Lack of Accessibility Offered in Mental Health and Substance Abuse Services in Boston
by Melissa Rosales, Gabriella Mrozowski, Vivi Bonomie and Maya Huter
Deaths related to opioids in the United States continue to permeate the media. This year alone over 70,000 people have suffered an opioid-related death in America. The impact this epidemic has had on Massachusetts is undeniable.
The data shows that states like California and Texas suffer from the highest number of opioid-related deaths in the country. However, when the numbers are made proportional to the states’ population, they tell a different story. Although California has the highest number of deaths by opioids, just over 39.5 million, this accounts for only 0.6 percent of the state’s population. Similarly, opioid-related deaths in Texas account for 0.5 percent of the population. Massachusetts, however, has a lower population, so the 6.9 million opioid-related deaths in the state account for 1.5 percent of the population, three times the amount it does in Texas.
By making the numerical data proportional to the state’s population, it is proven that states such as Massachusetts are suffering from a deeper opioid crisis than both California and Texas. This puts into context the rest of the methods for this story that analyze opioid-related deaths and treatment in the city of Boston.
These methods can be found here.
Access to mental health and substance abuse services are important in treating the opioid epidemic in Boston. Co-occurring disorders, several mental illnesses occurring simultaneously, are more common for individuals with substance use disorder.
According to the National Institute on Drug Abuse, individuals who develop a mental illness may be more vulnerable to substance abuse because of the associated changes in brain activity. The changes enhance the rewarding effects, reduce awareness of negative effects, or alleviate the unpleasant symptoms of the mental disorder or the side effects of mental health medication.
Dr. Mark Eisenberg, internal medicine physician who also treats patients with substance abuse disorder at Massachusetts General Hospital Charlestown said patients are less likely to follow through with substance use treatment if they have to set up different appointments or go to different clinics for mental health treatment.
Based on data collected from the Department of Mental Health (DMH), Department of Public Health (DPH) and Bureau of Substance Abuse Services (BSAS), there are more clinics that offer mental health services than substance use disorder services in Boston. Only 6.3% of 145 clinics did not offer mental health services, while 32% did not offer substance abuse treatment services.
“If you aren't addressing both things then one will overwhelm the other,” Eisenberg said. “If you're just treating someone with substance use disorder but their mental illnesses aren't addressed, that mental illness may lead to continued compulsion to use drugs and do things unsafely to self treat the untreated mental health disorder.”
While mental illnesses can contribute to developing a substance use disorder, National Institute on Drug Abuse said substance use and addiction can also lead to the development of mental illnesses. Drug use may change the brain structure and function and therefore stimulate a susceptibility to develop a mental illness.
The neighborhoods that have the most clinics that offer mental health and/or substance abuse services are Dorchester, Downtown, and Roxbury. There are 88 clinics (32.7% of all clinics) in Dorchester, 70 clinics (26.02% of all clinics) in Downtown, and 46 clinics (17% of all clinics) in Roxbury. Hyde Park and North End only have two clinics each.
In order to assess whether the quality and accessibility of mental health care services was linked to the demographic of the neighborhood where the clinic was located, the per capita income of each Boston neighborhood was evaluated. The results showed that the neighborhoods with the highest per capita income were Back Bay at an average income of $88,419.77 per household, and the North End at $68,956.94 per household. Back Bay is 85.12% white and the North End is 90.88% white. Both of those neighborhoods are in the middle of the city of Boston, so they are in a more central location than other neighborhoods that are further out.
The lowest per capita incomes were Roxbury at $16,693.54 and Mattapan at $20,282.94. Roxbury has a total population of 33,182, of which only 8.1% are white. 56.9% are Black or African, 2.9% are Asian, and 27.6% are Latino. In Mattapan, 35.6% of the population is foreign born 36,299. 82% are African American and only 11% are white.
Based on these demographics, and the fact that Back Bay and the North End are more centralized, it seems as though there would be more accessibility to healthcare services such as substance abuse and mental health treatment. However, this was not the case. There were far more clinics in low income areas than in Back Bay or the North End.
“I think there is some correlation with unemployment, poor housing, lack of education. There is probably some deliberate placement of facilities in these neighborhoods because of the ‘not in my neighborhood," said Dr. Eisenberg. "Back Bay Homeowners Associations probably are more effective in keeping a halfway house or sober house a treatment center around the neighborhoods in Roxbury or Mattapan. Communities of color always talk about their neighborhoods are dumping grounds for services and liquor stores and cigarette vendors and halfway houses and treatment centers.”
The most clinics in total were located in Dorchester, with 88 total clinics. Of those 88 clinics, there were 176 mental health clinics and 128 alcohol and substance abuse services. The per capita income of Dorchester was $22,746.59, which was the 5th lowest out of the 14 neighborhoods measured. There were 46 clinics in Roxbury and West Roxbury. Of those 46 clinics, 17 offered alcohol and substance abuse treatment, and 21 offered mental health treatment (some offered both at the same clinic). There were four clinics in Mattapan. Two of them offered both substance/alcohol abuse treatment and mental health treatment, one offered just substance/alcohol abuse treatment, and one offered just mental health treatment. There were only six clinics in Back Bay and two in the North End.
Based on this data, it is evident that income and the wealth of a neighborhood does not correlate to the accessibility of mental health and substance abuse treatment. This data shows that it is actually the neighborhoods with the lower per-capita incomes that have the most mental health care clinics for residents. This is likely due to the fact that there are higher numbers of residents dealing with substance abuse and mental health issues in areas with lower incomes, so the need for clinics is higher.
A lack of multilingual options proved to be another barrier for those seeking treatment in Boston. Over 35 percent of city residents spoke a language other than English at home, according to a 2012 New Bostonian Demographic Report. Of those residents, over 15 percent spoke Spanish and about 4 percent spoke Chinese.
Boston’s significant multilingual population warrants clinics within the city to offer services catered to such demographics. However, Massachusetts health care providers identified a lack of providers qualified to treat patients who do not speak English as the biggest barrier to care, according to a 2019 Massachusetts Health Policy Commission report.
The state’s only visible attempt at tackling this issue is the Multicultural Mental Health Resource Directory from the DMH. The document lists over 50 clinics in the Metro Boston area that provide culturally and linguistically appropriate care, according to the DMH’s website.
As the only comprehensive directory of multicultural and multilingual clinics, the following clinic statistics were derived from this list alone. The possibility exists of excluding some Boston clinics offering other languages and cultural services. But their disclusion from the directory shows a lack of state standard in their care.
Of the 145 health care clinics identified in Boston, only 25 offered services in Spanish. Neighborhoods like Downtown Crossing as well as Roxbury had the most density of Spanish-inclusive clinics, while Dorchester and Mattapan severely lacked these services. For Mandarin and Cantonese, the number decreased to nine clinics within the city. The highest concentration of Chinese-inclusive clinics were in Beacon Hill and South End, both of which housed two of such clinics.
Other languages represented by health care clinics around Boston included Haitian Creole, Cape Verdean Creole, Arabic, American Sign Language, French, German and Portugese. These 24 clinics were dispersed evenly across neighborhoods, expect for Dorchester and Mattapan.
It was extremely difficult to collect data on the clinics and services offered in Boston because clinics can be licensed by either the DMH, DPH, or BSAS. Each department covers different responsibilities.
Katherine Saunders, Manager of Data Analysis & Integrity of DPH said, “DPH focuses on hospitals, nursing homes, and traditional clinic services. DMH really focuses on mental health services. Bureau of Substance Abuse Services lists sites for methadone clinics and treatment centers not licensed by DPH.”
Since there is no universal resource, patients have limited knowledge on the availability of clinics in their area. For example, a patient looking through the DPH’s resources may not be aware there are other clinics in their area that are licensed by DMH and BSAS instead. Because the information on available services were spread out in multiple different department documents, the data collectors believe they may have even missed other clinics. Lack of complete information is another lack of accessibility. Patients may miss clinics that work better for their treatment, insurance, budget, and location.
To improve the lack of accessibility offered in mental health and substance abuse services, the researchers suggest that the Boston government provide a single complete resource that includes clinics licensed by DPH, DMH, and BSAS. There should also be more clinics that offer substance abuse services and access to clinicians who speak other languages.