Although attention has been given to racial disparities in mental health, gaps in care continue to exist, especially in the treatment of serious mental illnesses. Bipolar disorder (BD), a serious mental illness characterized by severe mood disturbances, is associated with substantial costs to the public, reduced quality of life, severe impairment, and is a leading cause of disability in the US. Sadly, it goes untreated far more often among blacks than whites in the US. Continued existence of the black-white gap in BD treatment is an important problem caused by the lack of knowledge about underlying mechanisms that cause the disparity. Until the gap is closed, black patients disproportionately and unnecessarily suffer. The PI's long-term goal is to reduce racial disparity in BD treatment. The next step toward achieving this, and the objective for this application, is to identify and tes a proposed mechanism underlying differential treatment in BD, namely treatment providers' contribution to the inadequate care of black patients with BD. The central hypothesis is that implicit racial biases, unintentional preferences for one race over another, enter clinical consultation at decision-making and lead to preferential treatment of white patients over black patients. This hypothesis is based on work showing that patient factors, including symptom presentation, socioeconomic status, and help- seeking do not explain the race gap in BD. The rationale for the proposed study is that implicit racial bias in psychiatric care could be immediately addressed by bias-reduction interventions that are already available to non-clinical populations. Guided by preliminary research from general medicine on provider bias, the central hypothesis will be tested by pursuing three specific aims: 1) establish that mental healthcare providers' clinical decisions are unduly influenced by patient race in ways that advantage white patients and disadvantage black patients; 2) demonstrate that mental healthcare providers hold implicit racial biases; and 3) show that implicit racial biases contribute to racially biased clinial decisions. To achieve these aims, this study will be informed by a social cognition theoretical framework. The approach will be to use the Implicit Association Test to measure mental healthcare providers' racial biases and simulate clinical decision-making with vignettes about theoretical black and white patients with BD. The unique predictive power of implicit racial bias on decision- making variables will be measured to show that provider biases account for the influence of patient race on providers' decisions. This approach is innovative, because it represents a substantive departure from the status quo in mental health research by using well validated measurements of racial bias drawn from the rich literature in social psychology to predict key facets of decision-making in BD. The proposed research is significant, because it is the first step in a program of research to develop an intervention to reduce racial bias in mental health treatment. Such an intervention promises fewer clinical errors, improved treatment rates for black patients, and reduced costs to the public.
The current study will use a well validated measure of implicit racial bias and sophisticated experimental design to test a model that explains black-white treatment disparity in bipolar disorder (BD). The proposed research is relevant to public health, because these findings are expected to guide the development of an intervention to reduce implicit racial bias in treatment providers, which holds the potential to improve treatment rates for black patients with BD and reduce the costs to the public that are associated with inadequate treatment and disability in this group. Thus, the proposed study is most relevant to the part of the AHRQ's mission that pertains to the improvement of provider performance to increase healthcare equity and access among vulnerable groups including racial and ethnic minorities.
