Commentary: racial bias in diagnosis and medication of mentally ill minorities in prisons and communities.

Dr. Hicks adds welcomed momentum to the rising tide of awareness of disparities in access, diagnosis, and treatment of ethnic and racial minorities who suffer from mental disorders. Disparities in caring for these populations are plain to see in communities throughout the country and, as the recent Human Rights Watch Report, “Ill-Equipped: U.S. Prisons and Offenders with Mental Illness” indicates, are especially glaring in forensic settings. The U.S. Department of Justice reported in 1999 that 16 percent of all inmates in state and federal jails had severe mental illness. Two hundred eighty-three thousand people with serious mental illnesses were in jail or prison—more than four times the number in state mental hospitals. The average daily number of patients in state and county psychiatric hospitals has steadily decreased from 592,853 in 1950 to 71,619 in 1994. Recent surveys have indicated that 40 percent of families of persons with mental illness report that index family members have been arrested at some point in their lives. Moreover, a recent Department of Justice report showed that more than three quarters of inmates with mental illness have at least one prior prison, jail, or probation term. Some individuals are incarcerated scores of times. Probation systems are also affected, as 16 percent of probationers were persons with mental illness. When incarcerated, mentally ill offenders present problems, particularly when they arrive in a disoriented or psychotic state. Once in jail, they remain longer than others with similar convictions. Often their condition deteriorates and they become a behavior problem. Further, there is little planning when an inmate with a mental illness is released. People leave jail without supplies of needed medications, public benefits to pay their living costs, or Medicaid for communitybased mental health services. As a result, many simply recycle through the criminal justice system. These alarming trends are directly related to the inadequacies of community mental health systems and services. The widespread adoption of systems with proven effectiveness in addressing the needs of people with the most severe mental illnesses, such as assertive community treatment programs, would sharply decrease the number of people with severe mental illnesses involved in criminal justice systems. However, since these programs are available only sporadically throughout the country, strategies for reducing criminalization focus both on improving community mental health services, such as supported housing and crisis intervention teams, and on making available mental health courts as a means of addressing the treatment and support needs of people with severe mental illnesses while in the community and when in the criminal justice systems. Without adequate mental health services, ethnic and racial minority patients are frequently mislabeled as criminals rather than as individuals suffering from a mental disorder. When a mental disorder is obvious to all, it is likely to be misdiagnosed, and if treatment follows, it may be rejected or be inappropriate because of the clinician’s lack of awareness of the cultural issues involved. In response to the U.S. Surgeon General’s Report entitled “Mental Health: Culture, Race and EthnicDr. Foulks is Sellars Polchow Professor of Psychiatry and Associate Dean of Graduate Medical Education, Tulane University School of Medicine, New Orleans, LA. Address correspondence to: Edward F. Foulks, MD, PhD, Tulane University Medical Center, 1430 Tulane Avenue SL77, New Orleans, LA 70112. E-mail: efoulks@tulane.edu