This column discusses burnout and moral injury among Black psychiatrists and other Black mental health professionals and highlights the contribution of racism to these outcomes. In the United States, the COVID-19 pandemic and racial turmoil have revealed stark inequities in health care and social justice, and demand for mental health services has increased. To meet the mental health needs of communities, racism must be recognized as a factor in burnout and moral injury. The authors offer preventive strategies to support the mental health, well-being, and longevity of Black mental health professionals.

Back to table of contents Previous article Next article Communications and UpdatesFull AccessBlack and Blue: The Origins and Consequences of Medical RacismAnnelle B. Primm, M.D., M.P.H., and Ezra E.H. Griffith, M.D.Annelle B. PrimmSearch for more papers by this author, M.D., M.P.H., and Ezra E.H. GriffithSearch for more papers by this author, M.D.Published Online:1 May 2013https://doi.org/10.1176/appi.ajp.2012.12101321AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail by HobermanJohn. Berkeley, Calif., University of California Press, 2012, 304 pp., $26.95.It is unusual for two African American psychiatrists to review a book, with a provocative title containing the “R” word, for the American Journal of Psychiatry (AJP). The request for an analysis of John Hoberman’s new text, Black and Blue: The Origins and Consequences of Medical Racism, came with a question about whether it warranted review at all in AJP. We agree that not only should a review of a book on this subject be published in AJP, but those in AJP’s audience who have an interest in the intersection of race and health should be introduced to Hoberman’s comprehensive work on this thorny and important subject. In fact, one of Hoberman’s assertions is that editorial gatekeepers have prevented the history of medical racism from being explored in medical literature. So from our vantage point, AJP readers and the medical profession have everything to gain from an honest, intellectual excursion into this subject. This is not to say that the going will be easy, as it requires some effort to follow the author’s wide-ranging argumentation, to sift through his substantial accumulation of data, to evaluate the reasoning he employs, and to weigh the political implications of his conclusions.The first part of the book’s title, Black and Blue, suggests that we African Americans have been beaten up along the way or perhaps have just suffered a great deal over the years in seeking equal medical care in this country. But that’s the psychiatrist in us looking for metaphors. Hoberman is concrete from the start: the title draws sharp attention to the unfortunate state of the African American community’s health status in contemporary America. Disparities in health and mental health status are prevalent in the United States. Black people die sooner and live sicker than their white counterparts. In recent literature, these disparities have been associated with disproportionate exposure to the social determinants of health that include poverty, racial discrimination, unsafe and unhealthful living environments, limited educational opportunities, and misguided social policies.Disparities have also been documented in the quality of care African Americans and other ethnically diverse population groups receive. The Institute of Medicine report, Unequal Treatment, presented a compelling review of the literature confirming that African Americans are more likely to receive substandard health care than whites and that this finding held even when socioeconomic status and other factors were controlled. Two of the explanations for substandard treatment of African Americans were negative stereotypes and unconscious bias.In Black and Blue, Hoberman sets out to prove that racial disparities in health care are the result of racism. He energetically pulls together data to buttress his claim: the historic racism of the American Medical Association (AMA); color-blind writing in medicine; the little that is written about the effect of race on the physician-patient relationship; resistance of doctors to penetration of their private and independent practice of medicine; doctors’ ignorance of the history of medical racism; and their denial, even when they know the history. While these data may contribute to racial disparities, they cannot account for the total picture of unequal outcomes in medical care and cannot explain the notion that the disparities are the result of intentional actions based on race. And indeed, Hoberman acknowledges this by noting that other elements may contribute to the disparities, such as black patients’ social conditions; their unusual trauma histories; doctors’ own fears, biases, and psychological defenses; and oral traditions about black patients’ traits and medical characteristics. Hoberman quickly dismisses his own acknowledgment and continues on his trek to prove his major claim. But every reader will understand that in logically proving a point, one cannot dispense with bothersome facts. The result is that Hoberman does not prove his claim, and we are left to contend with the result that vexes all of us: health disparities are a fact of life in this country. The problem is complex, and many factors likely contribute to the existence of these disparities, including racism.However, raising serious doubts about Hoberman’s principal theorem doesn’t deter him from continuing on the voyage that he has set for himself. That is at least partly why readers must be strong-willed and determined to stay the course. He goes on to criticize a number of groups and organizations. He blames them all for having some responsibility for these racial health care disparities and asserts that all the collectives should have done more to alleviate the suffering of those who come out on the dirty end of the inequalities. He attacks a long list of people, organizations, and areas of study, including the psychiatrist and public commentator Sally Satel, white physicians, medical researchers, Institute of Medicine reports, biomedical ethicists, the American Medical Association (AMA), the Department of Health and Human Services, and medical authors. He even holds medical journal editors responsible for not publishing manuscripts that focus on race-related issues, as though the editorial process relies solely on editors.Nevertheless, our analysis and critique of Hoberman’s false equation does not detract from the value of the book to the extent that we should conclude there is nothing to recommend it. Black and Blue examines interesting territory. In fact, one of the book’s strengths is its extensive historical review of how African Americans have been viewed as medical subjects. The author documents numerous examples of what he refers to as “defamatory racial folklore,” wherein blacks were regarded as an infectious reservoir of disease, lacking in self-discipline and intelligence, biologically degenerate, submissive, primitive, savage, lazy, child-like, and sexually promiscuous. While it is impossible to know with certainty when and how these stereotypes were manifested in the medical care black patients received from white doctors, these disturbing descriptions of black people by white physicians are documented in the peer-reviewed medical literature from previous decades, including AJP. These characterizations were clearly made before the emergence of the concept of political correctness.Another area of the text worth our attention is the consideration given to psychiatry. Our specialty receives a great deal of attention in Black and Blue. Stereotypes of the mental health status of blacks with terms like drapetomania, describing the inherent psychopathology of the runaway slave, at one end of the spectrum and at the opposite end denying that blacks were ever capable of being complex enough to present with depression or anxiety are just a few of the historical examples presented that exemplify yesteryear’s psychiatrists’ prejudiced views of African Americans. Hoberman goes on to point out how blacks’ own claims of their emotional hardiness and stoicism may have partly accounted for their unwillingness to seek psychological care. But white psychiatrists also relied on these claims to justify their own inattention to black patients.Hoberman is at his best when he brings to the fore the history of medical racism in this country. This historical aspect of the narrative can stand on its own, without its having to be forced into the functional theorem of the book, in proving certain groups’ responsibility for health care disparities. So it is important to read his account of the AMA’s systematic bias against African American physicians and how the AMA kept them out of the organization for many years. And while the AMA in recent years issued an official apology to black physicians and has joined with the National Medical Association to form the Commission to End Healthcare Disparities, it is necessary that black and white physicians understand the history of this significant organization called the AMA. Of course, the unspoken point here is that many young psychiatrists have little knowledge of the history of APA’s participation in this narrative of medical racism.There is one last important reason for reading this book. It concerns the indictment that Hoberman issues against all physicians and all medical associations. He challenges us to contemplate how much we have done to address the inequalities in medical care that black patients face and how much we have done to challenge the status quo and catalyze needed changes. If we have done nothing or little, we are therefore guilty of being complicit in the silence that surrounds this tragedy in American health care. Hoberman takes no prisoners here. He offers no sympathy and does no serious exploration of the reasons we might advance to account for how we have managed ourselves. We all have to look into our private mirrors, make our assessments, and talk with our inner selves about what we’ve done with our talents. But any book that can produce such contextualized introspection is worth reading.Arlington, Va.New Haven, Conn.Dr. Primm is Deputy Director and Director of the Office of Minority and National Affairs, American Psychiatric Association, Arlington, Va. Dr. Griffith is Professor Emeritus and Senior Research Scientist and Deputy Chair for Diversity and Organizational Ethics, Department of Psychiatry, Yale School of Medicine, New Haven, Conn. The authors report no financial relationships with commercial interests. FiguresReferencesCited byDetailsCited ByNone Volume 170Issue 5 May 2013Pages 562-563 Metrics PDF download History Accepted 1 October 2012 Published online 1 May 2013 Published in print 1 May 2013

Back to table of contents Previous article Next article Association NewsFull AccessOMNA Track Explores Intersection of ACA, Minority IssuesAnnelle Primm, M.D., and Alison BondurantAnnelle PrimmSearch for more papers by this author, M.D., and Alison BondurantSearch for more papers by this authorPublished Online:27 Aug 2013https://doi.org/10.1176/appi.pn.2013.9a31AbstractMultiple sessions at this year’s institute examine how provisions of the Affordable Care Act may bring significant improvements to the mental health care of minorities.Edward Savaria Jr.For this year’s Institute on Psychiatric Services (IPS), APA’s Office of Minority and National Affairs (OMNA) has developed a track that takes cues from the 2013 IPS theme, “Transforming Psychiatric Practice, Reforming Health Care Delivery.” The kickoff workshop, “Understanding the Impact of Health Care Reform on the Mental Health of Diverse and Underserved Populations,” will feature national experts in the delivery and study of culturally competent mental health services in context of the Affordable Care Act (ACA). This session will deal with aspects of care specifically relevant to diverse and underserved populations from the system, provider, and recipient points of view.Back by popular demand is Howard Stevenson, Ph.D., who at the 2012 IPS led participants in a dynamic step-by-step approach to providing therapy to an African-American family that was confronting challenging behavioral issues in their teenage daughter. Building upon the success of his 2012 session, Dr. Stevenson will lead the session “Trustin’ Wise Ole’ Owls: Racial Stress, Coping, and Socialization in Black Families.” This session will recreate a “learning community” in which attendees at all levels of practice can participate in discussions about approaches to achieving optimal clinical outcomes for culturally diverse recipients of mental health services. This session will help actualize a major goal of the ACA, namely promotion of high-quality, culturally appropriate care delivered by an informed workforce of mental health professionals.A focus on prevention is another feature of the ACA. The session “Suicide Screening and Response in General Hospitals: Addressing the TJC Patient Safety Goal” will discuss the many hurdles in implementing a suicide-prevention program, including the need for training in suicide-risk screening and the burden of using screening tools for this purpose, including time pressures involved in screening.Health care reform emphasizes improvements in quality of care. A critical aspect of quality psychiatric care is accurate diagnosis that takes into account cultural background and environmental context. In the session “Culturally Appropriate Assessment Revealed: DSM-IV-TR Outline for Cultural Formulation and Cultural Formulation Interview Demonstrated With Videotaped Case Vignettes,” presenters will discuss the DSM-IV-TR Outline for Cultural Formulation as an excellent tool for evaluating culturally diverse individuals. Attendees will be encouraged to learn how to assess their own and their patients’ cultural identities and how the ethnicity and culture of the clinician and patient affect transference and countertransference.The aforementioned sessions will illustrate a variety of dimensions of mental health care that are fostered by the ACA, including not only increased access to care, but access to quality, culturally competent care and prevention. Our hope is that this year’s OMNA on Tour track offerings will contribute to the development of a well-trained and enlightened workforce prepared to deliver culturally appropriate care to an increasingly diverse U.S. population. ■Annelle Primm, M.D., is director of APA’s Office of Minority and National Affairs. Alison Bondurant is the associate director. ISSUES NewArchived

Growing awareness of health and health care disparities highlights the importance of including information about race, ethnicity, and culture (REC) in health research. Reporting of REC factors in research publications, however, is notoriously imprecise and unsystematic. This article describes the development of a checklist to assess the comprehensiveness and the applicability of REC factor reporting in psychiatric research publications. The 16-itemGAP-REACH (c) checklist was developed through a rigorous process of expert consensus, empirical content analysis in a sample of publications (N = 1205), and interrater reliability (IRR) assessment (N = 30). The items assess each section in the conventional structure of a health research article. Data from the assessment may be considered on an item-by-item basis or as a total score ranging from 0% to 100%. The final checklist has excellent IRR (kappa = 0.91). The GAP-REACH may be used by multiple research stakeholders to assess the scope of REC reporting in a research article.

ObjectiveThe authors explored the process of implementing a medical student-initiated program designed to provide computerized mental health screening, referral, and education in a homeless shelter.MethodsAn educational program was designed to teach homeless shelter staff about psychiatric disorders and culturally-informed treatment strategies. Pre- and post-questionnaires were obtained in conjunction with the educational program involving seven volunteer shelter staff. A computerized mental health screening tool, Quick Psycho-Diagnostics Panel (QPD), was utilized to screen for the presence of nine psychiatric disorders in 19 volunteer homeless shelter residents.ResultsShelter staffs’ overall fund of knowledge improved by an average of 23% on the basis of pre- /post- questionnaires (p=0.005). Of the individuals who participated in the mental health screening, 68% screened positive for at least one psychiatric disorder and were referred for further mental health care. At the 3- month follow-up of these individuals, 46% of those referred had accessed their referral services as recommended.ConclusionMedical student-initiated psychiatric outreach programs to the homeless community have the potential to reduce mental health disparities by both increasing access to mental health services and by providing education. The authors discuss educational challenges and benefits for the medical students involved in this project.

Back to table of contents Previous article Next article APA MeetingsFull AccessCultural Issues, Recovery-Focused Care in Spotlight at This Year’s IPSAnnelle Primm, M.D., M.P.H., and Wesley Sowers, M.D.Annelle PrimmSearch for more papers by this author, M.D., M.P.H., and Wesley SowersSearch for more papers by this author, M.D.Published Online:7 Sep 2012https://doi.org/10.1176/pn.47.17.psychnews_47_17_11-aAbstractThe 2012 Institute on Psychiatric Services (IPS) in New York City October 4–7 will provide a broad array of compelling educational sessions. As recovery becomes a part of psychiatry’s vernacular and widely recognized as the outcome most desired by people who seek assistance for behavioral health issues, there is a growing need for psychiatrists to develop the skills needed to deliver the care that supports it.SeanPavonePhoto/ShutterstockWhile the IPS has offered a strong program of topics related to recovery in recent years, this year’s program is especially rich in this regard. Diversity, cultural competence, social inclusion, and the elimination of health disparities are frequently part of any consideration of recovery-oriented care, and these topics too will be prominently featured at this year’s IPS.The scientific program includes a presentation by OMNA on Tour, a traveling mental health disparities track customized for the local community that has become a fixture of IPS. This year, OMNA on Tour will focus for the first time on trauma-informed care and confronting organizational racism in an effort to stimulate an integrated approach to system change for people with mental illness and for mental health professionals.Presentations in the OMNA on Tour track will offer information on self-assessment tools and guidance regarding racial and cultural issues in mental health care. Other sessions will examine the historical underpinnings of racial bias surrounding behavioral health care in the child-welfare system.Preventive service delivery for families with multiple challenges will also be discussed. The track will include two courses that will enlighten audiences about incorporating culture into assessment, diagnosis, and treatment and understanding the mental health impact of racism in everyday life, as well as a symposium, a lecture, and concurrent “breakout” workshops that are designed to follow in sequence from the earlier sessions. Attending sessions in the OMNA on Tour track will give attendees a sense of participating in a mini-conference within a conference.Educational sessions on recovery and recovery-oriented care will range from the basics to the more-complex aspects of these concepts. A discussion group on psychiatry’s role in the Recovery to Practice project will provide an update on the progress of this effort, funded by the Substance Abuse and Mental Health Services Administration, in which APA and the American Association of Community Psychiatrists are developing an in-person and online curriculum and training for psychiatrists on how to deliver recovery-oriented psychiatric care. Audience feedback will be solicited to help refine the draft curriculum and ensure that psychiatrists at varying stages of development benefit from its contents and methods of delivery.Some of the other topics on the program related to recovery includeprevention and wellness in behavioral health careconsumer and family participation in psychiatric educationintegrated assessment and collaborative recovery planningsustained recovery for people with severe mental illnessrecovery-oriented practices in emergency psychiatryHIPAA in the context of recovery-based carerecovery principles as an integrative element in training community psychiatrists.One highlight of the program will be a discussion between Keris Myrick, a leading national mental health advocate and current president of the board of the National Alliance on Mental Illness, and her psychiatrist, Dr. Timothy Pylko, which will be held Saturday evening, October 6. They will discuss their therapeutic relationship and recovery-oriented approaches to care that have been instrumental in Myrick’s recovery. Their partnership was described in a 2011 New York Times front-page article by Ben Carey, which was a part of a series on successful professionals living with mental illness.This program has something for everyone and will inspire psychiatrists, other mental health professionals, and people with lived experience to work more productively and flexibly together to achieve the goal of a satisfying life in the community. Don’t miss it! Annelle Primm, M.D., M.P.H., is senior deputy medical director and head of the Office of Minority and National Affairs at APA; Wesley Sowers, M.D., is a consultant to the IPS Scientific Program Committee. ISSUES NewArchived

Objective To compare the effectiveness of standard and patient-centered, culturally tailored collaborative care (CC) interventions for African American patients with major depressive disorder (MDD) over 12 months of follow-up. Data Sources/Study Setting Twenty-seven primary care clinicians and 132 African American patients with MDD in urban community-based practices in Maryland and Delaware. Study Design Cluster randomized trial with patient-level, intent-to-treat analyses. Data Collection/Extraction Methods Patients completed screener and baseline, 6-, 12-, and 18-month interviews to assess depression severity, mental health functioning, health service utilization, and patient ratings of care. Principal Findings Patients in both interventions showed statistically significant improvements over 12 months. Compared with standard, patient-centered CC patients had similar reductions in depression symptom levels (-2.41 points; 95 percent confidence interval (CI), -7.7, 2.9), improvement in mental health functioning scores (+3.0 points; 95 percent CI, -2.2, 8.3), and odds of rating their clinician as participatory (OR, 1.48, 95 percent CI, 0.53, 4.17). Treatment rates increased among standard (OR = 1.8, 95 percent CI 1.0, 3.2), but not patient-centered (OR = 1.0, 95 percent CI 0.6, 1.8) CC patients. However, patient-centered CC patients rated their care manager as more helpful at identifying their concerns (OR, 3.00; 95 percent CI, 1.23, 7.30) and helping them adhere to treatment (OR, 2.60; 95 percent CI, 1.11, 6.08). Conclusions Patient-centered and standard CC approaches to depression care showed similar improvements in clinical outcomes for African Americans with depression; standard CC resulted in higher rates of treatment, and patient-centered CC resulted in better ratings of care.

A crisis in the behavioral health care workforce has drawn considerable attention from consumers, families, advocates, clinical professionals, and system administrators at local, state, and federal levels in the past decade. Its effects have been felt in the recruitment, retention, and performance of psychiatrists in the public sector, where a focus on biological aspects of illness and efforts to cut costs have made it difficult for public psychiatrists to engage meaningfully in leadership, consultation, prevention, and psychosocial interventions. An array of training opportunities has recently been created to meet the needs of community psychiatrists at various stages of their careers, from psychiatrists just beginning their careers to those who have been working as medical directors for several years. This article describes the development of these initiatives and their impact on public psychiatry in four key areas--training of experienced psychiatrists, ensuring retention of psychiatrists in community programs, providing fellowship training, and creating professional identity and pride. Although these programs constitute only initial steps, opportunities for psychiatrists to obtain advanced training in community psychiatry are much greater now than they were ten years ago. These initiatives will enhance the professional identity of community psychiatrists and provide a solid foundation for future development of public service psychiatry in the behavioral health workforce.