Disparities in Treatment of African-Americans in MH System

1. Disparities in Treatment of African-Americans in MH System The Legacy of Slavery Laura Cain Managing Attorney Maryland Disability Law Center laurac@mdlclaw.org

2. The End of Slavery & The Rise of “Insanity” • 1840 US Census: “insanity” 11 times more likely among African Americans living in Northern free-states than in South • Slavery Proponents: “Burdens of freedom” drive African Americans “insane” . . . Slavery saves them from “mental death” (Whitaker, 2002)

3. Post-Slavery Rise of “Insanity” & Incarceration • Between 1860 and 1880, incidence of “insanity” rose five-fold among African Americans (Whitaker) • Incarcerated in increasing numbers in mental institutions, jails and poorhouses (Whitaker) • Racist explanations continued – 1886 New York Medical Journal: “African Americans lack biological brainpower to live in freedom” (Beavis, 1921)

4. Turn of Century: Classification of Schizophrenia & Mood Disorders • African Americans in U.S. diagnosed with schizophrenia in numbers that far outpaced whites. Correspondingly, rarely diagnosed with mood disorder • Disparity attributed to an alleged lack of emotions “owing to fact that they have no strict moral standard” (O’Malley, 1914)

5. Medical Explanation for Racism • Mental Illness as a “brain disease” firmly rooted • 1921 American Journal of Psychiatry: African Americans not sufficiently biologically developed & thus prone to psychotic illnesses.

6. Through the Present: Race remains strongest predictor of schizophrenia diagnosis 2004: African Americans four times more likely to receive schizophrenia diagnosis than whites of European ancestry (Barnes, 2004) 2008: controlling for all demographic variables, African Americans still disproportionately given schizophrenia diagnosis versus whites (Barnes, 2008)

7. African-Americans diagnosed with most severe forms of schizophrenia 1970-1990: African Americans accounted for 19% of the general population in Virginia, yet accounted for 63% of the paranoid schizophrenia with psychotic features diagnosis (Lewis, 2010) 2008: African Americans typically received less specific diagnoses such as psychosis not otherwise specified at admission, but over course of hospital stay were more likely to be discharged with a diagnosis of paranoid schizophrenia (Anglin and Malaspina, 2008)

8. Consequences of Diagnosis • Wrong diagnosis = wrong medication • Stigma: schizophrenia diagnosis wrongly linked to violence and inability to make rational decisions • Diagnosis most likely to lead to involuntary treatment in state hospitals: 54% of all commitments (NASMHPD Research Institute)

9. Clinician Bias • 1988 experiment: 290 psychiatrists reviewed the same written case studies that were alternatively presented as white male, white female, black male and black female. The psychiatrists gave more severe diagnoses to black males and less severe to white males. According to the researchers, “clinicians appear to ascribe violence, suspiciousness, and dangerousness to black patients even though the case studies were the same.” (Loring, 1988) • 2000 Study on psychiatric inpatients found that African Americans had higher rates of both clinical and research-based diagnosis of schizophrenia because psychiatrists applied different decision rules to African American and white patients in judging the presence of schizophrenia (Supplement to Mental Health: A Report of the Surgeon General, 2001)

10. Treatment Studies Exclude Minorities & Ignore Impact on African Americans • Research shows that African Americans metabolize psychotropic medications more slowly than whites and may be more sensitive to side-effects (Link, 1995; Risby, 1996; A Report of the Surgeon General) • Randomized clinical trials on efficacy of pharmaceutical treatment largely exclude minorities. Even in studies where there were a limited number of African-American participants, studies failed to separately analyze efficacy for that population. Thus, recommended medicines and dosages are tailored for white population (AReport of the Surgeon General)

11. African Americans over-drugged • Standard dosages would present problems due to slower metabolism. However, clinicians in emergency rooms and inpatient settings prescribe both more and higher dosages of oral and injective antipsychotic medications to African Americans than to whites, and they are more likely to receive higher overall doses of neuroleptics (AReport of the Surgeon General, citing Segal, 1996; Chung, 1995; Marcolin, 1991, Walkup 2000); (Diaz 2002; Kuno 2002)

12. Health Consequences • Combination of slow metabolism and overmedication of antipsychotic drugs yield extra-pyramidal side effects, including stiffness, jitteriness, and muscle cramps, as well as increased risk of long-term severe side-effects such as tardive dyskinesia, which has been shown in several studies to be significantly more prevalent among African Americans than whites (AReport of the Surgeon General, citing Lin 1997; Morgenstern & Glazer, 1993; Glazer, 1994, Eastham & Jeste, 1996; Jeste, 1996)

13. Civil Admissions to State Hospitals • 2002: African Americans accounted for approximately 12% of US population, but accounted for approximately 30% of admissions to state hospitals. 2005: 21.7% admission rate, but was actually a 10% increase in the actual number of total admissions of all groups combined. (Davis, 2011) • 1970-2002: Percentage of African Americans admitted to state hospitals was 2 to 3 times their representation in general public (NASMPHD Research Institute, 2002)

14. Involuntary Commitment • More than twice as likely than whites to be involuntarily committed to state hospitals (Lewis 2010) • African American men most likely to diagnosed with most severe forms of schizophrenia and being involuntarily committed, whether civilly or through criminal courts (Davis 2010)

15. Demographic Variables Increasing Risk of Involuntary Treatment: Poverty • African American’s are nearly three times as likely than whites to have incomes below the poverty line in US and Baltimore City (Pew Research 2010; Baltimore City Health Department, 2008 Health Status Report) • Greater numbers of children living in poverty: 38.2% versus 12.4% of whites (National Poverty Center 2010) • Have median net worth 7% that of whites (Pew Research 2010)

16. Demographic Variables: Incarceration & Homelessness African Americans are incarcerated in jails and prisons in US at a rate of 6x that of whites; in Maryland, African Americans are incarcerated at a rate of 5.5x that of whites (US DOJ, Bureau of Statistics 2011) It is estimated that 57% of chronic homeless persons in US are African American (US Dept. of Housing and Urban Development 2009) In Baltimore City, African Americans account for 64% of total population, but 80% of sheltered homeless and 85% of unsheltered homeless (Mayor’s Office of Human Services, Morgan State University)

17. Demographic profile of persons ordered to outpatient treatment in New York between 1999-2007 • 34% African American, who make up 16% of state’s population • 30% Hispanic, who make up 17.6% of state’s population • 34% White, who make up 65.7% of state’s population • Thus . . . 64% of those under involuntary treatment orders since law enacted have been African American or Hispanic, despite accounting for only a combined 33% of total state population • 67% male; 73% diagnosed with schizophrenia (New York State Assistant Outpatient Treatment Program Evaluation, 2009; State demographic data from US Census Bureau, 2010)

18. NY Kendra’s Law Disproportionately Targets African Americans Just as African Americans are twice as likely as whites to be involuntarily committed inpatient to state facilities, they are twice as likely to be involuntarily committed to outpatient treatment

19. Is it Racism? • NY evaluators claim no racial bias in selecting IOC participants; cite “upstream” factors that lead African Americans to be overrepresented in the pool from which people are targeted (i.e, multiple hospital admissions, criminal incarceration, lack of stable housing, poor)

20. Are Those “Upstream Factors” Due to Historical Racism? • Disproportionately diagnosed with schizophrenia due to clinician bias • Disproportionately poor and homeless due to economic/social/educational exclusion • Disproportionately arrested & incarcerated due to institutional/overt racism and exclusion • Disproportionately involuntarily committed to state inpatient facilities due to above factors

21. Barriers to Voluntary Treatment • Lack of resources (insurance, transportation, housing) • Distrust of “the system” • Lack of African American mental health professionals nationwide – 2% psychiatrists, 2% psychologists, 4% social workers • Experience with coercion in MH system • Less likely to receive sought after care for depression or anxiety (less likely than whites to receive antidepressants and less likely to receive SSRIs) (A Report of the Surgeon General)

22. Forced Treatment Laws Are Racist MDLC believes that if we follow the trail of the treatment of African Americans in and by the mental health system from the waning days of slavery, the inescapable conclusion is that the legacy of slavery and the ongoing institutional racism that exists in our country leads to forced treatment laws that disproportionately target and negatively impact African Americans