The dominant model of mental health care in the United States is individual therapy and pharmacological treatment provided by highly trained mental health professionals. However, health care professionals have been prompted to shift their conceptualization of care from a focus on the individual to structural factors (e.g., inequalities in wealth, education, and neighborhood conditions) linked to mental health outcome disparities (1). For example, the time lag between seeking mental health services and actually receiving care is compounded for many people of color, who are more likely than White people to have severe and persistent mental health conditions yet are less likely to access high-quality care (2). This is due in part to cultural mistrust (3), racism and discrimination from medical establishments (4), historical traumas and oppression (5), and underinsurance (6). Research consistently demonstrates that Medicaid beneficiaries who are Black, Hispanic, American Indian, and Alaska Native experience, on average, poorer outcomes and more barriers to care compared to White beneficiaries (7). Given the evidence that the quality of mental health care for marginalized individuals has not meaningfully improved in the past 20 years (6), it is imperative that we, as a field, answer the long-standing calls for a paradigm shift to make mental health care more equitable.

Why a Public Health Approach Is Needed to Change the Tide

Efforts toward community-based mental health services increased in the early 1960s with the passing of the Community Mental Health Act and the creation of Medicaid (8), which contributed many advancements in our current model, such as the prioritization of interdisciplinary team-based approaches and evidence-based care (9). However, significant discrepancies in the accessibility and effectiveness of community-based mental health care have persisted, in part as a result of inadequate funding (10), high costs of effective services, insufficient insurance payment for providers (9), and the severe lag in translation from research to clinical practice (11).

Community-based mental health services are important for reducing inequities in mental health outcomes. Yet it is unlikely that place-based clinical services alone will reduce inequities anytime soon, largely because of the influence of social determinants of health, a shortage of workers in behavioral health professions, and the maldistribution and lack of affordability of professional therapists and medication prescribers in the workforce (12). Nonetheless, there are factors that are modifiable now, such as the low rate of psychiatrists participating in Medicaid (13), which might be increased through Medicaid payment reforms that raise rates to be comparable to Medicare and private insurance (14). Virtual delivery has also reduced disparities in access to mental health care (15). And beyond in-person or virtual services, there is also widespread recognition that interpersonal, institutional, community, and policy interventions have a powerful role in influencing mental health (16). Thus, the mental health field has a lot to learn from public health models, which reach more of the nation’s population through the provision of resources that are not only more affordable and accessible but also are multilevel (17).

The “Health Impact in 5 Years” (HI-5) initiative is one such framework (18) that emphasizes the importance of community approaches to improve health and exemplifies how investing in these approaches could serve to reduce inequities in communities of color. The HI-5 highlights nonclinical community-level approaches with evidence of positive health impacts within 5 years as well as cost-effectiveness within the lifetime of the population. The HI-5 pyramid published by the Centers for Disease Control and Prevention (CDC) (Figure 1) (18) illustrates five tiers of public health interventions. The bottom two tiers—“Social Determinants of Health” and “Changing the Context” (i.e., “making the healthy choice the easy choice”)—are wider and thus reflect approaches with the greatest potential for widespread population impact.

FIGURE 1. The CDC’s “Health Impact in 5 Years” frameworka

aReproduced with permission from the Centers for Disease Control and Prevention (CDC). Source: The CDC Health Impact in 5 Years, Office of the Associate Director for Policy and Strategy, 2018 (www.cdc.gov/hi5).

In this review, we present interventions that have sound evidence of improving mental health (e.g., decreasing or preventing clinical symptoms) or mental health–related outcomes (e.g., increasing quality of life or mental health literacy) among people of color in the United States within 5 years by addressing social determinants of health or changing the context so as to make the healthy choice the easy choice. In Tables 1–3, we describe the interventions selected and summarize evidence of their impact on mental health and mental health–related outcomes. This is not an exhaustive list, but these interventions serve as illustrative examples of possible investments. Similar to the CDC’s process of developing the HI-5 (18), we searched the Community Guide for interventions listed as “Recommended,” and searched the Robert Wood Johnson Foundation County Health Rankings and Roadmaps for interventions listed as “scientifically supported.” We also used search engines (e.g., PubMed, PsycInfo) to identify programs that met our criteria. In selecting the programs, we aimed to identify roughly four per age group—youths, adults, and older adults—so as to cover the lifespan. We also tried to select interventions that represent the different social determinants of health (e.g., income, housing, employment, nutrition) and reflect multiple ways of changing the context (e.g., policies that make it easier to save money for college, parks nearby that make it easier to exercise or socialize, integrated mental-physical health programs that make it easier to prevent disability).

TABLE 1. Children and adolescents: summary of included studies

Intervention Description Study Design and Study N Mental Health and Mental Health-Related Outcomes
1. Universal school meal programs State and federal government-funded programs that provide free meals to all students in public schools K-12. Implemented in Maine, California, and Massachusetts Longitudinal interview assessments with students (N=97) in 4th–6th grade and their parents, before and 6 months after the start of a universal free breakfast program in three Boston Public Schools (23) Increased daily nutrient intake was associated with improvements in psychosocial functioning, as measured by the Pediatric Symptom Checklist
Longitudinal (N=133) and cross-sectional (N=1,627) study of children in public schools (22) Reductions in hyperactivity, anxiety, and depression symptoms
2. Child Development Accounts (CDAs), also called Child Savings Accounts (CSAs) Savings accounts with public and/or private funding, often started at birth. The individual can begin to withdraw funds at age 18 for qualified expenses (e.g., education or business) Example: Maine has a universal, automatic program with participation of 100% of newborns in the state Experimental study with adolescents (N=267) randomly assigned to the intervention or control group (32) Improved mental health functioning compared with the control condition
Randomized controlled trial where children and their caregiver(s) were assigned to CDAs built on the existing Oklahoma 529 College Savings Plan (N=1,358) or a control group (N=1,346) and followed up after 4 years (31, 34) Enhanced socioemotional development outcomes; decrease in mothers’ depression symptoms compared with the control group; greater impact among families with lower income or lower education
3. Comprehensive Behavioral Health Model, Boston Public Schools Tiered model of mental health prevention and intervention currently in 68 Boston public schools (39). Tier I (prevention, for all students) includes teacher and parent consultation, professional development, universal socioemotional learning curriculum, and universal screening. Tier II (targeted, for some students) includes small group intervention and classroom managements. Tier III (intensive, for a few students) includes testing, counseling, and crisis work Longitudinal study of 1,200 students at 14 participating elementary schools (K-5) over a 3-year period (40); universal screening data were collected in Fall 2013, 2014, and 2015 and included the teacher-reported Behavior Intervention Monitoring Assessment System (BIMAS-2) Students with “some risk” or “high risk” on the BIMAS-2 screener experienced clinically meaningful improvements on the following BIMAS-2 scales: conduct, negative affect, cognitive attention, and social functioning; gains in year 1 were sustained into year 2, and no negative effects were observed for students with normative social, emotional, and behavioral health
4. Community-based interventions delivered by paraprofessionals in after-school recreational programs Workforce support: a model of mental health consultation, training, and support to enhance benefits of publicly funded recreational after-school programs in communities of concentrated poverty Randomized controlled trial of three after-school sites (staff, N=15; children, N=89) and three demographically matched comparison sites (staff, N=12; children, N=38) aiming to assess the feasibility and impact of the workforce support intervention on program quality and children’s psychosocial outcomes (42) Modest improvements in children’s social and behavioral functioning compared with the demographically matched sites
The Fit2Lead intervention is a park-based youth mental health promotion program involving activities for physical activity, meditation, resilience, and life skills Open trial design (N=9 parks) with 198 youths participating in the Fit2Lead program, who completed questionnaires before the intervention and after (end of the year); youths were ages 9–15, in middle school, predominantly Black and/or Latinx and living in low-income neighborhoods with high rates of community violence (45) Youths’ and parents’ mental health remained stable over the course of a school year, indicated by no significant change in self-reported mental health before and after the intervention