Conference Explores Disparities in Early Psychosis Care

It is well established that the faster people receive care after a first episode of psychosis, the more likely they are to respond to treatment. However, studies show that many people experiencing the onset of psychosis are delayed from receiving effective services. For instance, data from the National Institute of Mental Health’s Recovery After an Initial Schizophrenia Episode (RAISE) study shows Black patients may be less likely to receive some important services for first-episode psychosis than White patients.

How to address such inequities in early psychosis care was the focus of a virtual conference hosted by APA and SMI Adviser in November. The Third National Conference on Advancing Early Psychosis Care in the United States featured 20 sessions over two days.

Racial disparities in early psychosis care often begin with how patients are initially assessed, explained Jason Schiffman, Ph.D., a professor of psychology at the University of Maryland, Baltimore County. Basic screening tools such as the PRIME screen or the Brief Prodromal Questionnaire (PQ-B) ask patients only if they have experienced symptoms of psychosis and, if so, the frequency of the symptoms. Many of these screens do not include follow-up questions to further assess responses to these questionnaires.

Such context is key, explained Deidre Anglin, Ph.D., an associate professor of psychology at the City College of the City University of New York. For instance, a person living in a high-crime neighborhood may be more likely to be suspicious or experience posttraumatic symptoms that masquerade as delusions—a phenomenon known as trauma-induced dissociation—than a person living in a low-crime neighborhood. Even if assessments ask about trauma, they may not capture the effects of severe discrimination, which can also lead to dissociation in minorities, Anglin said.

Discrimination can also haunt patients during evaluations. “People of color still have their behavioral issues blamed on character flaws,” Maxie Gordon, M.D., the medical director of Gordon Medical Arts Clinic in Mississippi, noted during a plenary session. For instance, a physician might overlook cognitive symptoms or externalizing behaviors that might indicate psychosis risk because of certain assumptions they have about a person because of the color of his or her skin. This can lead to misdiagnoses during the early course of a psychotic illness.

Researchers like Stephen Strakowski, M.D., of the University of Cincinnati have also shown that co-occurring disorders including depression and mania are often missed when diagnosing Black patients with psychotic symptoms. This might reflect a bias among physicians to associate schizophrenia with aggressive behaviors in Black patients (a phenomenon captured in Jonathan Metzl’s book, The Protest Psychosis). Anglin noted that many Black patients diagnosed with schizophrenia are later determined to have schizoaffective disorder or psychotic depression, which involve different treatments.

So how can coordinated specialty care centers better meet the demands of minorities? More could be done to engage minority communities to learn about their needs and build trust, said Steven López, Ph.D., a professor of psychologyand social work at the University of Southern California.

Ensuring that mental health professionals use tools such as the DSM-5 Cultural Formulation Interview can improve the diagnostic process, and engaging family members early on can set patients up for success, said Oladunni Oluwoye, Ph.D., a research assistant professor at Washington State University’s Elson S. Floyd College of Medicine. Offering family members skills training or educational resources to help them better care for their loved one at home helps to build trust that can help retain new patients in treatment. ■