A Paradox of Bias: Racial Differences in Forensic PsychiatricDiagnosis and Determinations of Criminal Responsibility

Brea L. Perry • Matthew Neltner • Timothy Allen

� Springer Science+Business Media New York 2013

Abstract Although there is substantial evidence that

African Americans receive unequal treatment in both the

healthcare and criminal justice systems, less research has

investigated the role of race when these two systems con-

verge. Here, we examine the influence of race on patterns

of forensic psychiatric diagnosis and determinations of

criminal responsibility in pre-trial correctional facilities

(e.g., forensic psychiatric hospitals). Data are from a

medical chart review of 129 randomly selected competency

evaluations that occurred in a pre-trial correctional psy-

chiatric facility. Consistent with previous research, findings

indicate that African Americans are disproportionately

diagnosed with highly stigmatized psychotic spectrum

disorders relative to whites. In addition, they unexpectedly

indicate that African Americans are significantly more

likely than whites to be found not criminally responsible by

the court-appointed evaluating mental health professional,

controlling for sociodemographic characteristics, number

of violent and non-violent charges, and other potential

confounding variables. Mediation analysis reveals the

important and previously undocumented finding that the

effect of race on criminal responsibility determinations is

fully mediated by differential diagnosis. This suggests that

patterns of racial inequality and potential bias in the

diagnostic process may confer medical resources and other

benefits for African Americans in the context of the

criminal justice system.

Keywords Race � African American � Psychiatric

diagnosis � Criminal justice � Forensic psychiatry � Not

guilty by reason of insanity (NGRI)

Introduction

Racial and ethnic inequality is evident in both the Ameri-

can healthcare system and criminal justice system. With

respect to health care, research suggests that African

Americans have less access to health services and tend to

receive delayed treatment and lower quality acute and

long-term care than whites (Wright and Perry 2010;

Smedley et al. 2002; Williams and Rucker 2000). Dispar-

ities are particularly pronounced in the area of psychiatric

treatment, with documented differences in treatment-

seeking, barriers to receiving care, higher likelihood of

involuntary hospitalization, and provider bias that affects

clinician–patient interactions and treatment outcomes

(Segal et al. 1996; Snowden 1999; Snowden and Pingitore

2002; van Ryn and Burke 2000). Of central concern for this

analysis are racial disparities in diagnosis, wherein African

Americans are disproportionately likely to be diagnosed

with a psychotic disorder (Blow et al. 2004; Neighbors

et al. 1999; Strakowski et al. 2003). In general, undiag-

nosed or misdiagnosed mental illness among racial and

ethnic minorities is a major public health concern as it

results in worse acute and long-term outcomes for those

affected (Wang et al. 2005). In addition, because psychotic

disorders are more highly stigmatized by the American

B. L. Perry (&)

Department of Sociology, University of Kentucky, Lexington,

KY, USA

e-mail: breaperry@uky.edu

M. Neltner

University Health Service, University of Kentucky, Lexington,

KY, USA

T. Allen

Department of Psychiatry, University of Kentucky, Lexington,

KY, USA

123

Race Soc Probl

DOI 10.1007/s12552-013-9100-3

public, this pattern of misdiagnosis has critical implications

for the social status and life chances of labeled individuals

(Phelan et al. 2000; van Dorn et al. 2005).

In recent decades, the mental health and criminal justice

systems have become increasingly intertwined, with

greater numbers of people with serious mental illness now

being detained and treated in correctional facilities than in

psychiatric hospitals (Lamb and Weinberger 2001). Since

the deinstitutionalization movement began in the 1960s,

there has been a sharp reduction in in-patient psychiatric

hospital capacity that poses barriers to providing appro-

priate long-term care for the most severely impaired and

socioeconomically disadvantaged patients (Ehrenkranz

2001; Lamb and Bachrach 2001). Consequently, there has

been an increase in untreated mental illness in urban areas,

leading to homelessness, crime, and arrests (Markowitz

2006; Mechanic and Rochefort 1990). This trend has been

termed the criminalization of mental illness (Abramson

1972).

The mental health and criminal justice systems converge

most overtly in psychiatric pre-trial correctional facilities

and mental health courts. Criminal defendants are evalu-

ated by psychiatrists and psychologists for competency to

stand trial and criminal responsibility in cases where

mental illness is suspected. In a very small minority of

cases, individuals with mental illness may be determined

not guilty by reason of insanity (NGRI), meaning (in many

jurisdictions) that ‘‘…the defendant, as a result of severe

mental disease or defect, was unable to appreciate the

nature and quality or the wrongfulness of his acts’’ (Federal

Insanity Defense Reform Act, 1984). In such cases,

defendants are either released from custody or committed

to a psychiatric facility rather than a prison and released

when they pose no further threat rather than serving out a

mandated sentence in prison. An NGRI finding is a pref-

erable legal outcome in most cases since social conditions

and access to mental health treatment are substantially

better in psychiatric hospitals relative to prisons (Baillar-

geon et al. 2010; Birmingham 2003; Forrester et al. 2010).

On the whole, African Americans are disadvantaged

across nearly all sectors of the criminal justice system—

from higher arrest rates to harsher sentencing (Higginbo-

tham 2002; Pettit and Western 2004; Roberts 2004). Par-

adoxically, there is modest evidence that African

Americans are more likely than whites to be found NGRI

(Poulson 1990). However, mechanisms underlying this

counter-trend are not well understood. More research is

needed to determine how race affects criminal responsi-

bility determinations in criminal courts and diagnostic

decisions in forensic psychiatric facilities, and whether

these are related.

Here, we use data from 129 pre-trial competency eval-

uations in a forensic psychiatric facility obtained through

retrospective chart review. We examine whether African

American patients were more likely to be diagnosed with a

psychotic disorder and to be recommended not criminally

responsible relative to whites by the court-appointed

evaluator. Then, we assess whether the impact of race on

criminal responsibility determinations works through racial

disparities in diagnosis, conferring additional medical care

and other resources for African Americans in this small

sector of the criminal justice system.

Racial Disparities in Psychiatric Diagnosis

and Treatment

African Americans are about three to four times as likely as

whites to be diagnosed with psychotic disorders such as

schizophrenia (Blow et al. 2004), and only about a third of

the effect of race can be explained by socioeconomic status

(SES) differences across racial groups (Bresnahan et al.

2007). A substantial proportion of racial disparities in

psychiatric diagnosis reflects real differences in the inci-

dence of disorder and is likely attributable to social epi-

demiological factors such as racism and segregation into

impoverished neighborhoods (Williams 1999; Williams

and Jackson 2005). However, another source is provider

behavior and clinical decision-making (van Ryn 2002; van

Ryn and Fu 2003), which may artificially inflate rates of

psychotic disorders among African Americans.

Substantial evidence indicates that patient race signifi-

cantly affects psychiatric diagnosis such that African

Americans are more likely to receive a diagnosis of

schizophrenia and less likely to be diagnosed with

depression than whites similar on relevant characteristics

(DelBello et al. 2001; Kales et al. 2000; Lawson et al.

1994; Loring and Powell 1988; Neighbors et al. 1999;

Raybur and Stonecypher 1996; Takei et al. 1998; Trier-

weiler et al. 2000). For instance, Strakowski et al. (2003)

found that African American men diagnosed with affective

disorder by expert consensus were significantly more likely

than other patients to be diagnosed with a schizophrenia

spectrum disorder by clinical assessment and structured

interview. Research across a variety of settings and sam-

ples indicates that African Americans are 10–40 % more

likely to be diagnosed with psychotic spectrum disorders

than whites and other comparison groups (for reviews, see

Adebimpe 1981 and Neighbors et al. 1999).

Several potential explanations for over-diagnosis of

psychotic spectrum illness among African Americans have

been offered. It may be that diagnostic criteria are biased

and ethnocentric, making the DSM a less valid and reliable

diagnostic tool for some racial or ethnic groups relative to

others (Funtowicz and Widiger 1995; Widiger and Spitzer

1991). Alternatively, the application of diagnostic criteria

to different racial or ethnic groups by clinicians may be

Race Soc Probl

123

unintentionally biased. For example, there is evidence that

clinicians differentially attribute and weigh various symp-

toms (e.g., hallucinations, paranoia, and elevated mood) in

making diagnostic decisions about African Americans

versus other groups (Trierweiler et al. 2000). These pat-

terns can be the result of patients’ cultural mistrust of the

medical system, ineffective communication and weak

therapeutic alliance between clinicians and patients, or

clinicians’ cultural misunderstandings and racial prejudices

(Neighbors et al. 1999; Snowden 2003; Vasquez 2007).

Although clinicians are expected to objectively weigh

biomedical and behavioral evidence in making diagnostic

and treatment decisions, disregarding race, gender, socio-

economic status, and other sociodemographic factors, bias

may be unavoidable. Stereotyping and social categorization

are components of an adaptive cognitive strategy that helps

humans make sense of vast amounts of complex informa-

tion, increasing the speed and efficiency of cognitive pro-

cessing (Kunda 1999; Stangor 2000). Stereotypes about a

group may be applied to individuals during the clinical

encounter, unconsciously affecting beliefs and expectations

about patients (Lewis et al. 1990). For instance, van Ryn

and Burke (2000) found that race negatively influenced

clinicians’ ratings of patients’ intelligence, personality, and

adherence to treatment recommendations after controlling

for socioeconomic status, mental health status, gender, and

other patient and clinician characteristics. Studies find that

through this lens of racial or ethnic stereotypes, similar

patient behavior can be interpreted in very different ways,

particularly if the behavior is ambiguous (Dunning and

Sherman 1997; Lepore and Brown 1997; Sagar and

Schofield 1980; Trierweiler et al. 2000).

Other racial differences in psychiatric treatment have

been identified, some of which may contribute to differ-

ential diagnosis. Controlling for patient behavior and other

clinical factors, clinicians spend less time evaluating

African American patients relative to whites (Cooper et al.

2003; Segal et al. 1996). Consistent with disparities in

diagnosis, African Americans are more likely to be pre-

scribed antipsychotic medications (Dixon et al. 2001; Segal

et al. 1996). Also, African Americans are more likely to be

brought to psychiatric treatment by legal means, emer-

gency room use, and involuntary hospitalization (Akutsu

et al. 1996; Rosenfield 1984; Takeuchi and Cheung 1998;

Snowden and Cheung 1990; Snowden 1999), and less apt

to voluntarily seek or receive psychiatric treatment than

whites (Department of Health and Human Services 1999;

Snowden and Pingitore 2002; Wang et al. 2005).

Perceived dangerousness is the strongest factor in pre-

dicting support of forced treatment for mental illness

(Corrigan et al. 2003) and is closely linked to the presence

of psychotic symptoms by the American public, mental

health treatment providers, and family members of

individuals with psychotic disorders (Phelan et al. 2000;

van Dorn et al. 2005). Consequently, perceptions of dan-

gerousness and psychotic symptoms are associated both

with support for forced or coerced treatment and with more

stigmatizing attitudes and greater desire for social distance

from individuals with mental illness (Link et al. 1999;

Pescosolido et al. 2007; van Dorn et al. 2005; Watson et al.

2005). This research suggests that there may be a link

between misdiagnosis of psychotic disorders among Afri-

can Americans, perceived dangerousness of racial and

ethnic minorities with mental health problems, and invol-

untary entry into treatment through the criminal justice

system.

Racial Inequality in the Criminal Justice System

Racial and ethnic minorities experience inequality in the

criminal justice system (Maurer and King 2007), which has

become increasingly involved in detaining individuals with

serious mental illness (Lamb and Weinberger 2001). Pettit

and Western (2004) estimate that about twenty percent of

African American men are imprisoned by age 30 compared

to only three percent of white men in the same birth cohort.

African Americans, especially young men, are dispropor-

tionately likely to be both arrested and convicted of crimes

(Higginbotham 2002). Factors that contribute to this pat-

tern are family structure, living in areas of concentrated

poverty, low SES, and police and juror racial bias (Higg-

inbotham 2002; Kirk 2008). Once convicted, African

Americans receive harsher punishments than whites, with

disproportionate numbers of the minority group being

imprisoned for 1 year or more (Roberts 2004; Sweeney and

Haney 1992).

An area of the criminal justice system in which African

Americans may have an advantage is determinations of

criminal responsibility. In a very small minority of cases,

juries may determine that a defendant is not responsible for

his or her crimes due to mental disorder or defect, also

known as NGRI. One study suggests that jurors are more

likely to find a defendant NGRI if he or she is African

American (Poulson 1990). In addition, race has been shown

to affect jury determinations in other instances, for exam-

ple in cases where the jury is concerned that pre-trial

publicity is racist (Fein et al. 1997); the jury in such cases

tends to give the minority defendant more leeway to offset

discrimination. However, whether and how race influences

determinations of responsibility for criminal activity

among patients with mental illness is not well understood.

In cases where mental illness is suspected, defendants

are evaluated for psychiatric disorders that might affect

competency to stand trial and criminal responsibility

(Knoll and Resnick 2008). Attornies assigned to a case may

also request a psychiatric evaluation. Psychiatrists or

Race Soc Probl

123

psychologists provide observation evidence (descriptions

of behaviors and cognitions that provide evidence of

mental illness), mental disease evidence (psychiatric dis-

orders for which a defendant meets diagnostic criteria, if

any), and capacity evidence (whether the mental illness

reduced the defendant’s capability to perform mental pro-

cesses; Wortzel and Metzner 2006). The NGRI defense is

employed in \1 % of cases in the US court system and is

only successful in about one quarter of those cases (Silver

et al. 1994).

However, when a jury makes an NGRI determination,

defendants are often committed to a psychiatric facility for

an indeterminate period until they pose no further threat

rather than to a correctional facility for a pre-determined

sentence. Psychiatric facilities are preferred restrictive

environments since prisons provide comparatively fewer

and lower-quality mental health services, and are charac-

terized by conditions likely to exacerbate mental illness

(e.g., overcrowding, physical and emotional abuse by fel-

low prisoners and prison staff, social isolation; Baillargeon

et al. 2010; Birmingham 2003; Forrester et al. 2010).

Additionally, because inmates with mental illness detained

in prisons do not receive appropriate long-term mental

health treatment, their likelihood of recidivism and sub-

sequent re-arrest is high (Ditton 1999; NAMI 2004).

Despite the increasing role of mental health courts in the

criminal justice system and the sharp increase in mental ill-

ness among inmates in recent decades (Lamb and Wein-

berger 2001), little is known about how race or ethnicity

affect diagnostic determinations by clinicians in forensic

psychiatric facilities. Furthermore, whether and how race

influences determinations of responsibility for criminal

activity among pre-trial evaluees with mental illness is not

well understood. There is much at stake both in terms of

taxpayer burden and outcomes among prisoners with mental

illness. On average, in 2001, the annual cost per state inmate

was $22,650 (Stephan 2004), and costs are estimated to be

nearly fifty percent higher among inmates with serious

mental illness (Lovell et al. 2001). In addition, inmates with

mental health problems have higher recidivism rates, leading

to multiple imprisonments and progressively lengthy sen-

tences (Baillargeon et al. 2009). Since African Americans

are disadvantaged in both the criminal justice and mental

health treatment systems, understanding how race affects

diagnostic and legal outcomes when these systems converge

is critical.

The present study is of 129 pre-trial evaluees referred to

a forensic psychiatric facility for competency, criminal

responsibility evaluation, and/or psychiatric treatment.

During an initial examination of these data, we unexpect-

edly found that white pre-trial evaluees were significantly

more likely to be determined to be responsible for their

crimes by mental health evaluators than were African

Americans. The purpose of this study is to determine

whether differential diagnosis with psychotic mental illness

(e.g., schizophrenia, schizoaffective disorder, psychosis not

otherwise specified) in the forensic psychiatric facility

partially or fully accounts for the racial discrepancy in

being found responsible for crime.

Methods

Patients were sent to the Kentucky Correctional Psychiatric

Center (KCPC) by court order. Transfer to KCPC is typically

requested by Defense Counsel for competency to stand trial

and criminal responsibility evaluations. By definition, these

patients were thought to be cognitively or emotionally

impaired by a non-clinician prior to their referral. Medical

charts were selected randomly for review from all KCPC

discharges in 20061. A database was created recording

information from the medical chart, including sociodemo-

graphic information, criminal and psychiatric history, Axis

I–III diagnosis, and evaluator determinations of criminal

responsibility. Because the charts represent historical data,

and no identifying information was recorded, the Institu-

tional Review Board at the University of Kentucky waived

the informed consent requirement.

While 194 charts were selected for review, only 131 of

these contained information about criminal responsibility

determinations. Though efforts were made to contact

KCPC to obtain this information, it was not recorded in

either patient charts or the state’s electronic database in 63

cases. In addition, two cases were listed as ‘‘Hispanic’’

with no indication of race. These 65 cases (34 % of the

sample) were dropped from all analyses. Concerns about

the bias this potentially introduces are minimal since a

comparison of cases with and without missing data reveal

no significant differences by gender, race, socioeconomic

status, psychiatric diagnosis, or other study variables.

Measures

Sociodemographic variables are included in multivariate

models as controls. These include gender (1 = female;

0 = male) and race (1 = white; 0 = African American).

Age and educational attainment are measured in years. Two

1 According to statistics from the Kentucky Justice and Public Safety

Cabinet (2007), 23 % of all individuals arrested in Kentucky between

2003 and 2007 were African American. This figure is very similar to

the distribution of African Americans in our randomly selected

sample (22 %). However, this figure is substantially higher than the

overall percentage of the Kentucky population that is African

American (8 %). This suggests that African Americans are dispro-

portionately likely to be arrested in Kentucky, but once arrested, they

are probably not disproportionately likely to be sent to a psychiatric

correctional facility for evaluation prior to standing trial.

Race Soc Probl

123

additional variables measuring diagnosis with a cognitive

impairment (e.g., mental retardation) or learning disability

(1 = yes; 0 = no) and history of illegal drug abuse or

dependence (1 = yes; 0 = no) are included in models as

independent variables. Also, two independent variables

measure treatment and behavior while at KCPC are included

in models. Length of stay is measured in days and a dichot-

omous variable indicates whether the patient was physically

restrained while at KCPC (1 = yes; 0 = no). Independent

variables measuring criminal history are separated into total

number of violent and non-violent prior convictions and

current charges. Alternative coding strategies (e.g., sepa-

rating previous convictions from current charges) did not

alter regression results and resulted in poorer model fit.

With respect to dependent variables, Axis I diagnosis is

measured as a series of dichotomous indicators representing

affective disorders, substance use disorders (SUDs), and

psychotic disorders. Affective disorders include major

depression, bipolar, anxiety, and adjustment disorders.

Psychotic disorders include schizophrenia, schizoaffective

disorder, dementia, and psychosis NOS. All of the evaluated

patients were diagnosed with a psychiatric disorder. Diag-

nostic categories are used as dependent variables in the first

set of models and independent variables in the second set.

Finally, a dichotomous dependent variable represents mental

health evaluator determinations of criminal responsibility

(1 = responsible; 0 = not responsible).

Analysis

Binary logistic regression is employed to model the effects

of race and other independent variables on patients’ odds of

being diagnosed with a psychotic disorder and their odds of

being found responsible for their crimes. To facilitate the

use of these results in meta-analyses, odds ratios for the

effects of race are converted to effects sizes and presented

in text (Chinn 2000). For each outcome, related groups of

variables are added in a stepwise fashion, resulting in four

restricted models and one full model with all covariates.

This strategy permits a preliminary assessment of media-

tion, which is then fully tested using the sgmediation

command in Stata with a bootstrapped estimation of the

indirect effect (MacKinnon and Dwyer 1993)—a method

that has been shown to produce less biased estimates than

the Baron and Kenny (1986) and Sobel (1986) methods in

simulation studies (MacKinnon et al. 1995).

Initially, multinomial logistic regression was employed

to predict a nominal diagnosis outcome (where

1 = affective disorder; 2 = psychotic disorder; 3 = sub-

stance use disorder) rather than a binary one (1 = psy-

chotic disorder; 0 = affective disorder or SUD). However,

a binary model is presented for the following reasons: (1)

the number of patients with an Axis I SUD is relatively

small, introducing estimation bias associated with small

cell size; (2) Wald tests did not identify statistically sig-

nificant differences in the effects of independent variables

on the odds of being diagnosed with an affective disorder

versus a SUD; (3) results regarding race and psychotic

disorders are the same whether patients with SUDs are

omitted or combined with affective disorders; and (4)

interpretation of binary models is more straightforward and

comprehensible by a broader audience of readers. Full

results are available upon request. Finally, multicollinearity

was assessed using variance inflation factors (VIFs). None

of the VIFs exceed 1.5, suggesting that the level of mul-

ticollinearity is unproblematic.

Results

Descriptive Findings

Sample descriptive statistics are presented in Table 1.

About 12 % of the sample is female, 78 % is white, and

22 % is African American. Mean age is 33.20, and mean

year of schooling is 10.19. About 22 % of patients in the

sample were diagnosed with cognitive impairment or a

learning disability, and 78 % had a history of abusing

illegal drugs. With respect to primary Axis I diagnosis,

32 % were diagnosed with a psychotic spectrum disorder,

58 % with an affective disorder, and 10 % with a substance

use disorder. The average length of stay in the forensic

psychiatric facility is 46.41 days, and 19 % of patients

were secluded or restrained at least once while at the

facility. The mean number of past convictions and current

violent charges against patients in the sample is 1.92, and

the mean number of non-violent convictions and charges is

12.00. Finally, 81 % of patients evaluated at the forensic

psychiatric facility were determined responsible for their

crimes by the court-appointed evaluator.

Multivariate Findings on Predictors of Diagnosis

The effects of sociodemographic and other independent

variables on diagnosis with a psychotic disorder are

depicted in Table 2. According to Model 1, white patients

are estimated to be 78 % less likely than African Ameri-

cans to be diagnosed with a psychotic disorder (p \ 0.01)

versus an affective disorder or SUD. This constitutes a

large effect size (d = 0.89; CI 0.32–1.46). In addition,

higher levels of education are associated with a reduction

in the odds of being diagnosed with a psychotic disorder

(OR = 0.73; p \ 0.01). Findings in Model 2 indicate that

neither cognitive impairment nor history of drug abuse has

a significant effect on diagnosis. However, as shown in

Model 3, length of stay in the forensic psychiatric facility is

Race Soc Probl

123

positively associated with the odds of being diagnosed with

a psychotic disorder (OR = 1.03; p \ 0.01). Neither

number of violent nor non-violent convictions and charges

significantly predict psychotic diagnosis (See Model 4).

The full model with all covariates is presented in Model

5 of Table 2. The effects of race, educational attainment,

and length of stay remain significant in the full model, and

coefficients are slightly larger or unchanged. This suggests

that the effects of these variables are not confounded or

mediated by criminal charges, treatment factors, cognitive

impairment, or drug abuse history. Holding covariates at

their means, the predicted probability that an African

American at the forensic psychiatric facility is diagnosed

with a psychotic disorder is 56 %, compared to only 21 %

for white patients. Likewise, the predicted probability that

a patient with an 8th grade education is diagnosed with a

psychotic disorder is 48 %, compared to 15 % for a patient

with a high school degree and only 4 % for a patient with a

college degree. In all, findings are consistent with previous

research, suggesting that there are substantial racial and

socioeconomic status disparities in diagnosis of psychotic

disorders.

Multivariate Findings on Predictors of Court

Determination

Results from the regression of criminal responsibility

determination by mental health evaluators on race and

other independent variables are presented in Table 3.

According to Model 1, white patients are estimated to be

Table 1 Sample descriptive statistics (n = 129)

Mean SD Range

Female 0.12

Race/ethnicity

White 0.78

African American 0.22

Age in years 33.20 10.53 18–75

Educational attainment in years 10.23 2.37 2–20

Cognitive or learning disability 0.29

History of drug abuse 0.78

Axis I diagnosis

Psychotic disorder 0.32

Affective disorder 0.58

Substance abuse/dependence 0.10

Length of stay in days 46.41 32.65 4–330

Was physically restrained 0.19

Number of violent charges 1.92 2.68 0–18

Number of non-violent charges 12.00 48.31 0–506

Found criminally responsible 0.81

Table 2 Binary logistic

regression of psychotic

diagnosis on independent

variables (n = 129)

Table presents odds ratios

(standard errors in parentheses);

two-tailed tests; *** p \ 0.001,

** p \ 0.01, * p \ 0.05

(1) (2) (3) (4) (5)

Female 1.13 1.05 0.84 1.00 0.66

(0.72) (0.70) (0.61) (0.66) (0.51)

White 0.22** 0.24** 0.20** 0.19*** 0.20**

(0.10) (0.12) (0.10) (0.09) (0.10)

Age in years 1.02 1.02 1.01 1.03 1.01

(0.02) (0.02) (0.02) (0.02) (0.03)

Educational attainment in years 0.73** 0.70** 0.74** 0.70** 0.67**

(0.08) (0.08) (0.08) (0.08) (0.09)

Cognitive or learning disability 0.59 0.45

(0.30) (0.26)

History of drug abuse 0.39 0.41

(0.20) (0.23)

Length of stay in days 1.03** 1.03**

(0.01) (0.01)

Was physically restrained 0.56 0.51

(0.33) (0.31)

Number of violent charges 0.93 0.94

(0.08) (0.09)

Number of non-violent charges 0.99 0.99

(0.00) (0.00)

Pseudo-R2 0.14 0.17 0.22 0.15 0.26

Likelihood ratio X2 22.64*** 26.90*** 35.46*** 24.82*** 41.56***

Race Soc Probl

123

nearly three times more likely than African Americans to

be determined responsible for their crimes (OR = 2.85;

p \ 0.05). This constitutes a moderate effect size

(d = 0.58; CI 0.01–1.14). In addition, being older is

associated with a reduced likelihood of being determined

criminally responsible (OR = 0.94; p \ 0.05). As shown

in Model 2, neither cognitive impairment nor drug abuse

history is significantly related to criminal responsibility

determinations. However, being diagnosed with a psy-

chotic disorder rather than an affective disorder or SUD is

strongly predictive of criminal responsibility such that

those with a psychotic diagnosis are 94 % less likely to be

determined criminally responsible than those with another

diagnosis (p \ 0.001). This constitutes a very large effect

size (d = 1.53; CI 0.79–2.23). In the model that includes

diagnosis, the effects of race and age are substantially

reduced and become non-significant, indicating a possible

mediating relationship. Results in Models 3 and 4 dem-

onstrate that length of stay, physical restraint, and charges

are not significantly related to criminal responsibility

evaluations.

Findings from the full model are presented in Model 5 of

Table 3. Here, age and psychotic disorder remain signifi-

cant, suggesting that these effects are not confounded by

any of the independent variables included in this analysis.

Number of violent past convictions and current charges

reaches statistical significance in the full model, as well,

such that each additional conviction/charge is associated

with a 70 % increase in the odds of being determined

criminally responsible (p \ 0.05). The predicted probabil-

ity of being determined responsible if diagnosed with an

affective disorder or SUD is 99 %, compared to only 73 %

for those diagnosed with a psychotic disorder. Also, the

predicted probability of being determined criminally

responsible for patients with no violent convictions or

charges is 91 %, compared to 97 % for patients with two

violent convictions or charges and 100 % for those with six

or more.

Race becomes non-significant in the full model and the

coefficient is substantially reduced compared to Model 1.

Results from bootstrapped estimation support the presence

of mediation, indicating that the indirect effect of race

through psychotic diagnosis is 0.23 (OR = 1.26; p \ 0.05)

and the direct effect is only 0.01 (non-significant). This

constitutes a small effect size (d = 0.13; CI 0.05–0.28). In

all, 95 % of the total effect of race on criminal responsi-

bility determination is mediated through diagnosis with a

psychotic disorder. African Americans are significantly

more likely to be diagnosed with a psychotic disorder,

which in turn substantially decreases their likelihood of

Table 3 Binary logistic

regression of criminal

responsibility on independent

variables (n = 129)

Table presents odds ratios

(standard errors in parentheses);

two-tailed tests; *** p \ 0.001,

** p \ 0.01, * p \ 0.05

(1) (2) (3) (4) (5)

Female 0.59 0.49 0.64 0.81 0.75

(0.49) (0.39) (0.44) (0.58) (0.68)

White 2.85* 1.04 2.91* 3.87* 1.07

(1.75) (0.67) (1.53) (2.21) (0.83)

Age in years 0.94* 0.96 0.94* 0.93** 0.92*

(0.02) (0.03) (0.02) (0.02) (0.03)

Educational attainment in years 1.03 0.90 1.01 1.06 0.87

(0.10) (0.11) (0.10) (0.11) (0.12)

Cognitive or learning disability 3.48 3.11

(3.08) (2.94)

History of drug abuse 1.17 1.02

(0.77) (0.72)

Psychotic diagnosis 0.06*** 0.03***

(0.04) (0.03)

Length of stay in days 0.99 1.00

(0.01) (0.01)

Was physically restrained 0.81 0.50

(0.52) (0.42)

Number of violent charges 1.44 1.70*

(0.29) (0.44)

Number of non-violent charges 1.08 1.11

(0.07) (0.09)

Pseudo-R2 0.10 0.31 0.11 0.17 0.41

Likelihood ratio X2 12.35* 38.56*** 13.42* 21.14** 50.53***

Race Soc Probl

123

being determined responsible for their crimes by a court-

appointed evaluator.

Discussion

Consistent with previous research (Poulson 1990), our

findings indicate that African Americans are less likely than

whites to be found responsible for their crimes by mental

health evaluators at a forensic hospital even after controlling

for socioeconomic status, violence, number of prior offenses,

and other factors related to responsibility determinations.

However, this relationship is fully mediated by higher levels

of diagnosis with psychotic spectrum disorders among

African Americans in the forensic psychiatric facility.

These data indicate that individuals with psychotic

symptoms are nearly 25 times more likely to be found not

criminally responsible than those with affective or substance

use disorders—a finding that is unsurprising given the cri-

teria for NGRI laid out by the Federal Insanity Defense

Reform Act and most state insanity statutes. Namely,

defendants must have a severe mental illness that prohibits

them from knowing that their actions were wrong (cognitive

prong) and/or prohibits them from conforming their behavior

to the requirements of the law (volitional prong). While

affective disorders can be severe, unlike psychotic spectrum

disorders they are not often accompanied by delusions or

perceptual distortions that impair the experience of reality

(APA 2000). Additionally, defendants with psychotic spec-

trum disorders may be perceived by jurors as less responsible

for their crimes because their symptoms are often bizarre,

severe, and visibly distressing—clear signs of a medical

rather than a perceived moral condition. Along these lines,

research by Corrigan et al. (2003) suggests that people are

more likely to adopt a sympathetic orientation toward those

with mental disorders when they are perceived as having

little control over their illness.

More remarkably, since the court-appointed evaluator’s

opinion is accepted by the court in the vast majority of cases,

African Americans’ disproportionate diagnosis with psy-

chotic disorders probably confers medical resources and

other benefits in the context of this small sector of the

criminal justice system. Specifically, it leads to placement in

an environment that is more conducive to positive mental

health and legal outcomes and is less dangerous, disorga-

nized, and isolating (Baillargeon et al. 2010; Birmingham

2003; Ditton 1999; Forrester et al. 2010; NAMI 2004). This

is paradoxical to the impact of psychotic spectrum diagnoses

in the community, which have been associated with greater

stigma, social isolation, and reduced life chances (Link et al.

1999; Pescosolido et al. 2007; Phelan et al. 2000; Van Dorn

et al. 2005; Watson et al. 2005). However, diagnosis with a

psychotic disorder may have long-term consequences for

inmates following community reintegration, particularly if

this diagnosis is inappropriate and leads to ineffective

treatment and poor outcomes.

Differential diagnostic patterns observed in these data are

likely attributable to a variety of mechanisms. As previous

research has suggested, clinicians may be unintentionally

biased in their application of diagnostic criteria, or the criteria

themselves might be biased (Lewis et al. 1990; Trierweiler

et al. 2000; van Ryn and Burke 2000; Widiger and Spitzer

1991). These processes may be exacerbated in the context of

forensic psychiatric evaluations. First, clinicians’ biased per-

ceptions in this type of clinical interaction may be especially

negative and strong since stereotypes and images of African

Americans as criminal perpetrators are pervasive in American

culture (Kennedy 1997; Russell 1998). In other words, racial

biases are likely to be particularly salient and influential since

the individuals being evaluated appear to validate racial ste-

reotypes of criminality. In addition, clinician–patient inter-

actions and communication may be strained and ineffective to

an even greater degree than is typical of race-discordant

clinical encounters (Cooper et al. 2003; Johnson et al. 2004;

van Ryn 2002; Vasquez 2007), increasing the likelihood of

misdiagnosis. That is, in forensic psychiatric evaluations, the

power differential between a white doctor and minority

patient is exacerbated by the deviant label and probably also

by vast social class inequalities.

Racial disparities in diagnosis found in these data may

also reflect real differences in rates of disorder among whites

and African Americans in the criminal justice system.

African Americans are less apt to voluntarily seek or receive

psychiatric treatment than whites (Department of Health and

Human Services 1999; Snowden and Pingitore 2002; Wang

et al. 2005), often resulting in delayed treatment or no

treatment for mental illness (Snowden 2001). When symp-

toms of untreated mental illness eventually reach crisis

levels, it increases the likelihood of criminal activity and of

being brought to psychiatric treatment by legal means,

emergency room use, and involuntary hospitalization

(Akutsu et al. 1996; Takeuchi and Cheung 1998; Snowden

and Cheung 1990; Snowden 1999). Thus, for African

Americans with psychotic spectrum disorders, the forensic

psychiatric evaluation may constitute their first real contact

with the mental health treatment system. Conversely, whites

with symptoms of psychosis may be more likely to seek

treatment earlier and voluntarily, reducing the likelihood that

they will end up in the criminal justice system (Markowitz

2006; Mechanic and Rochefort 1990).

Limitations

Because data are from a chart review of pre-trial evaluees

referred for psychiatric evaluation, there are many points

where selection bias could be introduced. For example,

Race Soc Probl

123

because the detail and accuracy of information in medical

charts vary depending on both the individuals recording

and reviewing the chart, there may have been errors in the

data. However, there is no reason to believe that any sys-

tematic errors that might have biased results occurred.

Also, a relatively small convenience sample of pre-trial

evaluees in one state pre-trial forensic hospital was

employed, and there is substantial variation in forensic

psychiatric procedures and conditions across the American

criminal justice system. There is also a selection bias in

which patients sent to the forensic hospital are selected by

legal counsel, judges, and medical personnel in the jail

without systematic criteria. Consequently, these findings

may not be generalizable to other states or systems. We

hope that this research serves as a starting point for larger,

nationally representative studies on racial and ethnic dis-

parities in diagnosis and court determinations in correc-

tional psychiatric contexts.

Implications for Practice and Policy

From a clinical standpoint, it is critical to develop cultur-

ally sensitive assessment and treatment models for use in

correctional psychiatric facilities, as well as in the broader

community. There are several factors working against the

therapeutic alliance when the patient and clinician are from

differing racial and ethnic backgrounds (Vasquez 2007).

For example, due to a history of abuse by medical

researchers and practitioners, African Americans may be

skeptical of white clinicians and suspicious of the mental

health treatment system in general (King 1992). At times,

these attitudes may be mislabeled as symptoms of paranoia

during the diagnostic process, leading to higher rates of

diagnosis with psychotic spectrum disorders among Afri-

can Americans (Neighbors et al. 1999). One key compo-

nent to reducing such misunderstandings and promoting

recovery is development of a strong therapeutic alliance

(Horvath and Luborsky 1993; Martin et al. 2000). Pro-

moting mutual trust and understanding takes time. When

clinicians put more effort into engaging the patient, it

appears to reduce racial discrepancies in psychiatric treat-

ment (Segal et al. 1996; Davis et al. 2011). It is also

important to increase the diversity of the mental health

workforce so that racial and ethnic minorities can be

matched with clinicians who are more culturally sensitive

and have shared ethnic experiences.

With respect to public policy, this research provides

additional evidence that it is critical to reduce racial and

ethnic disparities in mental health services. Research sug-

gests that African Americans tend to activate alternative

coping skills and sources of support rather than seeking

formal psychiatric services, often resulting in delayed

treatment or no treatment for mental illness (Snowden

2001). Resistance to help-seeking may be part of the

African American cultural legacy of bearing up to prob-

lems and remaining strong in the face of adversity—a

coping mechanism that evolved as a result of slavery

(Poussaint and Alexander 2000). Also, because perceptions

of stigma associated with mental illness are higher among

African Americans than other racial and ethnic groups

(Anglin et al. 2006), fear of public exposure may prevent

them from seeking services for psychiatric symptoms.

Policies and programs are needed that target minority

communities to reduce the stigma associated with mental

health services utilization and to make treatment-seeking

more normative and accessible.

Acknowledgments The authors extend special thanks to Ms. Jen-

nifer Haynes for support and feedback related to this project, and to

Tyler Jones, MD, who helped initiate the chart review and data col-

lection. The first and second authors contributed equally in this

research. Address correspondence to Brea Perry, Department of

Sociology, University of Kentucky, 1515 Patterson Office Tower,

Lexington, KY 40506 (email: breaperry@uky.edu).

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