Race and patient violence

John Battaglia, MD, describes many valid factors that could predict violence in an inpatient setting (Current Psychiatry, February 2004). However, we disagree that being “nonwhite” is among these factors.

Studies that cite race as a predictor of patient violence have not been adequately controlled for significant variables. By contrast, Silver¹ showed that race does not predict violence among persons with mental disorders when neighborhood disadvantage is statistically well-controlled.

Using race to predict patient violence may explain why nonwhite patients inadvertently get excessive medication. In a retrospective study,² African-American patients with schizophrenia were:

• 1.8 times more likely than their white counterparts to receive excessive doses of typical antipsychotics
• more likely than white patients to be treated with older, high-potency antipsychotics.²

Many researchers have demonstrated other differences in treatment of nonwhite vs. white inpatients and have proposed that nonwhites face barriers to diagnosis and drug management of psychiatric disorders. A review of 344 persons with schizophrenia³ found pronounced variations in treatment (such as use of atypical neuroleptics) based on race, even though the data were adjusted for demographic and clinical characteristics. After controlling for relevant variables, Allegra et al⁴ found that poor Latinos and African Americans not classified as poor are less likely to receive specialty psychiatric care than their white counterparts.

Using race as a variable in inpatient settings discourages objective clinical management, albeit not deliberately. In this way, a relatively inexperienced doctor subconsciously learns to consider race to explain a patient’s violent actions.

Babatunde A. Adetunji, MD
Maju Mathews, MD
Department of psychiatry
Drexel University College of Medicine
Philadelphia, PA

Kumar Budur, MD
Department of psychiatry
Cleveland Clinic Foundation, Cleveland, OH

References

1. Silver E. Race, neighborhood disadvantage, and violence among persons with mental disorders: the importance of contextual measurement. Law Hum Behav 2000;24:449–56.
2. Diaz FJ, De Leon J. Excessive antipsychotic dosing in 2 U.S. state hospitals [comment]. J Clin Psychiatry 2002;63:998.
3. Kreyenbuhl J, Zito JM, Buchanan RW, et al. Racial disparity in the pharmacological management of schizophrenia. Schizophr Bull 2003;29:183–93.
4. Allegra M, Canino G, Rios R, et al. Inequalities in use of specialty mental health services among Latinos, African Americans, and non-Latino whites. Psychiatr Serv 2002;53:1547–55.

Dr. Battaglia responds

Drs. Adetunji, Mathews, and Budur raise some interesting questions about race and statistics, and this of course is an area of intense scrutiny that requires further study.

Race and culture are inextricably linked, and studies designed to ferret out the differential aspects are often subject to the same criticisms they attempt to clarify. I agree that we must all keep an open mind for interpreting data in this intriguing area.

John Battaglia, MD
Medical director, Meriter Hospital adult psychiatry program
Associate professor, department of Psychiatry
University of Wisconsin Medical School
Madison