Access to mental health care in the U.S. may vary by race and class because of biases on the part of psychotherapists, a new study suggests.

Based on calls to hundreds of therapists, the study found that middle class patients had an easier time than their working class counterparts getting an appointment, but among middle class callers, blacks were less likely to be offered an appointment than whites.

"Although we expected to see evidence of racial and class-based discrimination, the magnitude of discrimination against working-class therapy seekers, in particular, exceeded our grimmest expectations," said author Heather Kugelmass, a doctoral student in sociology at Princeton University in New Jersey.

"Deeply-rooted stereotypes associated with the working class could lead to negative reactions to their requests for care," she speculated. "Even though all therapy seekers in the study were covered by the same insurance, it is possible that mental health care providers view working-class patients as a financial risk because, for example, they cannot be relied upon to keep appointments or pay insurance co-payments at the time of treatment."

Kugelmass recruited four voice actors to record nearly identical voicemail messages using racially distinctive names as well as race- and class-based speech patterns. One voice actress played both the middle class and working class white female roles, while another played both black female roles, and two male actors did the same.

Each "help seeker" recording mentioned symptoms of depression or anxiety, named their health insurance plan, and requested an appointment for a weekday evening and for the psychotherapist to leave a return voicemail with available appointment slots.

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The messages were left for 320 psychotherapists with solo practices in New York, who each received messages from one black middle class and one white middle class help seeker or from one black working-class and one white working class help seeker.

Just 287 return calls were received, representing 44 percent of all the calls placed.

Middle-class messages received appointment offers at more than twice the rate of working class messages, according to results in the Journal of Health and Social Behavior.

But white middle class patients received appointment offers in response to 28 percent of their calls while black middle class patients got offers from 17 percent of their calls. In particular, the black middle class male message was left for 80 psychotherapists and only one-third of the therapists left messages in return, with just one offering him a weekday evening appointment.

"Even the middle class white therapy seekers received return messages only half of the time," Kugelmass said. "As consumers, or potential consumers, of mental health care, we'd like to think that everyone deserves a response," she added.

"If individuals experience a lack of responsiveness during their help-seeking process, they may view reaching out to psychotherapists as a fruitless activity or develop negative attitudes toward the profession," she said.

Appointment offer rates were similar for women and men, but women were more often given an appointment in their preferred time range, Kugelmass found.

"It is possible that working-class therapy seekers would receive more positive responses from social workers, who may be more willing to work with disadvantaged populations, or from group practices, where there could be more social pressure to be less discriminatory when selecting clientele," she told Reuters Health by email.

Audit studies have revealed similar discrimination in other marketplaces, such as real estate and employment, she said.

Among the study's limitations is that it did not have racial information about the therapists, and did not look at the reasons for their responses or failure to respond.

Kugelmass writes that there may be conscious and unconscious biases on the part of therapists, including a greater affinity for people more like themselves and self-doubt about their "cultural competence" to treat patients of a different class or race.

"This study identified racial and class-based disparities in access, but could not evaluate potential solutions," Kugelmass said. "Also, it's important to caution that this study investigated only doctoral-level psychotherapists in New York City who were sole practitioners; therefore, recommendations based on this research might not be generalizable."