Schizophrenia May Be Overdiagnosed in Black Patients

July 31, 2012 (New Orleans, Louisiana) — Black people are overdiagnosed with schizophrenia, frequently misunderstood by their psychiatrists, and largely disenfranchised, said William B. Lawson, MD, PhD, professor and chair of psychiatry at Howard University College of Medicine in Washington, DC.

Dr. Lawson discussed the topic of schizophrenia in blacks here at the National Medical Association 2012 Annual Convention and Scientific Assembly.

It is well documented that racial and ethnic minorities in the United States are less likely than whites to seek mental health treatment, which largely accounts for their underrepresentation in most mental health services. Despite symptoms of distress, treatment can be delayed or not sought; when it is accessed, it is often from professionals not in the field of mental health, he said.

"Many [blacks] diagnosed with schizophrenia, in fact, do not receive specialized treatment by a mental health professional," Dr. Lawson said. In addition, "they are overrepresented in treatment settings with limited mental health services."

Blacks are disproportionately more likely to be homeless, incarcerated, and uninsured. These factors, along with the fact that the annual direct costs of schizophrenia can exceed the median income of blacks, "creates disincentives for mental healthcare," he said.

Lower-Quality Care Begins at Diagnosis

The substandard care received by blacks begins at diagnosis, when they are more likely than whites and other ethnicities to be diagnosed with schizophrenia — often inappropriately, Dr. Lawson said.

The global prevalence of schizophrenia is 1%, but "I was taught long ago...that 1 in 10 black males has schizophrenia," he said.

That particular belief has been dispelled by studies that have controlled for socioeconomic status and other confounding factors. Nevertheless, the label of schizophrenia is applied more often to blacks than to whites, according to at least half a dozen studies conducted in a variety of care settings.

In a recent study by Dr. Lawson and colleagues (Arch Gen Psychiatry. 2012;69:593-600), the rate of a clinical diagnosis of schizophrenia was significantly higher in black subjects than in non-Hispanic white subjects (P = .01).

The study controlled for age, sex, income, treatment site, education, and the presence or absence of serious affective disorder as determined by experts blinded to race and ethnicity. Ethnicity-blinded and -unblinded diagnostic assessments were obtained for 241 black subjects, 220 non-Hispanic white subjects, and 149 Hispanic subjects.

Blacks were 2.7 times more likely than non-Hispanic whites to receive a diagnosis of schizophrenia. Although overall severity of manic and depressive symptoms did not differ significantly in the 2 racial groups, there was more severe psychosis in the black subjects.

"Schizophrenia is overdiagnosed in [blacks] and affective disorders are underdiagnosed," Dr. Lawson said, adding that "not all psychosis is schizophrenia," although it is frequently mistaken for that.

Why the Overdiagnosis?

Dr. Lawson believes that overdiagnosis occurs when the criteria for diagnosis are not properly applied. "When there is evidence of psychotic symptoms [in black patients], there is an immediate diagnosis of schizophrenia, [and] the presence of affective symptoms is often ignored," he said.

Overdiagnosis might also be explained by the finding that blacks with bipolar disorder and disorders other than schizophrenia are more likely to show psychotic symptoms, possibly as a result of a different genetic diathesis, he added.

"But overdiagnosis is not simply corrected by using standard diagnostic criteria appropriately," Dr. Lawson noted. "Many believe that cultural factors may be involved. In particular, the concept of 'cultural mistrust' has generated some interest in a variety of settings."

He explained that many blacks believe that racism is a core element in the American macroculture; therefore, they expect that institutions perceived as being created and controlled by the "white establishment" will not treat them fairly."

In people with schizophrenia, psychopathology has been shown to be correlated with cultural mistrust, which has implications for diagnosis, he said. "Cultural mistrust can be interpreted as psychopathology," Dr. Lawson explained.

The overdiagnosis of schizophrenia has led to inappropriate treatment, including excessive use of antipsychotics, excessive dosing, and underprescribing of mood stabilizers. The result is suboptimal care and poorer outcomes for black patients, he said.

"Lived Experience" Corroborates Findings

Keris Jän Myrick, MBA, PhD, president of the National Alliance on Mental Illness, commented on Dr. Lawson's presentation and offered insight as a black person with schizoaffective disorder and as president and CEO of Project Return Peer Support Network (PRPSN) in Los Angeles County, California.

PRPSN is in its eighteenth year as a client-run peer support program; staff members are themselves recovering from mental illness. The underlying concept is the belief that clients need and profit from having a greater voice in designing and running support programs.

"People at PRPSN are using the 'lived experience' to inform the work they do," Dr. Myrick told Medscape Medical News. "Who would be more qualified to help people navigate this complex system than those who have been through it themselves?"

Dr. Myrick said her anecdotal experience as both a patient and a counselor meshes with the finding by Dr. Lawson's team that blacks might be overdiagnosed with schizophrenia, or at least misdiagnosed.

"I was diagnosed with many things before landing in the schizophrenia/schizoaffective arena," she said. "At Project Return, we do not ask clients to reveal their diagnosis to access our services, but many do. I see a much larger number of [blacks] than whites or Asians with this diagnosis."

Dr. Myrick has also witnessed and experienced a cultural disconnect between black people with mental illness and psychiatrists of different ethnicities, and she believes that cultural mistrust can certainly be a factor in misdiagnosis. In dealing with individuation issues, she said her own white psychiatrists had trouble understanding her tight connections with extended family. She believes that was because of cultural differences.

However, this does not mean that black people are best cared for by black physicians. "Research does not show this," she said. "Ultimately, it's the therapist you identify with most."

Although the current system of mental healthcare delivery usually does not allow for this — certainly not publicly funded healthcare — optimal treatment would be individualized on the basis of a patient's "superordinate identity," (i.e., the underlying factor in the patient's history that "creates a strong bond" between patient and provider), she said.

Dr. Lawson and Dr. Myrick have disclosed no relevant financial relationships.

National Medical Association (NMA) 2012 Annual Convention and Scientific Assembly. Presented July 30, 2012.