Race, Ethnicity, and Behavioral Health: Are Disparities in Diagnosis and Treatment Contributing to Mass Incarceration?

By Jennifer Johnson, J.D.

A central feature of our criminal justice system is the dramatic overrepresentation of racial and ethnic minorities in jails and prisons in the U.S. According to the Bureau of Justice Statistics, in 2017, Black and African American men and women represented 12 percent of the adult population in the United States but 33 percent of the sentenced prison population; White people accounted for 64 percent of adults overall but only 30 percent of prisoners; and Latinos or Hispanics represented 16 percent of the general adult population, and 23 percent of the incarcerated population.[1] Alongside these disproportionalities, we also know that people with mental and substance use disorders are incarcerated at a staggeringly high rate and overrepresented on probation and parole. [2]

The question we should be asking is whether racial disparities in behavioral health diagnosis and treatment are contributing to the disproportionately high number of people behind bars and under correctional supervision. Data and existing research point us to a likely “yes.” This article serves to open a deeper conversation by laying out several well-documented realities that likely impede our ability to provide adequate treatment to racial and ethnic minorities. These include factors related to diagnosis and misdiagnosis, the effects of psychotropic medication on different populations, the lack of diversity in the mental health provider workforce, and barriers to accessing treatment for racial and ethnic minorities.

Diagnosis and Misdiagnosis

For the past three decades, research has consistently shown that African Americans are over-diagnosed or misdiagnosed with schizophrenia and underdiagnosed with mood disorders.[3] Those findings were recently confirmed in a 2019 study by Rutgers University: “The results are consistent with findings from a large body of literature suggesting that racial differences in the diagnosis of schizophrenia in the United States result in part from clinicians underemphasizing the relevance of mood symptoms among African Americans compared with other racial-ethnic groups.”[4]

Explanations for this phenomenon are numerous but the implications are clear: A misdiagnosis of schizophrenia can result in ineffective treatment, use of the wrong medication for the disorder, an inaccurate prognosis for the future, and lowered expectations for recovery. If the treatment is wrong, the odds of a patient adhering to it are slim and the chances for a poor treatment outcome more likely.[5]

For Whom Does Psychotropic Medication Work?

Since the introduction of Thorazine into the American way of life in the mid-1950s, psychotropic medication has been a centerpiece of treatment for mental illness. There is continued debate around whether medications should be the central treatment intervention for a serious mental disorder and whether those medications are prescribed evenly across different racial and ethnic groups. What we do know and should study more extensively is that psychotropic medications do not work for everyone.

In addition, studies in ethnopsychopharmacology reveal that different ethnic groups metabolize medication in different ways. Assuming an accurate diagnosis, the medications prescribed may not work as effectively for these groups, or the side effects may change the risk-benefit ratio of a particular medication. These differences may impact the selection of drugs prescribed and the appropriate dosage.[6]

Who Provides Mental Health Treatment?

There is a lack of diversity in the mental health workforce. According to SAMHSA’s Mental Health, United States, 2010 report, racial minorities account for only the following percentages of relevant professions:

  • 2 percent of all psychiatrists,
  • 1 percent of psychologists,
  • 5 percent of social workers,
  • 3 percent of counselors, and
  • 8 percent of marriage and family therapists. [7]

A 2017 survey of psychiatrists breaks down the demographics even further, highlighting the shockingly low number of Black and African American psychiatrists. The survey asked doctors to self-identify their ethnicity; 69 percent identified as White/Caucasian, 9 percent identified as Asian Indian, and 7 percent Hispanic/Latino, with Black/African American and Chinese both rounding to 3 percent, and Asian or Filipino both rounding to 2 percent. [8]

We may never achieve equal ethnic and racial representation in our mental health workforce, but we can do more to improve cultural competency among existing behavioral health care providers. Lack of training around issues of culture and ethnicity can have unintended consequences: underdiagnosis, misdiagnosis, lack of communication between provider and patient, delays in appropriate treatment, lower rates of compliance, and poor treatment outcomes.[9]

Barriers to Treatment

When looking at the relationship between behavioral health and racial and ethnic minorities, we must consider barriers to accessing treatment. In looking at service use data for adults with mental illness, patterns over the last two decades are relatively stable: White men and women access the greatest number of services, followed by Black or African Americans and Latinos or Hispanics, followed by Asians accessing the fewest services.[10]

In 2017, the American Psychiatric Association (APA) compiled data on mental health disparities in diverse populations. Most racial and ethnic groups have similar mental disorders to Whites yet access far fewer services. According to the APA, among adults with any illness, mental health services were received by just 22 percent of Asians and 31 percent of Black or African Americans and Latinos or Hispanics, compared with 48 percent of Whites.[11]

One of the reasons for the uneven distribution of behavioral health service use is the very real barriers to care that prevent or dissuade people of racial or ethnic minorities from getting treatment. Cultural barriers such as stigma among minority populations, language differences, cultural presentation of symptoms, and longstanding mistrust of the mental health system all contribute to the disparity in services accessed. Those cultural factors are compounded by structural barriers that include lack of insurance, underinsurance, and a paucity of available services.[12]

The relationship between race, ethnicity, and behavioral health is complex. While this article has touched on just a few of the reasons for the disparate treatment of racial and ethnic minorities in our behavioral health system, when we examine them through the lens of the criminal justice system, it is easy to see how these very factors contribute to higher numbers of people of color in our jails and prisons. Misdiagnosis, ineffective behavioral health treatment, and poor patient buy-in can lead not only to bad mental health outcomes, but also further incarceration, relapse on drugs and alcohol, continued illegal behavior, hospitalization, and homelessness. For many, the revolving door of repeat incarceration may stem from a breakdown in our behavioral health system.

It’s well past time for a deeper study of the relationship between underlying mental illness and race and ethnicity in our mass incarceration crisis. If we do not acknowledge differences in how we identify, diagnose, and treat racial and ethnic minorities in our behavioral health system, we will continue to provide ineffective mental and substance use disorder treatment. In turn, we will fail to fully address the public health crisis that is at the heart of our racially disproportionate jail and prison populations.

[1] Jennifer Bronson, and E. Ann Carson, Prisoners in 2017, report NCJ 252156 published by the U.S. Bureau of Justice Statistics, April 2019.

[2] Henry J. Steadman, Fred C. Osher, Pamela Clark Robbins, Brian Case, and Steven Samuels, “Prevalence of Serious Mental Illness Among Jail Inmates.” Psychiatric Services 60, no. 6 (2009): 761–65. https://doi.org/10.1176/ps.2009.60.6.761; Jennifer Skeem, and Jennifer Eno Louden, “Toward evidence-based practice for probationers and parolees mandated to mental health treatment.” Psychiatric Services 57, no. 3 (2006);57:333–42; Seth J. Prins, “Prevalence of Mental Illnesses in U.S. Prisons: A Systematic Review.” Psychiatric Services 65, no. 7 (2014): 862-872; Pamela S. Hyde, “Behavioral Health and Justice Involved Populations.” PowerPoint presentation, Substance Abuse and Mental Health Administration, February 11, 2011; Jennifer Bronson, and Marcus Berzofsky, Indicators of Mental Health Problems Reported by Prisoners and Jail Inmates, 2011-12, report NCJ 250612 published by the U.S. Bureau of Justice Statistics, June 2017; Jennifer Bronson, Jessica Stroop, Stephanie Zimmer, and Marcus Berzofsky, Drug Use, Dependence, and Abuse Among State Prisoners and Jail Inmates, 2007-2009, report NCJ 250546 published by the U.S. Bureau of Justice Statistics, April 2017.

[3]Robert C. Schwartz, and David M. Blankenship, “Racial Disparities in Psychotic Disorder Diagnosis: A Review of Empirical Literature.” World Journal of Psychiatry 22, no. 4 (2014): 133-140.

[4] Michael A. Gara, Shula Minsky, Steven M. Silverstein, Theresa Miskimen, and Stephen M. Strakowski, “A Naturalistic Study of Racial Disparities in Diagnoses at an Outpatient Behavioral Health Clinic.” Psychiatric Services 70, no. 2 (February 2019): 130–34.

[5]  “Research Weekly: Misdiagnosis of Schizophrenia in African Americans – Treatment Advocacy Center.” Accessed December 17, 2019. https://www.treatmentadvocacycenter.org/fixing-the-system/features-and-news/4159-research-weekly-misdiagnosis-of-schizophrenia-in-africanamericans.

[6] L. DiAnne Bradford, “CYP2D6 allele frequency in European Caucasians, Asians, Africans and Their Descendants,” Pharmacogenetics 3, no.2 (2002):229-243; Felicia K. Wong, and Edmond H. Pi, “Ethnopsychopharmacology considerations for Asians and Asian Americans”. Asian Journal of Psychiatry 5, no. 1 (2012): 18-23.

[7] Mental Health, United States, 2010, HHS Publication No. (SMA) 12-4681 prepared by the Substance Abuse and Mental Health Services Administration (Rockville, 2012). https://www.samhsa.gov/data/sites/default/files/MHUS2010/MHUS2010/MHUS-2010.pdf

[8] Carol Peckham, “Medscape Lifestyle Report 2017: Race and Ethnicity, Bias and Burnout,” (slideshow) Medscape, January 11, 2017.

[9] “Mental Health Disparities: Diverse Populations” American Psychiatry Association, accessed December 17, 2019. https://www.psychiatry.org/psychiatrists/cultural-competency/education/mental-health-facts; Improving Cultural Competence: Quick Guide for Administrators, HHS Publication No. (SMA) 16-4932 prepared by the Substance Abuse and Mental Health Services Administration, (Rockville, 2016). https://store.samhsa.gov/product/Improving-Cultural-Competence/sma16-4932.

[10] Racial/Ethnic Differences in Mental Health Service Use among Adults, Publication No. SMA-15-4906 prepared by the Substance Abuse and Mental Health Services Administration (Rockville, 2015). https://www.integration.samhsa.gov/MHServicesUseAmongAdults.pdf

[11] “Mental Health Disparities: Diverse Populations,” American Psychiatry Association, accessed December 17, 2019. https://www.psychiatry.org/psychiatrists/cultural-competency/education/mental-health-facts.

[12] Ibid.

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