Client Racial Composition in First-Episode Psychosis Programs Compared With Compositions in Program Service Areas

Data presented here came from the MHBG 10% Set Aside Study, a 3-year, mixed-methods evaluation funded by the Substance Abuse and Mental Health Services Administration and the National Institute of Mental Health. The MHBG 10% Set Aside Study included special focus on 36 study sites. This analysis included 35 of these sites; we excluded a program in Puerto Rico because of complexities in Census race categories among Puerto Ricans living on the island (15). Table 1 presents the basic characteristics of the CSC sites.

We adapted well-established methods for assessment of disproportionality that are used in U.S. federal special education policy (16) and that center on two metrics. The first metric was the “relative difference in composition,” indicating the relative difference between the percentage of a specific racial-ethnic group’s composition within a CSC program and the composition of that group within the service area. When the relative difference in composition score is 0 or close to 0, it indicates no or low disproportionality. If the relative difference equals 1, the composition of Black clients is twice as much as would be expected from the composition of the Black population in the service area; if it equals 2, then it is three times as much, and so on. The second metric, the risk ratio, was used to assess the risk for site enrollment for Black clients. The risk was expressed as the percentage of the Black population in the service area who participated at the site, and a risk ratio was the ratio between the risk for the Black population compared with the risk for the non-Black population. A risk ratio that is equal to or close to 1 indicates that the risk for site enrollment for Black and non-Black populations is close or equal, that is, no or low disproportionality. A risk ratio of 0 indicates that there are no Black clients in a site, and it indicates high disproportionality of the non-Black population (details on both metrics are available in an online supplement to this article).

In addition, we conducted a sensitivity analysis to address two issues. First, there was sampling error—a statistical error that arises from taking a sample from a population—associated with the ACS estimates of the percentage of the Black population in the service area. To address this error, 30 replications of each set of relative-difference and risk-ratio statistics were calculated with methods presented in Krenzke and Li (17). The replicated-estimates approach provides a way to account for the sampling error from the ACS in the analysis so that a measure of uncertainty in the analysis results can be estimated. The variation in the site estimates (i.e., relative difference and risk ratio) across replicated tables aligned with the estimated sampling variance associated with the site estimates. This provided evidence that our measure of uncertainty in the analysis results was accurate. Second, some of the 35 sites had a small number of participating clients. To address this limitation, we adjusted the results from the replicated tables to reflect the next person or persons to come into the site according to the following three scenarios: the next client is Black, the next five clients are Black, and the next client is non-Black. This strategy allowed us to evaluate how much the results would be affected by making a small change (i.e., adding one or five additional clients). We include details on sensitivity analysis in Table 2 (relative difference in composition) and Table 3 (risk ratio) as well as in the online supplement.

To compare Black and non-Black participants receiving Medicaid and having past experiences with agencies, we used chi-square tests. All aspects of this study were reviewed and approved by the Westat Research Ethics Board.

In some cases, disproportionality could be an artifact of site location and population. Namely, a site may be in an area of the city that is largely non-Black, but it may still serve a predominantly Black population by drawing heavily from Medicaid clients. We did not, however, observe an association between percentage of Medicaid recipients within a program and degree of disproportionality.

Young adults enter CSC programs through a variety of pathways, and some of these channels may have an aspect of racial bias. In Canada, for example, Black youths disproportionately enter the mental health system through emergency care systems and judicial avenues, compared with non-Black youths (4). We did not find differences between Black and non-Black clients in service receipt in an inpatient setting, in treatment in an ED or crisis center, or in experience of a legal issue within the 6 months before the study. These results alone, however, do not rule out the possibility of differences in referral patterns because it is possible that a higher proportion of Black clients than non-Black clients experienced one of these situations and were referred to the CSC programs. For example, a difference in referral patterns by inpatient physicians might occur if attending physicians are more likely to encourage private care (including referral to the physician him- or herself) for patients who are not Black and to recommend referral to CSC for Black patients.

Depending on demand for services, more than one CSC program may serve individuals with FEP in a community. This scenario is most likely in urban areas where the population can support multiple programs and where there may be a university-based program as well as a program in a community mental health center. In these situations, family choice could contribute to disproportionality. For example, site 34 in this study had no White clients, because according to team members at this site, White families with private insurance chose the reportedly more prestigious university-based CSC program over their community-based clinic. As a counterexample, site 10 team members believed that the stigma of going to a community mental health center was a reason that White families did not choose their clinic; however, this site also did not display evidence of disproportionality. Among the seven sites with the highest disproportionality, three were in areas with another CSC program, and four were not. Given these findings, it is difficult to determine whether client and family preferences played a role in driving disproportionality in this study.

A core element of the CSC model is to conduct outreach and activities in the community to raise awareness of FEP and to ensure that clients reach the clinic as early as possible (7). Disproportionality could theoretically result from more assertive outreach in predominantly Black schools and neighborhoods within a service area. We did not have data on specific outreach activities among these 35 sites, although we did not hear about such activities during the site visit interviews. Given the high number of sites that displayed some degree of disproportionality, we do not believe that targeted outreach was a likely explanatory factor for disproportionality.

Across many fields, disproportionality in racial makeup at a CSC site is considered a negative phenomenon. For example, decades of data show that Black students are more likely to be identified for special education under the “subjective” classifications, such as emotional disturbance and intellectual disability (18). After being placed in special education, Black students spend considerably more time in separate classrooms than do White students (19), a placement that is considered less beneficial than placement in general education. In contrast, disproportionality in this study could be viewed positively. Namely, Black young adults seem to be finding their way to evidence-based, specialized programs that many consider the best option available for someone experiencing early symptoms of psychosis, provided that the diagnosis is accurate. The primary clinical implication, therefore, is that programs must ensure that they are particularly responsive and racially sensitive in their work with these clients, especially if they are not accustomed to working with Black families and clients. Moreover, clinicians and other team members should reflect the race of the population they serve.

A primary limitation of this study was that we were unable to precisely compare the racial composition of clients in the CSC programs with that of the larger agency or clinic; moreover, at least in some sites, what appeared to be disproportionality in the program may have been comparable to the racial composition in other units or programs within the agency. We also could not distinguish between different subgroups of Blacks, such as African American, Black African, and Black Caribbean groups, even though such distinctions may be relevant for interpreting the findings (20).