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

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)

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)

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)

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.

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)

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)

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)

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)

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 (A Report of the Surgeon General)

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 (A Report of the Surgeon General, citing Segal, 1996; Chung, 1995; Marcolin, 1991, Walkup 2000); (Diaz 2002; Kuno 2002)

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 (A Report of the Surgeon General, citing Lin 1997; Morgenstern & Glazer, 1993; Glazer, 1994, Eastham & Jeste, 1996; Jeste, 1996)

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) More than twice as likely than whites to be involuntarily committed (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)

Demographic Variables Increasing Risk of Involuntary Treatment: Poverty AA’s more than twice as likely than whites to have incomes below the poverty line More likely to have incomes at or below 50% of the poverty threshold Greater numbers of children living in poverty (37% versus 20% of total) Have median net worth less than 10x that of whites (A Report of the Surgeon General )

Demographic Variables: Incarceration & Homelessness African Americans incarcerated in jails and prisons at a rate of 6x that of whites (Pew Research 2010) It is estimated that 40-45% of homeless persons are African American, 3.5 times as many as whites (US Conference of Mayors 1996)

Kendra’s Law implementation: 10-year review 34% African Americans, who make up only 17% of state’s population 67% male 73% diagnosed with schizophrenia (New York State Assistant Outpatient Treatment Program Evaluation, 2009)

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

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)

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

Barriers to Voluntary Treatment Lack of resources (insurance, transportation, housing) Distrust of “the system” Lack of African American mental health professionals – 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)

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