[NYAPRS Enews] CECC Looks at Overdiagnosis of Schizophrenia in African Americans

[Harvey Rosenthal]

NYAPRS Note: The following piece attempts to shed light on why people of
color, and especially African-Americans, are disproportionately
diagnosed with schizophrenia, a phenomenon that in turn may explain in
part why African Americans tend to be hospitalized more frequently,
treated with higher doses of antipsychotic medications and much more
likely to be subject to Kendra's Law involuntary outpatient commitment
orders in New York City.

 

SCHIZOPHRENIA: THE IMPACT OF RACE ON DIAGNOSIS

Cultural Competence Matters

Center of Excellence for Cultural Competence

New York State Psychiatric Institute

www.nyspi.org/culturalcompetence  ccinfo at nyspi.cpmc.columbia.edu  (212)
543-5416

 

Problem: Schizophrenia is a serious mental illness that affects
approximately 3 million people in the U.S. Individuals with
schizophrenia interpret reality abnormally, often experiencing visual or
auditory hallucinations or delusions, disorganized speech or behavior
and decreased emotional expression. Epidemiological research suggests
that rates of schizophrenia are relatively similar across racial groups.
Clinically, however, African Americans tend to be over-diagnosed with
schizophrenia and under-diagnosed with mood disorders (e.g., depression,
bipolar disorder) compared with non-Hispanic White patients. Research
with Asian American and Latino populations is sparse, but suggests
possible over-diagnosis of schizophrenia. Misdiagnosis can strongly
affect the quality of clinical care. Once diagnosed with schizophrenia,
for example, African Americans are more likely than Whites to be
hospitalized and to receive higher doses of medication.

 

A second cultural explanation for misdiagnosis is the way in which
clinicians obtain and use information during diagnostic interviews,
which appears to differ based on a patient's race or ethnicity. For
example, symptoms related to mood disorders were recorded less
frequently when clinicians interviewed non-White patients than when they
interviewed White patients. This resulted in greater likelihood of
diagnosis of nonaffective psychosis (e.g., schizophrenia) than affective
psychosis (e.g., psychotic depression). A third cultural factor
affecting diagnostic accuracy in African Americans involves judging
normal wariness of the medical establishment as paranoia. This wariness
or "cultural mistrust" is attributed to experiences of discrimination
and medical mismanagement in the Black community, including the legacy
of the Tuskegee experiment. Especially among depressed African American
men, this cultural mistrust may be mistaken for a symptom of paranoid
schizophrenia.

 

Findings: Reasons for these disparities in diagnosis and treatment among
African Americans remain unclear. Several important explanations,
however, involve issues of culture. The ways in which symptoms of mental
illness are expressed is often influenced by an individual's race and
ethnicity. For example, African Americans report "first-rank" symptoms
of psychosis more frequently than non-Hispanic Whites. These include
delusions considered particularly bizarre and indicative of
schizophrenia, such as thoughts being inserted or withdrawn from the
person's mind. But when these symptoms are evaluated without information
on the person's race (such as by transcripts of interviews without any
identifying information), African American and White patients are just
as likely to receive a diagnosis of schizophrenia. It appears that the
lack of race-related cues helps clinicians to consider these symptoms in
the context of the person's full presentation and enables them to render
a more accurate diagnosis, such as mood disorder with psychotic
features.

 

Implications: Accurate diagnosis is critical to effective clinical care.
Misdiagnosis of schizophrenia can lead to unnecessary hospitalization,
ineffective treatment, and adverse effects of potentially unnecessary
medication. To avoid misdiagnosis, clinicians must remain alert and
sensitive to potential bias and stereotypes that may influence their
diagnostic decisions. It is essential for clinicians to carry out a
thorough evaluation of all patients regardless of their race or
ethnicity and to consider alternative diagnoses throughout the
diagnostic and treatment process. The persistence of race-related
misdiagnosis argues strongly for dissemination of culturally competent
diagnostic techniques and instruments as well as increased cultural
competence training among clinicians. Additional research is necessary
to more fully understand the high rates of schizophrenia diagnosis among
African Americans. The Center of Excellence for Cultural Competence at
the NY State Psychiatric Institute focuses on improving our
understanding of and eliminating disparities such as this and improving
culturally and linguistically appropriate healthcare, from diagnosis to
treatment.

 

References:

- Arnold et al. (2004). Ethnicity and first-rank symptoms in patients
with psychosis. Schizophrenia Research, 67:207-21

- Barnes, A. (2008). Race and hospital diagnoses of schizophrenia and
mood disorders. Social Work, 53(1), 77-83.

- Flaskerud, J. & Hu, L. (1992). Relationship of ethnicity to
psychiatric diagnosis. The Journal of Nervous and Mental Disease,
180(5), 296-303.

- Strakowski, SM, Hawkins, JM, Keck, PE et al. (1997). The effects of
race & information variance on disagreement between psychiatric
emergency service & research diagnoses in first-episode psychosis.
Journal of Clinical Psychiatry, 58(10), 457-463..

- Whaley, AL. (2001). Cultural mistrust: An important psychological
construct for diagnosis & treatment of African Americans. Professional
Psychology: Research & Practice, 32(6):555-562.

 

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