CHAPTER 3

Mental Health Care for African Americans

Appropriateness and Outcomes of Mental Health Services

Upon entering treatment, do African Americans receive effective care? That effective treatments do exist was documented in the Surgeon General's Report on Mental Health (DHHS, 1999b). The questions that remain are whether novel, standardized treatments and treatment-as-usual are equally effective when administered to African Americans, and whether in settings where African Americans receive care, clinicians diagnose their problems correctly and assign effective forms of treatment.

Studies on Treatment Outcomes

Clearly, an effective treatment is better than no treatment at all. However, for psychosocial interventions that might be sensitive to social and cultural circumstances, there is the question of whether interventions are as effective for African Americans as they are for whites. Few researchers have addressed this question when considering either novel, standardized treatments or treatment-as-usual. Among the handful of studies available for review, many included small samples of participants and lacked adequate controls.

One preliminary effort found that African Americans and white Americans responded similarly to treatment for PTSD (Rosenheck & Fontana, 1994; Zoellner et al., 1999). Cognitive-behavioral therapy, which focuses on altering demoralizing patterns of thought, has been shown to be equally effective in reducing anxiety among African American and white children and adults (Friedman et al., 1994; Treadwell et al., 1995). Similarly, behavioral treatment for older medical patients has been shown effective for African Americans (Lichtenberg et al., 1996). A study of persons suffering from severe and persistent mental illness found that a heavily African American sample, drawn from an intensive psychosocial rehabilitation program located in an urban, predominantly African American area, demonstrated increased levels of adaptive functioning in the community (Baker et al., 1999).

On the other hand, African Americans were found less responsive than white Americans in a pilot study of behavioral treatment for agoraphobia (Chambless & Williams, 1995). In another study of treatment for depression, African Americans proved similar to whites in response to psychotherapy and medication, except that African Americans had less improvement in their ability to function in the community (Brown et al., 1999). In a study of treatment as usually provided in the Los Angeles County mental health system, African Americans improved less than whites and members of other racial and ethnic minority groups (Sue et al., 1991). Exposure therapy, which involves overcoming fears in graduated steps, proved ineffective as a treatment for panic attacks among African Americans (Williams & Chambless, 1994).

Studies of children and youth have largely shown positive effects from treatment. African American and white juvenile offenders were assisted comparably by multisystemic therapy, which engages a network of supportive figures in a helping effort (Borduin et al., 1995). In addition, African Americans showed positive out-comes for medication for attention-deficit/hyperactivity disorder (Brown & Sexson, 1988).

Diagnostic Issues

Appropriate care depends on accurate diagnosis. Carefully gathered evidence indicates that African Americans are diagnosed accurately less often than white Americans when they are suffering from depression and seen in primary care (Borowsky et al., 2000), or when they are seen for psychiatric evaluation in an emergency room (Strakowski et al., 1997).

For many years, clinicians and researchers observed a pattern whereby African Americans in treatment presented higher than expected rates of diagnosed schizophrenia and lower rates of diagnosed affective disorders (Neighbors et al., 1989). When structured procedures were used for assessment, or when retrospective assessments were made via chart review, the disparities between African Americans and whites failed to emerge (Baker & Bell, 1999).

One explanation for the findings is clinician bias: Clinicians are predisposed to judge African Americans as schizophrenic, but not as suffering from an affective disorder. One careful study of psychiatric inpatients found that African Americans had higher rates of both clinical and research-based diagnoses of schizophrenia (Trierweiler et al., 2000). The clinicians in the study were well trained and included both African Americans and white Americans. However, it was found that they applied different decision rules to African American and white patients in judging the presence of schizophrenia. The role of clinician bias in accounting for this complex problem has not yet been ascertained.

Evidence-Based Treatments

In a nationally representative telephone and mail survey conducted in 1996, African Americans were found to be less likely than white Americans to receive appropriate care for depression or anxiety. Appropriate care was defined as care that adheres to official guidelines based on evidence from clinical trials. (Wang et al., 2000). Similar findings emerged in another large study that examined a representative national sample (Young et al., 2001). One large study of antidepressant medication use included all Medicaid recipients who had a diagnosis of depression at some time between 1989 and 1994 (Melfi et al., 2000). This study found that African Americans were less likely than whites to receive an antidepressant when their depression was first diagnosed (27% versus 44%). Of those who did receive antidepressant medications, African Americans were less likely to receive the newer selective serotonin reuptake inhibitor (SSRI) medications than were the white clients. This is important because the SSRIs have fewer troubling side effects than the older antidepressants; therefore, they tend to be more easily tolerated, and patients are less likely to discontinue taking them. Failure to treat with SSRI medications may be widespread and might help to explain African American overrepresentation in inpatient facilities and emergency rooms. Also, in a large study of older community residents followed from 1986 through 1996, whites in 1986 were nearly twice as likely, and in 1996, alomst 4 times more likely, to use an antidepressant than were African Americans (Blazer et al., 2000).

Best Practices

Biological similarities between African Americans and whites are such that effective medications are suitable for treating mental illness in both groups. At the same time, recent evidence suggests that African Americans and white Americans sometimes have different dosage needs. For example, a greater percentage of African Americans than whites metabolize some antidepressants and antipsychotic medications slowly and might be more sensitive than whites (Ziegler & Biggs, 1977; Rudorfer & Robins, 1982; Bradford et al., 1998). This higher sensitivity is manifested in a faster and higher rate of response (Overall et al., 1969; Henry et al., 1971; Raskin & Crook, 1975; Ziegler & Biggs, 1977) and more severe side effects, including delirium (Livingston et al., 1983), when treated with doses commonly used for whites. However, clinicians in psychiatric emergency services prescribe both more and higher doses of oral and injectable antipsychotic medications to African Americans than to whites (Segel et al., 1996), as do other clinicians working in inpatient services (Chung et al., 1995). Other studies suggest that African Americans are also likely to receive higher overall doses of neuroleptics than are whites (Marcolin, 1991; Segel et al., 1996; Walkup et al., 2000).

The combination of slow metabolism and overmedication of antipsychotic drugs in African Americans can yield extra-pyramidal side effects, including stiffness, jitteriness, and muscle cramps (Lin et al., 1997), as well as increased risk of long-term severe side effects such as tardive dyskinesia, marked by abnormal muscular movements and gestures. Tardive dyskinesia has been shown in several studies to be significantly more prevalent among African Americans than among whites (Morgenstern & Glazer, 1993; Glazer et al., 1994; Eastham & Jeste, 1996; Jeste et al., 1996).