Racism and Disparities in Mental Health History
A brief internet search will reveal that psychiatry was first introduced as a medical specialty in the early 1800s and will outline how the field has advanced itself over the years with updates to the Diagnostic and Statistical Manual of Mental Disorders (DSM) and discovery of evidence-based interventions. Harder to find is American psychiatry’s dark history of systemic racism that has harmed marginalized populations, particularly the Black community and used psychiatric diagnoses and theories to perpetuate racism. Authors of a chapter in the book Racism and Psychiatry (Gordon-Achebe et al., 2019) outline how leaders in the field publicized theories that elevated the white race and pathologized the Black race. These theories were accepted as scientific, but at their core reflected the dominant social political culture of the time. The psychiatric illness, “Drapetomania” was described by a wellknown proslavery American physician in the 1850s to identify slaves who did not conform and could be treated by whipping (Gordon-Achebe et al., 2019). In the late 1960s, a change in the DSM-II diagnosis of schizophrenia resulted in psychiatrists using the new paranoid subtype criteria to diagnose “hostile” and “aggressive” Black men connected to the civil rights movement with schizophrenia and justify institutionalizing them (Metzl, 2010). These are two of many historical examples of psychiatric disorders being used by dominant white Americans to oppress and fuel racial By Diana Chapa, MD, Nakita Natala, MD and Raghu Gandhi, MD
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September/October 2020
Diana Chapa, MD
Nakita Natala, MD
disparities. As the world and social climate has changed in the United States, so has the field of psychiatry and how mental health diagnoses are utilized and at times weaponized against certain populations. What is still missing within mainstream current psychiatry training, research and patient care is how this history has been integral in generating the present distrust and the disparities that exist within mental health — particularly for racial and ethnic minority groups. Health Disparities
Health disparities in the US would not exist without structural racism. Centuries of racist practices has led to people from racial and ethnic minority groups being less likely to receive mental health care, evidenced-based treatment (US general surgeon 2001) and be included in research studies and more likely to use emergency rooms (Wang et al., 2000). In 2015, approximately 48% of white adults with mental illness received care, compared to 31% of Black and/or Latinx, and 22% of Asian adults (Agency for Healthcare
Raghu Gandhi, MD
Research and Quality, 2015). Racial and ethnic minority groups also have lower rates of using prescription drugs, outpatient services and higher rates of using inpatient services (SAMSA 2015). Barriers to care include: 1. Insurance/employment: 21.1% of Latinx Americans are uninsured, compared with 7.5% of white non-Hispanic Americans. Low rates of insurance coverage are likely to be a function of ethnicity, immigration status and citizen status (US census 2015). For American Indian populations, 21% lack health insurance, which is due to a higher rate of poverty, (26.6 % versus 14.7% national average). Higher unemployment and inflexible job demands affect the ability to arrange for transportation, child care and time off work. 2. Workforce: Lack of diversity among mental healthcare providers influence comfort levels when receiving care. 3. Lack of culturally competent providers: limited awareness of how culture
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The Journal of the Twin Cities Medical Society
