Being African American increases a mentally ill individual’s chance of being diagnosed with schizophrenia and reduces the likelihood of that person’s receiving an affective disorder diagnosis. While data have pointed to this fact for several years, psychiatrists are beginning to assess the ramifications of this finding for blacks and how it adds a host of complicating factors to their treatment.
Speaking at the 30th annual meeting of the Black Psychiatrists of America (BPA), which was held in Atlanta March 30 to April 1, Strakowski described a common pattern in which African Americans are assigned a diagnosis of schizophrenia, which lowers clinicians’ expectations for a good prognosis. They are then given inappropriate services because physicians have lower expectations that patients with schizophrenia will get better. These inappropriate treatment choices for people who do not have schizophrenia include excessive antipsychotics, inadequate thymoleptics, and no psychotherapy.
These patients are also more likely to end up hospitalized than are white psychiatric patients, he noted. That they are more often hospitalized also makes it more likely they will be saddled with a psychosis diagnosis, given powerful antipsychotic drugs, and, then when they don’t respond, have the schizophrenia diagnosis confirmed, said Strakowski, who is director of the Bipolar and Psychotic Disorders Research Program at the University of Cincinnati.
He cited a study he recently completed in which he found that antipsychotics were the drug of choice prescribed for African-American patients with bipolar disorder as well. In a follow-up of new-onset bipolar patients who are sent home after hospitalization, he found 70 percent of these patients, but only 34 percent of matched Caucasian patients, received antipsychotics within two years of discharge, independent of remission status.
Strakowski described two sets of factors—one clinician related and one patient related—that account for the troubling overdiagnosis of schizophrenia in black patients.
In the former category, he said, are failures by physicians to elicit symptoms, understand ethnic and cultural factors relevant to the patient, and perceive the different ways in which minority populations may express psychiatric symptoms. Also entering this equation, he added, are "overt and covert stereotyping of African Americans that is not based on any reality or data."
Patient-related factors that contribute to the schizophrenia overdiagnosis may be "real differences in symptom expression" and many African Americans’ "protective wariness" in dealing with the white medical establishment. The clinician interprets this wariness as paranoia, leading to a diagnosis of psychotic disorder, Strakowski said.
He cited several steps to solve this misdiagnosis problem, starting with more research to evaluate ethnic and cultural differences in symptom presentation and how minority patients describe their distress.
In addition, clinicians need to be better educated in the use of structured psychiatric interviews, which will reduce interpretation errors, he suggested, and far more minority clinicians need to be trained so African Americans have more opportunities to "bond with and relate to" their psychiatrist.
David Henderson, M.D., maintains that African Americans’ cultural beliefs play a significant role in determining whether treatment will succeed.
Even when African Americans receive an accurate diagnosis, a broad array of cultural factors play a role in how they respond to psychiatric care, particularly psychotropic medications, stated David Henderson, M.D., an assistant professor of psychiatry at Harvard Medical School and associate director of the schizophrenia research program at Massachusetts General Hospital.
Their cultural beliefs and expectations of what treatment will mean often determine the success of psychopharmacological agents in African Americans, as well as in other minority patients. Some of these patients are extremely concerned that they will become addicted to a prescribed drug, for example, and clinicians often fail to discuss the medications’ addictive potential, as well their side effects, with their patients, many of whom mistrust the medical system to begin with.
Psychiatrists and other physicians also neglect to ask whether patients are using alternative or herbal therapies, thus overlooking possible interactions with the drugs they are prescribing. The side effects of these interactions will make it more likely that patients will stop complying with medication regimens, Henderson explained at the BPA meeting.
Clinicians can also maximize positive treatment outcomes if they ask their African-American patients about the social support system available to them, he said. Doing so will provide a key to how the clinician "can work within that system to increase treatment compliance and give these patients the care they need."
African-American patients’ communication style can impact compliance and treatment success as well, Henderson emphasized. Some patients may find self-disclosure an extremely difficult task, and psychiatrists need to remember that this characteristic "is a style, not the sign of a bad patient." The reluctance to communicate with the clinician may also signal that they are concealing or suppressing hostility toward societal institutions represented by the health care system, he added, "a legacy of fraudulent and unethical scientific studies in the black population."
The compliance obstacles psychiatrists may find with black patients stem from several other factors as well. He cited incorrect dosing and medication choices as frequently found problems, as well as a poor therapeutic alliance, a lack of community support, the stigma attached to having a psychiatric illness, lack of money or transportation, and substance abuse problems. Clinicians need to explore all of these concerns to give their African-American patients optimal care, Henderson said.
"It is important to acknowledge that racism is a real part of everyday life" for African Americans, and it has a "tremendous psychological impact" on them, he stated. "Add mental illness on top of racism, and you have a person who is very difficult to treat." ▪