Relationship Between Race and Ethnicity and Forensic Clinical Triage Dispositions

Economic and social factors, in combination with the debilitating nature of serious mental illness and clinicians' perceptions, may contribute to differences in dispositional outcomes for persons from ethnic and racial minority groups. In a study that examined racial and ethnic disparities in admissions to public and private psychiatric hospitals, nonwhites were found to be more likely than whites to be treated in public hospitals, rather than private hospitals (3). In a study from Washington State, persons with mental illness who were from locally predominant ethnic minority groups were sent to prison, rather than to a state psychiatric facility, more frequently than persons from non-minority groups (4). Latinos, African Americans, and non-Latino whites were also shown to differ in their mental health service use patterns (5). Specifically, poor Latinos had less access to mental health care than poor non-Latino whites. Similarly, African Americans who were not classified as poor appeared less likely than whites to receive mental health services.

Clinical decisions may also be influenced by racial and ethnic factors. For example, several studies have shown that blacks receive diagnoses of certain serious mental illnesses more frequently than whites (6,7,8,9,10). Furthermore, Iwamasa and colleagues (11) found that diagnoses of antisocial and paranoid personality disorder were more likely to be assigned to African Americans than to European Americans. A recent study found that Latinos were disproportionately given a diagnosis of major depression, compared with European Americans, even though Latinos tended to have greater numbers of self-reported psychotic symptoms (10). The study also found that African Americans with fewer self-reported psychotic symptoms were more likely to receive a diagnosis of schizophrenia. These findings raised further questions about disparities in clinicians' diagnoses across racial and ethnic groups. The findings may reflect culturally based differences in symptom presentations (7,8,12,13,14,15). In contrast, Neighbors and colleagues (16) suggested that the impact of race and ethnicity on psychiatric diagnosis could result from clinicians' different interpretations of symptoms exhibited by blacks and whites. This disparity may be especially true when clinicians are unfamiliar with the belief systems of cultural minority groups (17). These clinical factors may lead to higher rates of diagnosis of serious mental illness and to higher hospitalization rates among persons from ethnic minority groups, both of which have been found in psychiatric emergency services (18,19). Racial and ethnic differences among psychiatric inpatients may also affect length of stay (20). In clinical settings, it is therefore important to consider how racial and ethnic factors may influence diagnostic assessments and disposition recommendations.

As indicated above, the state forensic mental health system occupies a unique niche in the spectrum of psychiatric services. The role of race and ethnicity has not been extensively explored in this area, but opportunities abound for these factors to affect individuals who are processed through this system. Before a person is referred to a forensic mental health bed, they have already been through several decision points in the criminal justice system (21,22). Many factors are involved in these decisions, but previous studies suggest that race and ethnicity play some role. For example, a comparison of white and nonwhite defendants who were evaluated for competence to stand trial showed that the number of nonwhite defendants who have been found incompetent to stand trial increased disproportionately compared with whites since the beginning of the deinstitutionalization period (23). Furthermore, after the deinstitutionalization period, among defendants who were found incompetent to stand trial, nonwhites typically had a higher number of previous arrests and hospitalizations than whites.

In forensic settings, clinicians often play a significant role in advising courts about defendants, which influences key decisions about defendants' receipt of mental health services and legal outcomes. Thus any racial or ethnic bias among clinicians could further affect the proportion of persons from ethnic minority groups who are found in such settings.

Our study examined the relationship between race and ethnicity and dispositions in forensic mental health evaluations that were conducted in Massachusetts court clinics. In our study, race and ethnicity were identified by clinicians. Because research suggests that defendants who are from racial and ethnic minority groups are more likely to be incarcerated than hospitalized and to receive diagnoses of serious mental illness and possibly antisocial personality disorder, we hypothesized that defendants from racial and ethnic minority groups would be more likely than whites to be referred for inpatient evaluation and that defendants from racial and ethnic minority groups would be more likely than whites to have the evaluation occur in a strict-security inpatient setting rather than in the non-correctional mental health system. This measurement is especially significant in light of research showing that persons with mental illness who are from an ethnic minority group may be more likely to be referred to the criminal justice system than the mental health system.

As Table 1 shows, of 12,289 cases, 3,892 defendants (31.7 percent) were referred for inpatient evaluation. Additional analyses showed that 32.4 percent of men (N=3,224) were referred by the court clinic for inpatient evaluation. Of these men, black defendants had the highest referral rate (666 defendants, or 36.8 percent of the 1,808 black male defendants evaluated) and Hispanics the lowest (397 defendants, or 26.7 percent of the 1,437 Hispanic male defendants evaluated). Whites had a referral rate of 32.2 percent (1,978 defendants of the 6,151 white male defendants evaluated). Thirty-eight percent of men who were referred for inpatient evaluation (N=1,225) were assigned to a strict-security facility for their evaluation. Black men (246 defendants, or 36.9 percent of the 666 black men sent for inpatient evaluation) and Hispanic men (150 defendants, or 37.8 percent of the 397 Hispanic men sent for inpatient evaluation) were more likely than white men (510 defendants, or 25.8 percent of the 1,978 white men sent for inpatient evaluation) to be referred to a strict-security facility; the rates for black and Hispanic men were roughly equivalent.

Odds ratios (ORs)—which were adjusted for age, diagnosis, and severity of offense—and their 95 percent confidence intervals (CIs)—which were derived from the logistic regression analysis for the race and ethnicity variables in the three models—are shown in Table 2. In model 1, which included both genders, black defendants were 1.26 times as likely to be hospitalized as white defendants after adjustment for other factors in the model. Hispanics had slightly lower odds of hospitalization than whites, but the difference was not statistically significant.

In model 2, black and Hispanic men had adjusted odds of hospitalization that differed significantly from those for whites, although these effects were in opposite directions. The adjusted OR for blacks indicated that they were 1.25 times as likely to be referred for inpatient evaluation as whites. However, the adjusted OR for Hispanic men indicated that they were only .82 times as likely to experience such referrals.

Model 3 shows the adjusted ORs for being referred to a strict-security facility for inpatient evaluation. As in model 2, the effects of race and ethnicity were significant, but model 3 shows a different pattern. In model 3, the OR for black men shows them to be 1.87 times as likely as white men to be evaluated in a strict-security facility. However, unlike the results found in model 2, model 3 indicated that Hispanic men were 1.37 times as likely as whites to be referred to a strict-security facility.

In our study we analyzed data from one jurisdiction, Massachusetts, to examine potential racial and ethnic disparities in the dispositions of pretrial defendants for inpatient forensic mental health evaluations. Our findings showed statistically significant racial and ethnic effects in the referral patterns of defendants after a court clinic screening. Specifically, black defendants were more likely than white defendants to be referred for inpatient evaluations; no significant difference was found between Hispanic defendants and white defendants of either gender, although Hispanic men were less likely than whites to be referred for inpatient evaluations. In addition, compared with white male defendants, a significantly greater percentage of both Hispanic men and black men were sent for inpatient evaluation in a strict-security facility. Our data showed no significant racial and ethnic differences in defendants' diagnoses or in the severity of criminal charges that could account for the difference in dispositions, and any such effect was controlled for statistically in our analyses.

Our data must be interpreted with caution. It is worth noting that disposition decisions were influenced by the defendant's history of criminal charges, which was available to the legal professionals and clinicians involved. That history, which is an important component in determining a defendant's risk, was not part of our database. Therefore, we were unable to ascertain what influence past criminal charges might have had on dispositions and whether this history differed across racial and ethnic groups.

Another caveat relates to data collection. Screening evaluations and initial diagnoses were based on a limited clinical examination and limited information, and there may be a tendency for clinicians to overdiagnose or underdiagnose defendants simply because of the nature of the screening. Moreover, race and ethnicity, which have recently been recognized even in the U.S. Census as increasingly difficult to categorize, were assigned by clinicians—who may themselves be in error—during the screening. This factor reflects a critical issue in all studies that are related to race and ethnicity (26). It is thus unclear whether clinical assignments to a particular racial and ethnic category correspond to how defendants view themselves.

As noted, the path for defendants to forensic mental health beds involves numerous complicated decisions. Our data described only one point in the process, and one cannot interpret our study's findings on the basis of only this point. It is clear from numerous reports that racial and ethnic disparities exist in criminal justice decision making that have nothing to do with mental health factors. No clear data are available from Massachusetts that examine the percentage of persons from ethnic minority groups who are arrested relative to the percentage of persons from minority groups who are hospitalized. Valid data are also lacking about the race of arrestees in general. However, the Bureau of Justice Statistics noted that the lifetime chance of going to prison is higher for blacks (18.6 percent) and for Hispanics (10 percent) than for whites (3.4 percent) (27). Furthermore, a bulletin of the Bureau of Justice Statistics indicated that in 2001 black men in their twenties and thirties were incarcerated at higher rates than both Hispanic men and white men (28). Our data examined decisions that were made only after a person had been arraigned on criminal charges. Data collected at this level cannot be used to ascertain how many persons were diverted from the criminal justice system to the mental health system, either before or after their arrest, or what the racial and ethnic makeup of such a group might be. Such information would be useful in shedding further light on decisions in the processes in which racial and ethnic factors may play a role. Thus, although we found an association between race and ethnicity and dispositional outcome, we did not find any evidence of a causal connection.

Importantly, a request for recommending where a defendant should be evaluated may be the first point in the process in which a clinician's input is sought. As such, this input may be a minor factor that is interjected late in a defendant's processing. The disparate rates of referral for inpatient evaluation of defendants who were black, Hispanic, or white should be interpreted in light of the possibility that these results are a function not of clinician variables but rather of a difference in the threshold—that is, more or less severe symptoms—that is required for certain minorities to be referred by legal professionals for a mental health evaluation (29). Although our data are only from Massachusetts, this interpretation is consistent with data obtained in Alabama. In that study, Cooper and Zapf (30) found that black defendants were more likely than white defendants to be referred for competency evaluations. They also noted that the racial disparities found in their study were more likely attributable to systemic variables than to clinician bias.

We do not have data about the potential role of other factors, such as socioeconomic status, level of education, living conditions, and availability and willingness to obtain resources that are essential to understanding the nuances of these types of findings (4,26). What does seem to be clear, however, is that racial minority groups are overrepresented throughout the criminal justice system and that this disparity likely extends to the forensic mental health system. Our study highlights yet another venue in which racial and ethnic disparities require further research attention. Our findings point to the need for increased awareness among clinicians about who ends up in the forensic mental health system. Informing forensic mental health professionals about these disparities as well as assisting them to achieve cultural competence represent but the initial steps toward understanding these complex issues.

The authors are affiliated with the law and psychiatry program in the department of psychiatry at the University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, Massachusetts 01655 (e-mail, [email protected]).