The Association of Racial and Ethnic Social Networks with Mental Health Service Utilization Across Minority Groups in the USA

  • Sung W. ChoiEmail author
  • Christal Ramos
  • Kyungha Kim
  • Shahinshah Faisal Azim


Though they have comparable prevalence of mental illness, American racial and ethnic minorities are less likely to receive mental health services than white Americans. Minorities are often part of racial and ethnic social networks, which may affect mental health service utilization in two ways. While these networks can encourage service utilization by working as a channel of knowledge spillover and social support, they can also discourage utilization by stigmatizing mental illness. This study examined the association of racial and ethnic social networks with mental health service utilization and depression diagnosis in the USA. Using the 2012 Behavioral Risk Factor Surveillance System (BRFSS) data, a multilevel mixed-effect generalized linear model was adopted, controlling for predisposing, need, and enabling factors of mental health service utilization. The association of racial and ethnic social networks with mental health service utilization and depression diagnosis was significant and negative among African Americans. Despite having a comparable number of bad mental health days, the association was insignificant among Hispanic, Asian, and non-Hispanic white respondents. An African American living in a county where all residents were African American was less likely to utilize mental health services by 84.3–86.8% and less likely to be diagnosed with depression by 76.0–84.8% than an African American living in a county where no residents were African American. These results suggest racial and ethnic social networks can discourage mental health service utilization and should be engaged in efforts to improve mental health, particularly among African American communities in the USA.


Mental health service utilization Depression diagnosis Social network Racial and ethnic minorities 


Compliance with Ethical Standards

Conflict of Interest

Sung W. Choi, Christal Ramos, Kyungha Kim, and Shahinshah Faisal Azim declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Ethical Approval Retrospective Studies

Although retrospective studies are conducted on already available data or biological material (for which formal consent may not be needed or is difficult to obtain), ethical approval may be required dependent on the law and the national ethical guidelines of a country. Authors should check with their institution to make sure they are complying with the specific requirements of their country.


  1. 1.
    Abe-Kim J, Takeuchi DT, Hong S, Zane N, Sue S, Spencer MS, et al. Use of mental health-related services among immigrant and US-born Asian Americans: results from the National Latino and Asian American Study. Am J Public Health. 2007;97(1):91–8.Google Scholar
  2. 2.
    Aizer A, Currie J. Networks or neighborhoods? Correlations in the use of publicly-funded maternity care in California. J Public Econ. 2004;88(12):2573–85.Google Scholar
  3. 3.
    Albert M, Becker T, McCrone P, Thomicroft G. Social networks and mental health service utilisation—a literature review. Int J Soc Psychiatry. 1998;44(4):248–66.Google Scholar
  4. 4.
    Alegria M, Canino G, Rios R. Inequalities in use of specialty mental health services among Latinos, African Americans, and non-Latino whites. Year Book of Psychiatry & Applied Mental Health. 2004;2004(1):184–5.Google Scholar
  5. 5.
    Alegria M, Mulvaney-Day N, Torres M, Polo A, Cao Z, Canino G. Prevalence of psychiatric disorders across Latino subgroups in the United States. Am J Public Health. 2007;97(1):68–75.Google Scholar
  6. 6.
    Andersen R. A behavioral model of families' use of health services. Chicago, Illinois: University of Chicago; 1968.Google Scholar
  7. 7.
    Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav. 1995;36(March):1–10.Google Scholar
  8. 8.
    Anglin DM, Alberti PM, Link BG, Phelan JC. Racial differences in beliefs about the effectiveness and necessity of mental health treatment. Am J Community Psychol. 2008;42(1–2):17–24.Google Scholar
  9. 9.
    Armstrong K, Ravenell KL, McMurphy S, Putt M. Racial/ethnic differences in physician distrust in the United States. Am J Public Health. 2007;97(7):1283–9.Google Scholar
  10. 10.
    Bailey RK, Blackmon HL, Stevens FL. Major depressive disorder in the African American population: meeting the challenges of stigma, misdiagnosis, and treatment disparities. J Natl Med Assoc. 2009;101(11):1084–9.Google Scholar
  11. 11.
    Behavioral Risk Factor Surveillance System. (2012). Behavioral Risk Factor Surveillance System Questionnaire. Retrieved from Accessed 25 March 2019.
  12. 12.
    Berger M, Wagner TH, Baker LC. Internet use and stigmatized illness. Soc Sci Med. 2005;61(8):1821–7.Google Scholar
  13. 13.
    Bertrand M, Luttmer EF, Mullainathan S. Network effects and welfare cultures. Q J Econ. 2000;115(3):1019–55.Google Scholar
  14. 14.
    Blank MB, Mahmood M, Fox JC, Guterbock T. Alternative mental health services: the role of the Black church in the south. Am J Public Health. 2002;92(10):1668–72.Google Scholar
  15. 15.
    Borjas GJ. Self-selection and the earnings of immigrants. Am Econ Rev. 1987:531–53.Google Scholar
  16. 16.
    Budhwani H, Hearld KR, Chavez-Yenter D. Depression in racial and ethnic minorities: the impact of nativity and discrimination. J Racial Ethn Health Disparities. 2015;2(1):34–42.Google Scholar
  17. 17.
    Bussing R, Meyer J, Zima BT, Mason DM, Gary FA, Garvan CW. Childhood ADHD symptoms: association with parental social networks and mental health service use during adolescence. Int J Environ Res Public Health. 2015;12(9):11893–909.Google Scholar
  18. 18.
    Center for Disease Control and Prevention. (2013). Mental illness: mental health information. Retrieved from Accessed 25 March 2019.
  19. 19.
    Center for Disease Control and Prevention. (2015). The Behavioral Risk Factor Surveillance System. Retrieved from Accessed 25 March 2019.
  20. 20.
    Chiswick BR, Miller PW. Ethnic networks and language proficiency among immigrants. J Popul Econ. 1996;9(1):19–35.Google Scholar
  21. 21.
    Conner KO, Copeland VC, Grote NK, Rosen D, Albert S, McMurray ML, et al. Barriers to treatment and culturally endorsed coping strategies among depressed African-American older adults. Aging Ment Health. 2010;14(8):971–83.Google Scholar
  22. 22.
    Cook BL, Zuvekas SH, Carson N, Wayne GF, Vesper A, McGuire TG. Assessing racial/ethnic disparities in treatment across episodes of mental health care. Health Serv Res. 2014;49(1):206–29.Google Scholar
  23. 23.
    Corrigan PW, Penn DL. Lessons from social psychology on discrediting psychiatric stigma. Am Psychol. 1999;54(9):765–76.Google Scholar
  24. 24.
    Cruz M, Pincus HA, Harman J, Reynolds CF III, Post EP. Barriers to care-seeking for depressed African Americans. The International Journal of Psychiatry in Medicine. 2008;38(1):71–80.Google Scholar
  25. 25.
    Das AK, Olfson M, McCurtis HL, Weissman MM. Depression in African Americans: breaking barriers to detection and treatment: community-based studies tend to ignore high-risk groups of African Americans. J Fam Pract. 2006;55(1):30–40.Google Scholar
  26. 26.
    Deri C. Social networks and health service utilization. J Health Econ. 2005;24(6):1076–107.Google Scholar
  27. 27.
    Dubay L, Kenney GM. Health care access and use among low-income children: who fares best? Health Aff. 2001;20(1):112–21.Google Scholar
  28. 28.
    Downs MF, Eisenberg D. Help seeking and treatment use among suicidal college students. J Am Coll Heal. 2012;60(2):104–14.Google Scholar
  29. 29.
    Evans WN, Oates WE, Schwab RM. Measuring peer group effects: a study of teenage behavior. J Polit Econ. 1992;100(5):966–91.Google Scholar
  30. 30.
    Frerichs RR, Aneshensel CS, Yokopenic PA, Clark VA. Physical health and depression: an epidemiologic survey. Prev Med. 1982;11(6):639–46.Google Scholar
  31. 31.
    Gaskin DJ, Dinwiddie GY, Chan KS, McCleary R. Residential segregation and disparities in health care services utilization. Med Care Res Rev. 2012;69(2):158–75.Google Scholar
  32. 32.
    Gonzalez A, Miller CT, Solomon SE, Bunn JY, Cassidy DG. Size matters: community size, HIV stigma, & gender differences. AIDS Behav. 2009;13(6):1205–12.Google Scholar
  33. 33.
    Han M, Pong H. Mental health help-seeking behaviors among Asian American community college students: the effect of stigma, cultural barriers, and acculturation. J Coll Stud Dev. 2015;56(1):1–14.Google Scholar
  34. 34.
    Hansen MC, Fuentes D, Aranda MP. Re-engagement into care: the role of social support on service use for recurrent episodes of mental health distress among primary care patients. The journal of behavioral health services & research. 2018;45(1):90–104.Google Scholar
  35. 35.
    Hedeker D. A mixed-effects multinomial logistic regression model. Stat Med. 2003;22(9):1433–46.Google Scholar
  36. 36.
    Iceland J, Goyette KA, Nelson KA, Chan C. Racial and ethnic residential segregation and household structure: a research note. Soc Sci Res. 2010;39(1):39–47.Google Scholar
  37. 37.
    Kim G, Jang Y, Chiriboga DA, Ma GX, Schonfeld L. Factors associated with mental health service use in Latino and Asian immigrant elders. Aging Ment Health. 2010;14(5):535–42.Google Scholar
  38. 38.
    Lee S, Juon HS, Martinez G, Hsu CE, Robinson ES, Bawa J, et al. Model minority at risk: expressed needs of mental health by Asian American young adults. J Community Health. 2009;34(2):144–52.Google Scholar
  39. 39.
    Lindstrom DP. Economic opportunity in Mexico and return migration from the United States. Demography. 1996;33(3):357–74.Google Scholar
  40. 40.
    Llena-Nozal A. The effect of work status and working conditions on mental health in four OECD countries. Natl Inst Econ Rev. 2009;209(1):72–87.Google Scholar
  41. 41.
    Mackenzie CS, Gekoski WL, Knox VJ. Age, gender, and the underutilization of mental health services: the influence of help-seeking attitudes. Aging Ment Health. 2006;10(6):574–82.Google Scholar
  42. 42.
    Malhotra NK. A comparison of the predictive validity of procedures for analyzing binary data. J Bus Econ Stat. 1983;1(4):326–36.Google Scholar
  43. 43.
    Marin H, Escobar JI, Vega WA. Mental illness in Hispanics: a review of the literature. Focus. 2006;4(1):23–37.Google Scholar
  44. 44.
    Masuda A, Anderson PL, Edmonds J. Help-seeking attitudes, mental health stigma, and self-concealment among African American college students. J Black Stud. 2012;43(7):773–86.Google Scholar
  45. 45.
    Maulik PK, Eaton WW, Bradshaw CP. The role of social network and support in mental health service use: findings from the Baltimore ECA study. Psychiatric Services. 2009;60(9):1222–9.Google Scholar
  46. 46.
    Moulton BR. An illustration of a pitfall in estimating the effects of aggregate variables on micro units. Rev Econ Stat. 1990;72:334–8.Google Scholar
  47. 47.
    Munshi K. Networks in the modern economy: Mexican migrants in the US labor market. Q J Econ. 2003;118(2):549–99.Google Scholar
  48. 48.
    Murphy JM, Monson RR, Olivier DC, Sobol AM, Leighton AH. Affective disorders and mortality: a general population study. Arch Gen Psychiatry. 1987;44(5):473–80.Google Scholar
  49. 49.
    National Institute of Mental Health. (2017). Statistics: mental illness. Retrieved March 26, 2018, from Accessed 25 March 2019.
  50. 50.
    Nelder JA, Wedderburn RW. Generalized linear models. J R Stat Soc: Ser A (Gen). 1972;135(3):370–84.Google Scholar
  51. 51.
    Pachter LM, Caldwell CH, Jackson JS, Bernstein BA. Discrimination and mental health in a representative sample of African-American and Afro-Caribbean youth. J Racial Ethn Health Disparities. 2018;5(4):831–7.Google Scholar
  52. 52.
    Pinquart M, Duberstein PR. Depression and cancer mortality: a meta-analysis. Psychol Med. 2010;40(11):1797–810.Google Scholar
  53. 53.
    Primo DM, Jacobsmeier ML, Milyo J. Estimating the impact of state policies and institutions with mixed-level data. State Politics & Policy Quarterly. 2007;7(4):446–59.Google Scholar
  54. 54.
    Probst JC, Laditka SB, Moore CG, Harun N, Powell MP. Race and ethnicity differences in reporting of depressive symptoms. Adm Policy Ment Health Ment Health Serv Res. 2007;34(6):519–29.Google Scholar
  55. 55.
    Sclar DA, Robison LM, Skaer TL. Ethnicity/race and the diagnosis of depression and use of antidepressants by adults in the United States. Int Clin Psychopharmacol. 2008;23(2):106–9.Google Scholar
  56. 56.
    Shao Z, Richie WD, Bailey RK. Racial and ethnic disparity in major depressive disorder. J Racial Ethn Health Disparities. 2016;3(4):692–705.Google Scholar
  57. 57.
    Shim RS, Compton MT, Rust G, Druss BG, Kaslow NJ. Race-ethnicity as a predictor of attitudes toward mental health treatment seeking. Psychiatr Serv. 2009;60(10):1336–41.Google Scholar
  58. 58.
    Shim RS, Ye J, Baltrus P, Fry-Johnson Y, Daniels E, Rust G. Racial/ethnic disparities, social support, and depression: examining a social determinant of mental health. Ethnicity & disease. 2012;22(1):15–20.Google Scholar
  59. 59.
    Spoont MR, Nelson DB, Murdoch M, Rector T, Sayer NA, Nugent S, et al. Impact of treatment beliefs and social network encouragement on initiation of care by VA service users with PTSD. Psychiatr Serv. 2014;65(5):654–62.Google Scholar
  60. 60.
    Stevens GD, Seid M, Halfon N. Enrolling vulnerable, uninsured but eligible children in public health insurance: association with health status and primary care access. Pediatrics. 2006;117(4):e751–9.Google Scholar
  61. 61.
    Sussman LK, Robins LN, Earls F. Treatment-seeking for depression by black and white Americans. Soc Sci Med. 1987;24:187–96.Google Scholar
  62. 62.
    Thompson MS, Peebles-Wilkins W. The impact of formal, informal, and societal support networks on the psychological well-being of black adolescent mothers. Soc Work. 1992;37(4):322–8.Google Scholar
  63. 63.
    Tucker JS, Wenzel SL, Golinelli D, Zhou A, Green HD. Predictors of substance abuse treatment need and receipt among homeless women. J Subst Abus Treat. 2010;40(3):287–94.Google Scholar
  64. 64.
    Vaillant GE. Natural history of male psychologic health: effects of mental health on physical health. N Engl J Med. 1979;301(23):1249–54.Google Scholar
  65. 65.
    Välimäki M, Anttila K, Anttila M, Lahti M. Web-based interventions supporting adolescents and young people with depressive symptoms: systematic review and meta-analysis. JMIR mHealth and uHealth. 2017;5(12):e180.Google Scholar
  66. 66.
    Vogel DL, Wade NG, Wester SR, Larson L, Hackler AH. Seeking help from a mental health professional: the influence of one's social network. J Clin Psychol. 2007;63(3):233–45.Google Scholar
  67. 67.
    Wahl OF, Harman CR. Family views of stigma. Schizophr Bull. 1989;15:131–9.Google Scholar
  68. 68.
    Ward EC, Clark LO, Heidrich S. African American women’s beliefs, coping behaviors, and barriers to seeking mental health services. Qual Health Res. 2009;19(11):1589–601.Google Scholar
  69. 69.
    Wasserman S, Faust K. Social network analysis: methods and applications (Vol. 8). Cambridge: Cambridge University Press; 1994.Google Scholar
  70. 70.
    Weaver AJ, Flannelly KJ, Flannelly LT, Oppenheimer JE. Collaboration between clergy and mental health professionals: a review of professional health care journals from 1980 through 1999. Couns Values. 2003;47(3):162–71.Google Scholar
  71. 71.
    Williams, D. R., & Collins, C. (2001). Racial residential segregation: a fundamental cause of racial disparities in health. Public health reports, 2001;116(5):404.Google Scholar
  72. 72.
    Wulsin LR, Evans JC, Vasan RS, Murabito JM, Kelly-Hayes M, Benjamin EJ. Depressive symptoms, coronary heart disease, and overall mortality in the Framingham Heart Study. Psychosom Med. 2005;67(5):697–702.Google Scholar
  73. 73.
    Wulsin LR, Vaillant GE, Wells VE. A systematic review of the mortality of depression. Psychosom Med. 1999;61(1):6–17.Google Scholar
  74. 74.
    Yang JA, Garis J, Jackson C, McClure R. Providing psychotherapy to older adults in home: benefits, challenges, and decision-making guidelines. Clin Gerontol. 2009;32(4):333–46.Google Scholar
  75. 75.
    Zhang X, Norris SL, Gregg EW, Cheng YJ, Beckles G, Kahn HS. Depressive symptoms and mortality among persons with and without diabetes. Am J Epidemiol. 2005;161(7):652–60.Google Scholar

Copyright information

© W. Montague Cobb-NMA Health Institute 2019

Authors and Affiliations

  1. 1.School of Public AffairsThe Pennsylvania State University, HarrisburgMiddletownUSA
  2. 2.Health Policy CenterThe Urban InstituteWashingtonUSA
  3. 3.College of MedicineThe Pennsylvania State University, HersheyHersheyUSA

Personalised recommendations