45*** 0.10*** 0.21 0.47*** 0.13***

***pG0.001; **pG0.01; *pG0.05, the reference groups are the White females/males

The Journal of Behavioral Health Services & Research 2014

Table 3 also shows significant associations between other covariates and physician visits andprescription drug utilization for mental disorders. Particularly, age, education, family income,health care access, and insurance coverage were positively associated with mental health careutilization.

Based on the negative binomial regression models, the authors estimate the association betweenthe recession year indicators 2007–2009 and the utilization of prescription drugs and physicianvisits, adjusting for all the other covariates. Figure 1 shows the overall increasing trends inprescription drug utilization during the recent recession by gender and race/ethnicity. Results showthat during the 2007–2009 recession, prescription drug utilization for mental disorders increased by11% among females (increased from 1.91 to 2.12 for white females, 1.44 to 1.60 for Latinas, and1.35 to 1.50 for African American females), and 8%–9% among males (increased from 1.71 to1.85 for white males, 1.24 to 1.35 for Latino males, and 1.29 to 1.40 for African American males),after controlling for all the covariates.

Figure 2 shows the estimated frequency of physician visits, after adjusting for all the covariates.Females and males of all racial and ethnic groups had lower rates of physician visits during therecession. The model estimates that physician visits decreased by 7%–8% among females(decreased from 3.06 to 2.85 for white females, 2.65 to 2.45 for Latinas, and 2.21 to 1.96 forAfrican American females) and decreased by 25% among males (decreased from 3.06 to 2.31 forwhite males, 2.9 to 2.17 for Latino males, and 2.22 to 1.66 for African American males).

Discussion

This study shows mixed evidence of utilization patterns of prescription drugs and physicianvisits by gender. Females had a greater increase in prescription drugs utilization, and males had agreater reduction in physician visits during the Great Recession. The sample size of females whohad been diagnosed with depression or anxiety is almost three times the size of males. The femaleand male populations are similar in the general populations in the USA. The disproportionatelyhigh ratio of females in the sample may indicate gender differences in healthcare-seeking behavior,particularly in mental health care possibly because of the greater stigma of seeking mental healthcare among males and the greater ability of females to identify their mental health problems.16,17

Meanwhile, increased utilization among females during the recession might reflect their worsemental health status and higher demand for mental health care, due to job insecurity or stressduring the economic recession.4,5 Since males are more likely to lose jobs in the recessioncompared to females18, one would expect that males are more likely to experience mental healthproblems and have high demand for mental health care. However, this study shows lowerphysician visits among males during the Great Recession. The following reasons are speculated.Males are more likely to take the financial responsibility of the family, and sacrifice physician visitsto save money. The difference in physician visits can also be explained by gender differences inhealth care-seeking behaviors, particularly for mental health services for the reasons discussedearlier.

Gender differences in health insurance coverage may also contribute to the gender differences inutilization. The results show that the rate of being uninsured is 3%–4% points higher, and the rateof being covered by public health insurance is 2%–8% points lower among males compared tofemales. The lack of health insurance coverage among male populations with depressive andanxiety disorders can be an important barrier for them to access health care, especially during therecession. It is worth noting that there is substantial variation in state Medicaid coverage of mentalhealth care, and the levels of benefits by gender vary widely. For example, Medicaid typicallycovers only low-income pregnant women and their children and women’s coverage usually ends6 weeks after delivery.42 Some states have a “medically needy” category that could include men,but the FPL is usually 50% or less, which excludes many men.43

Mental Health Care during the Recession

Table 3Negative binomial results of differences in prescription drug use and physician visits before and

during the recession by gender and race/ethnicity

Females Males

Prescriptiondrug use

Physicianvisits

Prescriptiondrug use

Physicianvisits

IRR P IRR P IRR P IRR P

Whites Reference Reference Reference ReferenceLatinos 0.75 0.00 1.01 0.89 0.72 0.00 0.72 0.04African Americans 0.71 0.00 0.71 0.01 0.84 0.08 0.87 0.52Age

18–24 Reference Reference Reference Reference25–34 1.37 0.00 1.22 0.11 1.31 0.02 1.32 0.1335–44 1.66 0.00 1.20 0.17 1.45 0.00 1.10 0.5945–54 1.80 0.00 1.21 0.12 1.45 0.00 0.99 0.9755–64 1.81 0.00 1.08 0.53 1.51 0.00 0.92 0.63

Married 0.96 0.17 0.71 0.00 1.08 0.07 0.66 0.00Self-reported health status

Poor/fair Reference Reference Reference ReferenceGood 0.99 0.84 0.94 0.43 1.05 0.38 1.07 0.63Very good/excellent 1.02 0.54 1.19 0.06 1.09 0.18 1.25 0.14

Self-reported mental health statusPoor/fair Reference Reference Reference ReferenceGood 0.83 0.00 0.56 0.00 0.76 0.00 0.56 0.00Very good/excellent 0.69 0.00 0.35 0.00 0.65 0.00 0.33 0.00

SF12-PCS 0.83 0.09 1.11 0.75 0.90 0.60 0.81 0.63SF12-MCS 0.37 0.00 0.05 0.00 0.47 0.00 0.05 0.00Education

No high school degree Reference Reference Reference ReferenceHigh school degree 1.07 0.03 1.17 0.02 1.08 0.14 1.01 0.96College degree 1.16 0.00 2.17 0.00 1.02 0.74 1.16 0.32Advanced degree 1.07 0.07 1.98 0.00 1.13 0.09 1.54 0.02

Family incomeG100% federal poverty line (FPL) Reference Reference Reference Reference100–200% FPL 1.08 0.02 0.94 0.48 1.02 0.82 0.82 0.149200% FPL 1.19 0.00 1.06 0.52 1.06 0.42 1.07 0.60

Unemployed 1.17 0.00 1.45 0.00 1.21 0.00 1.25 0.04Having usual source of care 1.54 0.00 1.37 0.00 1.80 0.00 1.65 0.00Health insurance

Uninsured Reference Reference Reference ReferencePrivate health insurance 1.33 0.00 1.22 0.06 1.28 0.00 1.21 0.19Public health insurance 1.53 0.00 1.63 0.00 1.42 0.00 1.62 0.00

Urban 0.99 0.75 1.54 0.00 1.07 0.11 1.68 0.00US region

North East Reference Reference Reference ReferenceMidwest 1.01 0.83 0.76 0.00 1.04 0.58 0.83 0.18South 1.04 0.24 0.69 0.00 1.10 0.10 0.84 0.26

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The overall trends of the estimates show increased utilization of prescription drugs and decreasedphysician visits during the same time period. Physician visits and prescription drugs are usuallyconsidered as complementary goods, i.e., patients receive prescription drugs from physician visits, andthus, increase the utilization of prescription drugs reflect increased physician visits. The negativerelationship between prescription drug utilization and physician visits during the economic recessionmay indicate that physician visits and prescription drugs are more likely to be substitutes to each other,due to the higher prices and limited budgets people face. Patients need to make choices between thesetwo services, and may end up using the services with lower payments, i.e., prescription drugs. Since thesample in this study includes populations who have been diagnosed with depression and anxietyalready, these patients may likely resort to prescription drug utilization (using refills, for example),without consulting physicians. Future research is needed to estimate the relationship between physicianvisits and prescription drug utilization during the economic recession.

Table 3(continued)

Females Males

Prescriptiondrug use

Physicianvisits

Prescriptiondrug use

Physicianvisits

IRR P IRR P IRR P IRR P

West 0.88 0.00 0.74 0.00 0.87 0.04 0.73 0.02Year indicator

2000 Reference Reference Reference Reference2001 1.02 0.71 1.17 0.17 0.88 0.22 1.05 0.822002 1.02 0.73 1.10 0.37 0.90 0.26 0.83 0.352003 0.99 0.87 1.10 0.44 0.94 0.51 0.88 0.552004 1.02 0.72 1.01 0.91 0.98 0.79 0.79 0.242005 1.05 0.34 1.05 0.67 0.99 0.87 1.12 0.622006 1.05 0.33 0.94 0.60 0.91 0.30 0.89 0.592007 1.07 0.23 0.94 0.68 0.98 0.79 0.66 0.062008 1.20 0.00 1.28 0.05 1.13 0.19 0.74 0.162009 1.20 0.00 1.03 0.83 1.11 0.25 0.55 0.00

Interaction termsLatino * 2001 0.98 0.83 0.80 0.25 1.15 0.39 1.15 0.64Latino * 2007 1.07 0.50 0.70 0.12 0.80 0.19 1.67 0.08Latino * 2008 1.01 0.90 0.69 0.10 0.92 0.66 2.13 0.07Latino * 2009 1.06 0.52 0.86 0.48 1.00 0.98 2.16 0.12African American * 2001 0.88 0.40 0.81 0.45 0.82 0.42 0.28 0.00African American * 2007 1.26 0.04 1.19 0.41 0.75 0.36 0.79 0.51African American * 2008 0.83 0.12 0.54 0.03 0.61 0.03 0.42 0.02African American * 2009 0.90 0.35 1.22 0.49 0.74 0.15 0.71 0.37

Constant 0.89 0.28 4.13 0.00 0.78 0.19 6.54 0.00

The IRRs indicate the estimated incident ratio relative to its reference group. For example, the IRR of thevariable “Latino” in the female regression is 0.75. It indicates that Latinas had a rate of 0.75 times fewerprescription drugs used compared to Whites, holding other variables constant

Mental Health Care during the Recession

This study shows that racial and ethnic minorities might have faced more barriers to access tomental health care during the Great Recession. Both male and female African Americans had areduction in physician visits. African American males also had a more significant reduction inprescription drugs, while African American females had an increase in prescription drugs duringthe recession years of 2007 and 2008. Latinos, on the other hand, faced a modest change in mentalhealth care utilization compared to whites. These findings are consistent with previous literature,which shows that racial and ethnic minorities experienced poorer access to health care than whitesbefore the Great Recession and that access may have worsened during the recession.44 However,

Figure 2Estimated frequency of physician visits among patients with depression and/or anxiety by gender

and race/ethnicity before and during the Great Recession

3.06

2.65

2.1

3.092.9

2.22

2.85

2.45

1.962.31 2.17

1.66

0

0.5

1

1.5

2

2.5

3

3.5

Whites Latinos AfricanAmercians

Whites Latinos AfricanAmercians

Females Males

before 2007

2007-2009

Figure 1Estimated frequency of prescription drug utilization among patients with depression and/or anxiety

by gender and race/ethnicity before and during the Great Recession

1.91

1.441.35

1.71

1.24 1.29

2.12

1.61.5

1.85

1.35 1.4

0

0.5

1

1.5

2

2.5

Whites Latinos AfricanAmercians

Whites Latinos AfricanAmercians

Females Males

before 2007

2007-2009

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the analysis can only identify patients with diagnosed depression and anxiety. Since mentaldisorders are generally under treated and under diagnosed, the racial/ethnic differences may bemore substantial when taking into account mental disorders other than depression and anxiety.

The results also show that compared to private health insurance, having public health insurance,such as Medicaid or other local/state-funded insurance, is associated with higher mental health careuse, particularly physician visits. Recent estimates show a significant reduction in mental healthspending by the private sector during the economic recession.8 More importantly, the annualgrowth rate of out-of-pocket payments on mental health care dropped from 6.7% to 0.2% duringthe same period.10 Although it is likely that patients might have switched from brand name drugsto generics, the substantial reduction in growth rates might also reflect the reduced utilization and/or unaffordability of mental health care under private health insurance coverage.

Factors associated with increased drug utilization and physician visits differed by gender. Thesefindings indicate that strategies to improve treatment adherence may work differently by gender.For example, results show that higher family income is associated with higher prescription drugutilization for females, but not males. In addition, years of schooling are more likely to increaseprescription drug utilization and physician visits for females, but not for males. It is likely that thestrategies of improving treatment adherence by improving health literacy may work better amongfemales. Financial subsidies to improve mental health care access may also work better amongfemales. On the other hand, strategies focusing on reducing the stigma associated with mentalhealth care utilization or accommodating cultural background may work better among males.

This study has several important limitations. First, the association of the economic recessionwith mental health care utilization may have been underestimated. The utilization of mental healthcare is only observed among the patients diagnosed with primary depressive or anxiety disorders.Mental health care utilization is not calculated if the respondents had depressive or anxiety assecondary disorders. Moreover, this study uses 3-digit ICD9 codes to categorize the diseases. Morespecific ICD9 codes can work better to match the mental health condition with mental health careutilization. Second, mental health care utilization is patient self-reported, so there might be recallbias. However, these reports of mental health care utilization have been further validated bypatients’ doctors and pharmacists. Third, this study examines two of the most cost effective andmost common treatments of depression and anxiety. Alternative forms of care, such as hospitalutilization, consultation with friends, looking for religious help, may increase during the recession.The authors are also not able to specify the location of the physician office. It is likely that thevisits increased at the federally qualified health centers and free clinics during the recession.Fourth, given the data limitation, this study is not able to tell the generic/brand name status of theprescription drug. It is likely that increased prescription drug utilization is due to switching frombrand name drugs to generics. Fourth, to capture the severity of mental disorders, the authorscontrol for four mental and physical health measures in the analyses: self-reported mental healthstatus, self-reported physical health status, SF12-MCS score, and SF12-PCS score. But it is likelythat the severity of the mental disorders or other comorbidities associated with mental disorderswas not fully captured. Fifth, given the MEPS survey design, the authors are not able to conduct alongitudinal analysis. Thus, it is difficult to derive the causal relationship of the economic recessionand mental health care use. It is likely that the trends of prescription drug use and physician visitsduring 2007–2009 were due to other unobserved factors, such as the policy variation by geographicarea. It will be interesting to see the impact of the economic recession on long term mental healthoutcomes.

Implications for Behavioral Health

The Affordable Care Act (ACA) will improve mental health care coverage through theexpansion of Medicaid or increased provision of private health insurance, and function as a safety

Mental Health Care during the Recession

net for people with mental health disorders. Implementation of the health insurance exchanges ormarketplace will provide opportunities for people who have no employer-sponsored insurance andearn above the Medicaid eligibility line to purchase health insurance at more affordable rates thanthose charged by the private health insurance market. States that plan to expand Medicaid willmake mental health care coverage available to both males and females if they meet eligibilitycriteria. Hence, the gender differences potentially can be reduced by the ACA. However, not everystate will expand Medicaid eligibility, and the states that are not planning to expand Medicaidtypically have higher proportions of poor and uninsured adults (e.g., in the Southeast of the USA).

In addition to the ACA, the increased availability of generic psychiatric drugs45 and the recentlyimplemented law of the Mental Health Parity and Addiction Equity Act46 have the potential tofacilitate access to prescription drugs. The integrated care of mental health treatment advocated inrecent years has been considered as one of the core clinical features to improve mental health.47

Under the integrated care model, patients will be more likely to receive effective treatment formental disorders.48 Future research should examine the impact of these policies on mental healthcare and should separately examine mental health care utilization by gender and race/ethnicity.

Conflict of Interest The authors declare no conflict of interest.

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