Centering equity in mental health crisis services
The review by Johnson et al1 tells a compelling story: the evidence is significantly lacking in major domains regarding acute and crisis mental health services. We address here the major gaps in this area that relate to research on existing inequities in access to and quality of crisis services, as well as the degree to which new models and interventions are able to advance equity.
In the US, calls for diversion from overcrowded and under-resourced emergency departments, psychiatric hospitals and carceral settings have been long standing2, with increased attention in the aftermath of the death of D. Prude, an African American man in mental health crisis who died while in police custody. Both consumer advocacy organizations and racial justice movements such as Black Lives Matter have advocated for alternatives to police response to people in mental health crisis. This momentum has been carried further by the increased burden of mental illness in the setting of the COVID-19 pandemic, as well as the highly anticipated rollout of 988 (a three-digit number specifically for mental health emergencies) across the US3.
Diversion to mental health services is often put forward as a remedy for addressing the problems occurring at the intersection of mental health access and criminal-legal systems4. However, data about crisis programs resulting in meaningful diversion and reducing disparities have been equivocal. Unlike the criminal-legal system, the manifestations of racial inequity and structural harms in the mental health care system seldom go viral. But they most certainly exist, and are well documented as it relates to access, engagement, coercive practices and reception of evidence-based services5.
A recent evaluation of a co-responder team composed of a mental health clinician and a police officer found that short-term incarceration risk was reduced, but not long-term risk of justice involvement; initial findings suggested that incarceration was significantly reduced among recipients of the co-responder services who identified as Black6. Also, unpublished data from Arizona suggest that Medicaid beneficiaries seen by mobile crisis teams and crisis facilities were actually more likely to be booked into jail within 30 days of a crisis episode.
To improve the evidence base for crisis services as a mitigator of mental health inequities, multiple challenges must be addressed. Major deficiencies in socio-demographic data infrastructure make it difficult to consistently measure baseline or changes in inequities by race, ethnicity, sexual orientation, indigenous groups (typically referred to as Native-American or American-Indian in the US, but also including other groups internationally), immigration status, socio-economic status, education level, homelessness, disability, and language preference.
Notably, relevant socio-demographic hierarchies vary regionally and internationally, especially in low- and middle-income countries, where other factors (e.g., caste or last name) may manifest in inequities more so than the issue of race that is often highlighted in the US. While all of these socio-demographic factors should be studied for disparities, we focus here on racial equity with the understanding that learnings from this area will help advance equity more broadly.
One reason for the lack of socio-demographic data is the lack of incentives to collect this important information. Neither quality measures nor payors (public or private) routinely require measurement of these attributes. Although US organizations such as the National Quality Forum are developing risk adjustment methods that would incorporate relevant data on socio-economic status and other factors, widespread adoption is a long way off.
Another challenge to measuring equity in crisis intervention services is diagnostic overshadowing, which refers to assessments resulting in diagnoses at different rates for certain subgroups based on non-clinical factors (e.g., over-diagnosis of schizophrenia in African American men). Such biases at baseline can reduce the validity of control groups and confound outcome data. This issue is of particular concern in the measurement of coercive interventions such as involuntary hospitalization and forced medication administration, that have been shown to be administered in a racially inequitable manner7.
As crisis programs are implemented globally, system administrators, policy makers and providers must commit to utilizing an equity framework in both the design and evaluation of crisis response systems. A crucial first step is to engage communities directly in crisis system design in a meaningful, ongoing collaboration, with mechanisms in place to measure progress and ensure accountability.
Leaders must make an explicit commitment to first account for extant inequities and then be held accountable to address them. Relevant activities include trainings, education, and intentional design related to structural inequities. Programs can utilize resources such as the Racial Equity Toolkit from the Government Alliance on Racial Equity8 as well as the Self-Assessment for Modification of Anti-Racism Tool (SMART)9. Programs can support investments in the behavioral health workforce pipeline by hosting internships and other training opportunities aimed at diversifying the workforce to reflect communities served. Inclusion of peer specialists can also benefit the socio-economic and racial/ethnic diversity of the workforce, with the additional benefit of reducing stigma.
With regard to design and evaluation of crisis services, resources are needed to support rigorous, outcomes-driven strategies to measure a program’s impact on perpetuating, worsening or dismantling inequity. Programs can draw on community-based participatory research models and implementation science methods to invite input from community stakeholders and advisory boards in the research process, to facilitate the identification and inclusion of outcome data that is meaningful to key stakeholders.
To improve data quality, evaluators can provide specialized training to clinical staff on how to collect the socio-demographic data that are needed to inform equity analyses. Similar to the need for diversification of the clinical workforce, supporting researchers of diverse backgrounds is an essential way to promote equity. Finally, increased funding of mental health crisis services research is needed to advance these goals, and equity-focused analyses should be part of every research project that is funded.
Facilitating proactive approaches to measuring and studying disparities can help advance the goal of truly achieving equity in how systems respond to people in crisis. Metrics must go beyond simple descriptive measures such as capacity and response times, and focus on more meaningful process and outcome measures, such as linkage to outpatient care and symptom improvement. So as not to perpetuate inadequate insurance payments for outpatient mental health services, it is essential that evaluations of crisis systems examine treatment outcomes as well as disparities between important subgroups.
The lack of hard data on the role for crisis services in advancing equity is deeply problematic. The increased attention to this key component of the mental health care system is a tremendous opportunity for addressing disparities in the mental health field.
