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

Diana Chapa, MD Nakita Natala, MD Raghu Gandhi, 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 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

influences perception of mental illness and idioms of distress commonly used in different cultures. Implicit bias among healthcare providers: Black Americans more frequently receive a diagnosis of schizophrenia and less frequently receive a diagnosis of mood disorders (Gara et al., 2012). Physicians were 23% more verbally dominant and engaged 33% less in patient-centered communication with Black compared to white patients (Johnson R, et al., 2015). Language barriers: Latinx Americans are more likely to report poor communication with healthcare providers. Studies have found bilingual patients are evaluated differently when interviewed in English versus Spanish. Limited availability of trained interpreters impacts communication. Distrust in the healthcare system: Previous discriminatory experiences, unethical research practices, intergenerational trauma with forced removal from land, internment camp placement and separation from families.

A Call to Action

The killing of Mr. George Floyd highlighted how systemic racism continues to have a strong hold in our society. In spite of knowledge gained, society and we in health care have allowed our institutional practices and policies to be driven and determined not by biological and social science, but by individual biases and a centuries old race classification and demarcation system that justifies white privilege. White privilege has then allowed for the ability to, without guilt, look away from the inaccurate, toxic racial ideologies that have contributed to the determinants that cause disparities. Racism and discrimination have real physical and emotional consequences that persist lifelong. Studies “point to discrimination as a clear contributor to the racial/ethnic health disparities observed for African American, Latino, and Native American populations, compared to their white counterparts” (A. D. Benner, 2018). Census Bureau data as reported onUS households’ emergency weekly surveys shows that since the video showing Mr. Floyd’s killing, depression and anxiety symptoms have continued to increase and especially in Black and Asian Americans (A. Fowers, 2020). Racism, microaggressions and biased thought and behavior remain a daily occurrence. Health care is no exception. As an institution it has continued to function with policies that do not promote a diverse professional climate, continues to train in a culture that perpetuates biases and continues to provide biased influenced care with consequences over which our patients have no choice but to bear. Today society finds itself at a turning point. It has become uncomfortably difficult for us to continue with the status quo of the past. The time is now for the institution and providers of health care to lead the way to an anti-racist society and to function as an institution that accepts the genuine and detrimental consequences of unaddressed racism and biases. What can each of us do to contribute toward this anti-racist movement? 1. Commit to learn about and accept how racism, an invented social construct, has impacted us. 2. Demand and support workforce diversity and inclusive work environments. 3. Implement implicit bias training and make changes to our general medical education curriculum to include topics around racism, diversity, equity and inclusion. 4. Commit to having the difficult conversations about racism and necessary change. 5. Advocate for research and allocating of resources to address the determinants that contribute to healthcare disparities. Without our commitment to action, the biases, microaggressions, white privilege and racism will continue. With the knowledge we have gained and the visual evidence we now have of needless loss of life, we can no longer justify inaction as racial inequity will easily continue with inaction. Today, we know inaction is complicit racism. Diana Chapa, MD, has been working as a child and adolescent psychiatrist and consultant for the past 25 years. She has held positions as both clinical and medical director for inpatient psychiatric services. She has also enjoyed teaching in the Ethnic Studies Department at St. Cloud State University, and in the Child and Adolescent Psychiatric Departments at University of Minnesota and Medical College of Wisconsin.

Nakita Natala, MD, Child and Adolescent Psychiatrist, Assistant Professor, Department of Psychiatry and Behavioral Sciences, University of Minnesota. Dr. Natala is passionate about cross-cultural psychiatry, global mental health and developmental disorders, particularly autism.

Raghu Gandhi, MD, is an Assistant Professor at the University of Minnesota and is board certified in Child and Adolescent psychiatry. Dr. Gandhi is passionate about children’s mental health and neurodevelopmental disorders.

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