The Journal of Common Sense

Jane Stein
We wish it were not necessary to consider the relationship between race and ethnicity and the Mental Health care system. But we are all too aware of issues of unequal access to health care, differential diagnoses and treatment regimens, biases in the criminal (in)justice system, and stigmatization to assume that all population sub-groups are treated alike.
The Surgeon General's report states:

Research documents that many members of minority groups fear, or feel ill at ease with, the mental health system … These groups experience it as the product of white, European populations. They may find only clinicians who represent a white middle-class orientation, with its cultural values and beliefs, as well as its biases, misconceptions, and stereotypes of other cultures.

      There is a national cry for culturally competent health services that can handle language differences and where there is an awareness and understanding of cultural differences as they affect health, utilization of care, and a patient's perception of his or her condition. But we are far from providing such services at this time.
      We do know that where there are differences in the prevalence of mental disorders, it appears to be due to socioeconomic differences, with lower income groups having a higher prevalence.

      The literature (www.wiche.edu/MentalHealth/CCStandards/ccsaf5.htm) shows that consumers of African-American descent:

with major mental illness, drop out of services at a significantly higher rate than white populations,

use fewer treatment sessions for their mental health problems than white populations,

enter mental health treatment services at a later stage in the course of their illness than do white populations,

under-consume community mental health services of all kinds,

twice

are more often misdiagnosed by mental health practitioners than white populations, and

are more often diagnosed as having a severe mental illness than whites.

      Thus African-Americans are under-represented in outpatient programs and over-represented in public inpatient facilities. In a 1987 study, African-Americans between the ages of 18 and 24 were admitted to state psychiatric hospitals at a rate of 598 per 100,000. The national average was 163.6. Insured African-Americans are particularly under-represented in private care. Also in need of explanation are findings that African-Americans are more likely than whites to be diagnosed with schizophrenia and less likely with depression.
      Much research is needed to understand Latino mental health and the differences among different subgroups. More women than expected are classified as depressive and these women are seen more often by general medical providers than by mental health providers.
      Even less is known about Native Americans, except that they also reflect higher than expected rates of hospitalization in public facilities.
      For information on how The National Institute of Mental Health (NIMH) is planning to address the DHHS initiative to reduce health disparities, see their draft plan, available at www.nimh.nih.gov/strategic/strategicdisparity.cfm.

      The only North Carolina information on race, ethnicity, and mental health that we have to present in this issue is a table (see next page) of Area Program African-American clients. This table is organized by ranking the programs based on over-hospitalization rates. Looking at the last line, the figures for the entire state, we see that 22 percent of the population was African-American in 1990. However 32 percent of Area Program clients were Black, almost 1.5 times more than their proportion in the population.
      African-Americans were almost 1.9 times more likely to be hospitalized in a state psychiatric hospital, reaching 41 percent of those sent to hospitals by Area Program. It is important to remember, however, that African-Americans have less access to private care than whites. Therefore it may be understandable (though not justifiable) that they are over-represented in the public system.
      For this reason it is important to look at the ratio of clients hospitalized to those seen in the community. The final column is an indication of whether or not an Area Program disproportionately hospitalizes African-Americans as compared to treating them in the community. For example Trend African-American clients are 2.2 times more likely to be hospitalized than to be treated in the community. River Stone African-American clients are equally represented in the program and in hospitals and those clients are exactly proportional to their percent in the general population.
      We offer these numbers for the programs and for their constituents to investigate and interpret.

Black Population in the Mental Health System in North Carolina in FY 2000

Area Program	Percent Black in Area Program counties (Based on 1990 Census Data)	Percent pop. served by the Area Program that is Black	Percent of total Area Program submissions to state psychiatric hospitals that is Black (LOS greater than 60 days)	Ratio of percent Blacks served to percent of population that is Black	Ratio of percent Blacks hospitalized to percent of population that is Black
Trend	4%	7%	15%	1.83	4.10
Southeastern	21%	34%	59%	1.62	2.78
Randolph	6%	22%	14%	3.65	2.38
Mecklenburg	26%	47%	57%	1.80	2.18
Tideland	28%	42%	59%	1.49	2.12
O-P-C	20%	30%	42%	1.48	2.08
Wayne	32%	47%	67%	1.45	2.06
Rutherford-Polk	11%	16%	21%	1.54	2.02
Duplin Sampson	33%	42%	67%	1.28	2.00
Wake	21%	42%	40%	2.03	1.91
Johnston	18%	28%	33%	1.54	1.86
Alamance-Caswell	23%	32%	41%	1.41	1.83
Neuse	21%	26%	38%	1.25	1.80
Lenior	39%	50%	68%	1.28	1.74
Guilford	26%	43%	46%	1.62	1.72
Southeastern Reg	30%	39%	50%	1.31	1.67
Sandhills	29%	39%	48%	1.34	1.65
Pathways	14%	21%	24%	1.44	1.65
Onslow	20%	26%	33%	1.29	1.64
Albemarle	25%	27%	40%	1.10	1.63
New River	3%	5%	5%	1.74	1.59
Blue Ridge	7%	12%	10%	1.88	1.58
Catawba	9%	14%	14%	1.52	1.58
Edgecombe-Nash	42%	59%	65%	1.41	1.55
Wilson-Greene	39%	50%	57%	1.29	1.48
Davidson	10%	17%	14%	1.79	1.47
Pitt	33%	52%	48%	1.57	1.45
CenterPoint	21%	34%	30%	1.60	1.42
Rockingham	20%	27%	29%	1.34	1.40
Piedmont	15%	24%	20%	1.65	1.38
Foothills	11%	8%	15%	0.71	1.38
Lee-Harnett	23%	26%	29%	1.12	1.29
Durham	37%	63%	48%	1.68	1.28
V-G-F-W	42%	45%	51%	1.06	1.22
Roanoke Chowan	58%	68%	63%	1.19	1.09
River Stone	50%	50%	50%	1.01	1.01
Cumberland	32%	44%	31%	1.38	0.96
Smoky Mountain	2%	1%	0%	0.69	0.00
NC Totals	22%	32%	41%	1.44	1.86

The Journal of Common Sense is published by The Common Sense Foundation.