The 911-call system plays an important and frequently overlooked role in the provision of access to public mental health services. It can protect the community from violence by individuals in psychiatric crisis who are engaging in dangerous or threatening behavior (1
). It is also a means through which individuals who are at risk of harming themselves can contact the public safety system, and through which others can alert the system of danger and thus prevent suicide or other self-injurious behavior. Through 911 calls, persons with severe mental illness in crisis receive acute psychiatric services that can subsequently connect them to other mental health care.
Well-established, persistent and troubling racial/ethnic disparities exist in mental health services delivery and access in the United States (2
). These disparities are seen in the psychiatric emergency system: black patients are disproportionately represented in psychiatric emergency rooms (3
); Asian patients are underrepresented in outpatient mental health services and tend to access the mental health care system later and at more severe levels of illness than do whites (4
); Spanish-speaking Latinos with severe mental illness are less likely than English-speaking Latino and white patients to use psychiatric emergency services (5
). The psychiatric emergency response systems of cities are potentially important settings in which to explore racial/ethnic differences in mental health service use.
Although the 911 system handles many types of emergencies, it is linked closely with law enforcement. Law enforcement officers’ role in the disposition of calls makes them de facto
gatekeepers to safety net mental health services (6
). Distrust of law enforcement is common in communities of color (7
). Police and ambulances have been found to bring black patients with psychoses to psychiatric emergency service more frequently than other patients (8
). Distrust and fear of law enforcement may lead some communities of color not to trust that mental-health-related calls will be handled appropriately and therefore be reluctant to use the 911 system when they or people they know experience a mental health crisis. Furthermore, the perceptions of persons with mental illness within racial/ethnic minority communities may also affect the community’s response to those exhibiting symptoms of illness. Stigma concerns and the fear of hospitalization have both been identified as obstacles to mental health treatment in black, Asian and Hispanic communities (9
). Although prior work has examined racial disparities in emergency service utilization and the social context of help-seeking behaviors (10
), differences between racial/ethnic groups in the perception of law enforcement and use of 911 services have not, to our knowledge, been previously explored.
We would expect both distrust of law enforcement and stigma about obtaining mental health services to lead to a reduced tendency of racial/ethnic minorities to seek help in psychiatric crises through the 911 system. Calls to the 911 system regarding mental-health-related crises generally originate in the physical location where the crises occur, so attitudes in those places towards public health and safety authorities, as well as towards mental illness, could affect the rate of mental-health-related 911 calls. From this it follows that neighborhoods with higher proportions of residents from racial/ethnic minority groups would be expected to have a lower frequency of calls related to mental-health-related crises than neighborhoods with fewer minority residents. Fewer 911 calls would then keep persons with severe mental illness in minority communities at risk of harming themselves or others and delay needed mental health treatment during psychiatric crises.
This paper investigates the hypothesis that the rate of mental-health-related 911 calls is negatively associated with the percentage of racial/ethnic minority residents, after controlling for other sources of differences in propensity to call 911, such as crime (11
), neighborhood socioeconomic status, and demographic composition. We tested this hypothesis using existing 911-call data and Census 2000 data from San Francisco, a racially heterogeneous city with a population in 2005 of approximately 739,000, of which about 33.0% are Asian/Pacific Islander, 7.3% are black, and 14% are Latino (12