Prevalence & Incidence of Mental Disorders
Health Care and Race (Davis, 1997)
Historical and current data about the health status of American populations confirms that there are very significant differences in prevalence and incidence of physical and mental health problems between groups based on color, income, and residence. Also noted are major differences in help seeking patterns (Neighbors, 1986). In two special reports, (Robert Wood Johnson, 1991; Center for Health Economics Research, 1993), it was noted that people of color, particularly residents of inner cities, showed major disparities in their health status when compared to other populations. The disparities noted in the literature cover the range of disorders from high neonatal mortality rates per live birth, higher rates of heart and circulatory problems, disproportionate rates of AIDS and related deaths, greater prevalence of chronic conditions, higher rates of edentulism, and higher rates of admissions to psychiatric facilities (Robert Wood Johnson, 1991; Center for Health Economics Research, 1993). The high incidence of substance abuse, physical injuries and deaths from violence greatly distinguish low income black neighborhoods and communities in terms of potential and actual costs of health care. According to some reports, substance abuse is the most significant health problem in the nation(Institute for Health Policy, 1993). These populations also show lower availability of health insurance and a significantly lower proportion of health professionals within easy access of their neighborhoods.
Historic Patterns of Utilization of Mental Health Service Use by Race
From the time that state governments decided to provide and finance residential care for the long term mentally ill, major public policy paradoxes have been raised and debated about race and mental illness (Jarvis, 1844). The first of these paradoxes centers on the incidence and prevalence of severe mental illness in populations of African descent, while the second centers on the extent to which these populations require and consume public and/or proprietary mental health services (Snowden & Cheung, 1990).
Historically, the answers to these two interrelated sets of public policy paradoxes concerning race and mental illness have been more a reflection of the prevailing racial climate in American society at large than with objective epidemiological or ethnographic data. A cursory review of the data on admissions to inpatient psychiatric facilities (Snowden & Cheung, 1990; Scheffler, & Miller, 1989; Manderscheid, 1987) shows disproportionately high rates of admissions by race to all types of facilities. This data (Snowden & Holschuh, 1992; Snowden & Cheung, 1990; Manderscheid, 1987) shows that between 1980 and 1992, the rate of admission for all persons to state hospitals in the United States was approximately 163.6 per one hundred thousand. The rate for whites was 136, while the rate for Hispanics was 146 and the rate for Native Americans and Asians was 142 per 100,000 (Manderscheid,1987). The admission rate to state hospitals for consumers of African descent for that same year was 364.2 per 100,000 population. When admissions to private psychiatric hospitals is considered by race, it is noted that the rate for all persons was 62.6 per 100,000, while the rate for whites was slightly above the mean at 63.4. The rate of admissions to private psychiatric hospitals for Hispanics was 34.4, while the rate for Native Americans and Asians was 29.6. The rate for consumers of African descent was close to the national mean at 62.9. Admissions to general hospitals with psychiatric units showed similar patters by race and ethnicity. For the population as a whole the rate per 100,000 was 295.3 per 100,000, while the rate for the white population as a whole was 284.9. The rate of admissions for Hispanics was 227 and the rate for Native American and Asians was 221.7. The rate during the same period for consumers of African descent admitted to general hospital psychiatric units was 386.6 per 100,000. While the national mean admission rate to Veterans’ Administration Hospitals was 70.4 per 100,000, populations of African descent had a rate of 118.2 per 100,000. No other racial or ethnic population had an admission rate to the Veterans’ Administration Hospitals that approximated the rate for populations of African descent.
When age is examined, the relationship between admissions to psychiatric hospitals and race is more pronounced. For example, the rate of admissions to state psychiatric hospitals for consumers of African descent between the ages of 18-24 was 598 per 100,000 while the national mean was 163.6 (Manderscheid, 1987). The most excessive rate found was for consumers African descent between the ages of 25-44 where 753 per 100,000 were admitted to state psychiatric hospitals (Manderscheid, 1987). Although admissions are not indicative of actual prevalence rates in the population, what is shown clearly is a inveterate pattern of service utilization differentiated by race and class.
To a great extent, access to and consumption of psychiatric inpatient services by consumers of African descent has historically paralleled the prevailing theoretical views of their vulnerability and morbidity. During the colonial era, when blacks were believed to be less susceptible to mental disorder, public policies extended inpatient services to free blacks but denied similar services to enslaved blacks. Given the numerical imbalance between free and enslaved blacks at that time, the low utilization of existing services by slaves supported the hypothesis of lower susceptibility. The more recent idea that blacks were more vulnerable to major mental disorder parallels the socio-economic and political conflicts surrounding the abolition of slavery. As slavery drew to a close in 1863, public policies created separate mental institutions for blacks throughout the Southern and border states (Jarvis, 1844). As freedom for blacks drew closer, it was predicted that there would be a need for a major increase in mental hospital beds to accommodate those who would suffer from post slavery stress disorder. Data from the 1840 census was used to show that the frequency of mental illness was eleven times higher for free Northern blacks than for those in bondage in the South (Thomas & Sillen, 1972). Similar data was used to show that the ratio of serious mental illness in Southern blacks was considerably less than the ratio in Southern whites, while the reverse was found in Northern states.
At the other extreme in the policy paradox was the view current between 1945 and 1985 that black and other urban populations were far more susceptible to major mental illness because of a greater frequency of poverty, life stress and migration to urban areas. It was this data and its conclusions that President Kennedy used to base a portion of his successful legislative rationale for the establishment of community mental health centers in 1963. The prevailing belief that blacks were more vulnerable to mental illness resulted in policies that facilitated excess admissions from 1863 to the 1990's. During this time, the number of blacks admitted to various psychiatric institutions grew at a disproportionate rate, with a sizeable number admitted involuntarily (Snowden & Holschuh, 1992; Manderscheid, 1987; Romm, 1988).
Data drawn from the National Institute of Mental Health (Manderscheid, 1987) showed that blacks were more frequently diagnosed on admission with severe mental illness than other ethnic or racial populations. Admissions of blacks to state mental hospitals showed that 56% of these individuals received a primary diagnosis of schizophrenia, while only 38% of all individuals admitted received a similar diagnosis. Hispanics too received a disproportionately high(44%) rate of severe mental illness diagnoses on admission to state mental institutions. Jones (1986), Garretson (1993), Flaskerud (1992), and Lawson et al (1994) conclude that the primary reason for the disproportionate rate of severe mental illness diagnoses are errors made by diagnosticians who are unfamiliar with mental illness as it is manifested in populations of color.
Decades of knowledge in the literature on how populations of African descent consume mental health services shows the following trends:
- Consumers of African descent, with major mental illness, drop out of services at a significantly higher rate than white populations
- Consumers of African descent use fewer treatment sessions for their mental health problems than white populations
- Consumers of African descent enter mental health treatment services at a later stage in the course of their illness than do white populations
- Consumers of African under-consume community mental health services of all kinds
- Consumers of African descent over-consume inpatient psychiatric care in state hospitals at twice the rate of corresponding white populations
- Consumers of African descent are more often mis-diagnosed by mental health practitioners than white populations
- Consumers of African descent are more often diagnosed as having a severe mental illness than whites
Managed Behavioral Health Care and Race: Implications
This data reflects a number of conclusions that may be helpful as the nation sets it course towards managed behavioral health care in the public and private sectors. First, it is clear that under the present and prior systems of care, consumers of African descent with serious mental illness were not served well: diagnoses were found to have been in error; admission rates were disproportionately high; involuntary admissions were used with great frequency; and the most severe mental illness labels were ascribed at a rate that appears higher than its expected frequency in the population. Of significance as well are the findings of different patterns of help seeking and help utilization on the part of African American populations. Populations of African descent tend to delay seeking help for psychiatric problems(as well as major health problems) from formal health systems until conditions have become more serious or chronic and most other community and familial resources have been exhausted. Consumers of African descent also do not tend to remain engaged in outpatient services or utilize as many service units as other populations, although their diagnoses are more severe. Each of these conclusions portends important clinical and marketing issues for managed behavioral health care processes and values. As new managed care policies and services are being developed there is a greater need to focus more attention on the service issues and dilemmas related to race and severe mental illness. While a key aim of managed care policy and processes is designed to reduce unnecessary services and excessive costs, the role of race and service utilization remains poorly understood.
The paradoxes associated with race and mental illness are likely to impact disproportionately on low income communities of color with the onset of managed care policy. For managed care to effectively serve consumers of African descent with severe mental illness, there will need to be a significant focus on issues of access, as well as accuracy of diagnosis and quality of treatment. Too often clinical issues are not examined from an ethnic or racial perspective because they do not fit the dominant cultural perspective. Even those professionals who have been educated in urban areas with large concentrations of minority populations, may be conditioned to assess consumers using standards and guidelines that are not culturally specific or sensitive. In a behavioral health care environment that seeks to penetrate the market of consumers of African descent, there is a need for the establishment of standards and guidelines for managed care systems, organizations, and providers.