By Rosaland Tyler
New Journal and Guide
While about 20 percent of African-Americans who were diagnosed with schizophrenia also tested positive for major depression, a new study questions the accuracy of this diagnosis.
The new Rutgers University study underscores years of reports that claim conscious and unconscious bias can affect the types of mental-health diagnoses minority patients receive. Records from about 600 African-Americans and 1000 whites were examined in the new study, which means a total of 1600 medical records were examined at a community behavioral clinic for the new study recently published in the journal Psychiatric Services.
“Let’s face it, people stereotype,” said Michael Gara, coauthor of the study and a professor of psychiatry at Rutgers’ Robert Wood Johnson Medical School. “It’s not necessarily malicious. They do it implicitly. It’s automatic.”
What may be happening, Gara said, is that during a clinical interview, an African-American patient might report psychotic symptoms like hearing voices. “The clinician might stop right there and say ‘He’s clearly psychotic’ and make a diagnosis,” Gara said. “But maybe there were a lot of mood symptoms and they never looked for those.”
The latest research found that about 20 percent of African-Americans who had been diagnosed with schizophrenia also screened positive for major depression — nearly six times the percentage ratio for white patients. Past research has found that African-American patients are 17 times more likely to be diagnosed with conditions such as schizophrenia or bipolar disorder.
In plain terms, this suggests some of the African-American patients may have been misdiagnosed, Gara said.
Schizophrenia is a diagnosis of exclusion, he explained. Clinicians must rule out other potential causes of symptoms first, like mood disorders, before the diagnosis of schizophrenia is given. Specifically, a mood disorder distorts your general emotional state or mood. You may be extremely sad, empty, or irritable (depressed), or you may have periods of depression alternating with being excessively happy (mania). Mood disorders can be successfully treated with medications and talk therapy (psychotherapy).
However, research shows clinicians may focus on psychotic symptoms, like hallucinations, and overlook symptoms of major depression (which is a mood disorder), only when they are treating African-Americans.
While large studies have found no significant difference in the likelihood of African-Americans and whites having schizophrenia, the diagnosis disparities persist.
What can increase the diagnosis disparity is the fact that many white therapists are dismissive of the impact of racism, Dr. Monnica T. Williams wrote in a 2013 Psychology Today article titled, How Therapists Drive Away Minority Clients.
“Having never been subjected to the minority experience, it may not have occurred to them that racism could be traumatic,” Williams wrote. “These are typically therapists who ascribe to a colorblind approach as their method of choice for working with people who are culturally different. However colorblind ideology is actually a form of racism, as it provides an excuse for therapists to remain ignorant of the cultures and customs of their non-White fellow human beings,” Williams said, adding, “This illustrates the therapist’s own discomfort with the idea that racism and mental health are linked.”
The diagnosis disparity for African-Americans was consistent at medical schools nationwide, according to a previous study Gara completed with Stephen Strakowski from the University of Texas Austin’s Dell Medical School. However, they did not find the same trend in Latino patients, so Gara didn’t include Latino patients in the new study.
Other factors may lead to diagnosis disparities including racial microaggressions. The clinician may make statements like, ‘Don’t be so sensitive about that racial stuff, If African-Americans only worked harder they could be successful like other groups,’ Williams noted.
“Minority clients may find it difficult to respond to racist comments in counseling situations due to self-doubt and power dynamics,” Williams said. “These problems contribute to feelings of distance from the therapist, unwillingness to disclose sensitive information, and early termination from treatment. Thus, clients may be unable to overcome the condition for which they sought help due to undesirable therapist factors, creating a barrier to treatment. The degree of harm therapists may cause in this way is unknown and likely underestimated.”
A 2003 study by Dr. Stephen M. Strakowski showed that African-American patients are more likely to be diagnosed with paranoid schizophrenia. While patients of both races have been wrongly diagnosed with schizophrenia, the pattern is stronger and more persistent in African-Americans.
Strakowski said, “In particular, African-Americans were most likely to be misdiagnosed with paranoid schizophrenia.” The problem is that a misdiagnosis may lead the psychiatrist to rely excessively on antipsychotics, rather than attempting thymoleptic (antidepressant medication) and psychotherapy trials.
Strakowski said, “Studies suggest that African-American patients are more likely than similar white patients to receive antipsychotics and less likely to receive psychotherapy.”
While there is scant data on disparities in schizophrenia diagnoses among other minority groups, the Office of Minority Health has compiled some statistics, which show, for example, that adult African-Americans are 20 percent more likely to report serious psychological distress than adult whites.
African-Americans with low incomes are three times more likely to report serious psychological distress than those living above the poverty line. More likely to experience feelings of sadness, hopelessness, and worthlessness than adult whites, and less likely than whites to die from suicide as teens, African-Americans of all ages are more likely to be the victim of a violent crime. Therefore, they are more likely to be diagnosed with post-traumatic stress disorder (PTSD).
The problem is racial bias can launch a vicious cycle. A person experiences racial bias, seeks therapy but encounters bias in a therapeutic setting.
“When people say they’re not prejudiced but give subtle signals that they are, for example – those on the receiving end may be left anxious and confused,” Tori DeAngelis wrote in a March 2019 report on the American Psychological Association’s website.
Here is one solution. It is called prejudice habit-breaking intervention, which adopts the premise that bias, whether implicit or explicit, is a habit that can be overcome with motivation, awareness, and effort, DeAngelis said. Those who received the intervention were more likely after 14 days to feel concern about the targets of prejudice and to label biases as wrong, though that awareness later declined.