Black patients get higher drug doses for mental illness in county emergency rooms -- for no apparent reason

by Pat McBroom

Berkeley -- Far stronger medication is being given to many black mentally ill patients in county emergency rooms than to other patients with the same condition.

In at least a third of cases, black patients got twice the dosage of a powerful anti-psychotic drug compared to patients of other races, according to a five-year, on-site investigation of more than 400 cases by a UC Berkeley team from the School of Social Welfare. Only about half of the black patients were treated similarly to others.

This study in three county hospitals in the San Francisco Bay Area and Los Angeles appears to be the first to demonstrate that poor, mentally ill patients are treated differently by race in emergency rooms, and it may be a signal for the nation, said the researchers who published their work in a recent issue of the journal, "Psychiatric Services."

They said they could find no reason for the higher drug dosages except for race and one other difference: emergency room clinicians, who were primarily white, spent less time talking to and evaluating the black patients.

When the clinicians engaged black patients in conversation about their condition, the drug treatment was more nearly comparable to other patients, although still slightly higher, the study shows.

It was conducted by Professor of Social Welfare Steven P. Segal, with researcher John R. Bola, and Margaret A. Watson, who is now with the Western Montana Regional Mental Health Center in Missoula. The hospitals were not named in the study and Segal declined to identify them because he said he did not want to single them out.

Segal said the high levels of medication given to black patients were "probably outside the range of recommended dosages."

"There is no justification for it," he said. "Our study showed that black patients who received the extra medication were not more dangerous or more severely ill than anyone else."

Segal said an extra dose of Haldol, the most commonly used antipsychotic drug, would probably create physical discomfort and restlessness.

"You can't sit still and you might feel stiff, with some spastic motor side effects," said Segal. He added that the medication would be unlikely to cause permanent damage, primarily because patients would probably stop taking it.

The UC Berkeley study was unusual for its depth of observations on such a large number of subjects. Observers followed patients from the time they entered the emergency room, through the clinical evaluation to final disposition, spending from 15 minutes to eight hours on each, depending on the case. Using a scale of dangerousness developed by Segal, the observers rated each patient independently of the clinician's evaluation and also observed and rated the interaction between doctor and patient.

Over five years, observers evaluated the care given to 442 mental patients, taking care to collect cases around the clock and throughout the year. Whoever came in the door while an observer was in the emergency room became a part of the study.

The researchers found that not only did black patients get higher doses of antipsychotic drugs, but they were also likely to get more doses of other kinds of psychiatric medication such as antidepressants and antianxiety agents, and they received more injections of antipsychotic drugs. Segal's group was unable to account for this on the basis of any difference in the behavior or symptoms of the patients.

"We wonder if this is the tip of an iceberg," said Bola. "We can't prove that this situation is true of other emergency rooms in California or the nation, but it is certainly suggestive. This is one of a few pieces of solid evidence of differential treatment of African Americans, and that is significant," said Bola.

The good news, said Segal, is that the problem can be corrected once it is acknowledged. Researchers found, for instance, that the amount of effort clinicians put into making contact with the mentally ill person and drawing him or her into the treatment plan was key to lowering the drug dose for black patients.

"Clinicians need to engage black patients more. Spending more time finding out what their needs are translates into less medication," said Segal.

But he emphasized that he does not want to blame county hospital clinicians who are "doing a yeoman's job under a state of siege."

"To treat the thousands of patients who sometimes overwhelm these emergency rooms, clinicians shave time off the psychiatric evaluations, giving everyone less than optimal time. But they shave off more with the black patients than with the others," he said.

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