Running Head: OVERDIAGNOSIS OF SCHIZOPHRENIA IN AFRICAN AMERICANS 1
The Overdiagnosis of Schizophrenia in African American Populations:
A Discussion of Diagnostic Bias in the Untied States Anna Allison University of San Francisco
OVERDIAGNOSIS OF SCHIZOPHRENIA IN AFRICAN AMERICANS 2
Introduction Over the past decade, increased attention has been paid how racial and ethnic differences affect clinical diagnosis of mental illness. Race and ethnicity have a role to play in the allocation of resources, the method of treatment, and even the diagnosis itself. African Americans are more likely to be recommended to inpatient care while European Americans are often treated with less invasive and stigmatizing out-patient care (Feisthamel & Schwartz, 2009). Similar studies found that African Americans are more likely to be first admitted and then readmitted to hospitals for mental illness. During diagnosis, African Americans are more likely to be diagnosed with specific psychotic disorders, such as schizophrenia while European Americans are more likely to be diagnosed with mood disorders (Feisthamel & Schwartz, 2009). There is, in fact, an under diagnosis of mood disorders among African Americans, despite the fact that mood disorders are often considered a safer diagnosis due to improved prognosis and less invasive interventions (Feisthamel & Schwartz, 2009). One study found that African Americans were as much as three times more likely to be diagnosed with schizophrenia than European Americans (Begg, Bresnahan, Brown, Insel, Schaefer, Sohler, Susser & Vella, 2007). Diagnostic bias can be seen in both counseling and non-counseling professions and are applied to African American children as well as adults (Feisthamel & Schwartz, 2009). Once diagnosed with schizophrenia, African Americans are 13 times more likely to experience forced hospitalizations than non-diagnosed individuals. Once diagnosed, these hospitalizations are also much longer than they otherwise would be (Feisthamel & Schwartz, 2009). As children, misbehavior among African Americans is more likely to be seen a symptomatic of ADHD or ODD, whereas similar behavior of European American children is viewed as the normal OVERDIAGNOSIS OF SCHIZOPHRENIA IN AFRICAN AMERICANS 3 rambunctiousness of childhood (Feisthamel & Schwartz, 2009). While not specifically related to schizophrenia, this indicates that African American children are more likely to be considered mentally ill than counterparts from other racial groups. Poor access to mental health services, inadequate insurance and low quality care may all affect how an individual is diagnosed and treated. However, clinician bias is well established and plays a significant role in the diagnostic disparity among African Americans. This bias has a significant impact on the patient, caregiver and community (Feisthamel & Schwartz, 2009). When hospitalization is long and drawn out, it leads to more missed days of work, increased stigma, and deepened distrust of medical providers. This indicates a clear need for increased multicultural training, diversity in the field, and adherence to standardized diagnostic tools such as the DSM. History of Diagnostic Bias After the abolition of slavery, medical reports began to speak of a rapid and general decline of African American health (Jarvis, 2008). Before 1883, the rate of psychosis among African Americans was believed to be nearly non-existent. The behavioral controls placed on slaves supposedly shielded them from mental illness, as such afflictions were believed to only occur among the upper class society (Jarvis, 2008). However, by the end of the 19th century, reports of psychosis among African Americans had increased significantly. Moreover, medical reports indicated that African Americans were more likely to be aggressive, destructive and disruptive than European Americans when psychotic (Jarvis, 2008). In a complete reversal of earlier beliefs, scientists of the time believed African Americans were predisposed to severe forms of mental illness, and more likely to experience psychosis than European Americans. Ironically, OVERDIAGNOSIS OF SCHIZOPHRENIA IN AFRICAN AMERICANS 4 this psychosis supposedly manifested in African Americans irrational suspicion and fear of bodily harm. These reports represent the obvious bias that lingered, and still linger, long after the abolition of slavery. While institutionalized racism may not be as pronounced as it once was, current diagnostic bias mimics much of the prejudice that permeated the 19th century. The Civil Rights Movement sparked a review of current medical literature, and the obvious bias of previous studies were exposed, leading to a general discrediting of many of the beliefs surrounding African American psychosis. Even at that time, there was some attention paid to unusual rates of schizophrenia among African Americans compared to the Black British. In 1972, Cooper et al. reported that the, New York concept of schizophrenia is much broader than that used in London and embraces many patients who would be regarded by British psychiatrists as suffering from depressive illnesses, neurotic illnesses or personality disorders, and nearly all those who would be regarded as suffering from mania (Jarvis, 2008). This anecdote speaks to the overdiagnosis of psychosis and under diagnosis of mood disorders that was already occurring among African Americans. In 1972, American psychologists ability to diagnosis schizophrenia was already being called into question. However, many British psychiatrists believed American psychiatrists to be unfit to diagnosis, regardless of the race of their patient. In the same article, Cooper et al. stated, the New York concept of schizophrenia is not a useful one and is likely to inhibit fruitful research if it is widely adopted (Jarvis, 2008). The severity of this statement may reflect international anti-Americanism as much as it represents American diagnostic bias towards African Americans. As more reliable information was published, psychiatrists reported equal rates of schizophrenia among African and European Americans. Instead of reporting elevated rates of disorder, they began to report elevated rates of diagnosis. In 2004, the American Psychiatric OVERDIAGNOSIS OF SCHIZOPHRENIA IN AFRICAN AMERICANS 5 Association released a statement, officially calling attention to diagnosing bias in the United States: Compared with Caucasians, African Americans, especially men, are less likely to receive a diagnosis of a mood disorder and more likely to receive a diagnosis of schizophrenia . . . These remarkably consistent findings suggest that clinicians should be mindful of the extent to which cultural factors influence their diagnostic approach (American Psychiatric Association, 2004). Since then, diagnostic bias as been a consistent theme for African American patients with schizophrenia. Observed bias may be conscious or unconscious and may be a mix of racial bias as well as poverty bias. Teasing out the cause of overdiagnosis is not a cut and dry procedure as several factors are likely to feed into it. Remaining Biases While prejudiced literature of the 19th century has been discredited, similar themes are still seen in modern day studies. Arnold et al. found that African American patients were more likely to be identified as having first-rank symptoms of schizophrenia, regardless of their actual diagnosis (Arnold, Amicone, Adebimpe, Collins, Corey, Fleck, Keck & Strakowski, 2004). The perceived presence of first-rank schizophrenia symptoms led many psychologists to assign African Americans a diagnosis of schizophrenia, even when patients had been previous diagnosed with a mood disorder. When clinicians participated in a blinded trial, where a diagnosis of the patient was made based on redacted medical histories, and their race kept hidden, there was a lower rate of diagnosis among African Americans. However, men of any race were still more likely to be diagnosed with schizophrenia than women (Arnold et al., 2003). OVERDIAGNOSIS OF SCHIZOPHRENIA IN AFRICAN AMERICANS 6 This indicates that racial bias is skewing clinician diagnosis, rather than actual differences between African American and European American patients. In several clinical trials, African American patients were diagnosed with schizophrenia at rates of 10 to 40 percent higher than European American patients (Trierweiler, Neighbors , Binion, Thompson, Munday & Jackson, 2006). In 2000 and again in 2006, S.J. Trierweiler et. al found that when nearly 3000 adult inpatients were studied at two different psychiatric hospitals, 62 percent of African Americans were diagnosed with schizophrenia while only 40 percent of European Americans received a diagnosis of schizophrenia (S.J. Trierweiler et. al, 2006). European Americans not diagnosed with schizophrenia often received a diagnosis of major depressive disorder, or another mood disorder (S.J. Trierweiler et. al, 2006). Trierweiler et. al hypothesized any difference in population rates of schizophrenia for African American and non-African American patients should correspond to differences in rates of the symptom attributions clinicians make in support of their diagnoses (S.J. Trierweiler et. al, 2006). They believed that it was possible that clinicians link particular attributions to a schizophrenia diagnosis differently for African American patients than for non-African American patients (S.J. Trierweiler et. al, 2006). Throughout their course of study, they found that clinicians were not more likely to observe positive symptoms of schizophrenia in African Americans, but they were more likely to observe negative symptoms (S.J. Trierweiler et. al, 2006). Among non-clinicians, positive symptoms are more closely associated with schizophrenia than negative symptoms as these symptoms included an excess or distortion of normal functions (Mayo Foundation, 2013). Positive symptoms include delusions, hallucinations and disorganized behavior. Negative symptoms, on the other hand, are a diminishment or absence of normal functioning. These symptoms include loss of interest in everyday activities, appearing to lack OVERDIAGNOSIS OF SCHIZOPHRENIA IN AFRICAN AMERICANS 7 emotion, social withdrawal and neglect of personal hygiene (Mayo Foundation, 2013). Many of the negative symptoms of schizophrenia can also be attributed to other mental illness, such as depression (Mayo Foundation, 2013). However, when these symptoms are present in an African American patient, clinicians are more likely to see it as schizophrenia, rather than depression. Among European American patients, and patients of other ethnic groups, these symptoms are more often diagnosed as depression. The findings of Trierweilers 2006 trial remained consistent with findings in 2000, indicating that clinician bias remained, and remains a deciding factor in the diagnosis of schizophrenia in African Americans. However, this bias was not solely found in clinicians of a specific ethnic or gender group (S.J. Trierweiler et. al, 2006). An important component of Trierweilers trial were the clinicians utilized in the trail. Each clinician was either a third or fourth year psychiatry resident, and each one had a minimum of two years working with inpatient populations. The clinician group was comprised of five African Americans and five European Americans. Each ethnic group consisted of two females and three males. Diagnosis of schizophrenia was dispersed evenly throughout the group, meaning that a European American woman was as likely to diagnosis an African American with schizophrenia as an African American man was, and vice versa (S.J. Trierweiler et. al, 2006). This is an important indication that better cultural competency training is needed, regardless of the diagnosticians race or gender. Socio-cultural Factors of Diagnosis Many factors can influence an individuals mental status. Genetics, socioeconomics, and the environment all play an important role in shaping mental health. There was a slight OVERDIAGNOSIS OF SCHIZOPHRENIA IN AFRICAN AMERICANS 8 correlation between socioeconomic status and schizophrenia diagnosis, regardless of race. This indicates that factors such as maternal education, paternal occupation, total family income, and maternal marital status does play a role in affecting an individuals likelihood of being diagnosed with schizophrenia (Begg et. al, 2007). However, socioeconomic status cannot mitigate the affects of race on a diagnosis of schizophrenia. Children of African American mothers were still three times more likely to be diagnosed with schizophrenia than children of European American mothers with similar socioeconomic status (Begg et. al, 2007). Separating the effects of race and socioeconomics on a diagnosis of schizophrenia is very difficult. In 2010, and in several earlier studies, poverty is found to be a powerful predictor of psychosis, and that poverty is more closely tied to schizophrenia than other forms of mental illness (Read, 2010). However, since African Americans are more likely to live in poverty than European Americans, it is difficult to determine whether the elevated risk of schizophrenia is due to race or poverty. In all likelihood, both play a role. However, elevated diagnosis of schizophrenia was found in European Americans living in poverty as well (Read, 2010). This indicates that greater cultural competency is needed when dealing with impoverished populations, as well as African American populations. Possible Solutions There is an apparent and well documented bias permeating diagnostic practices of clinicians. Clinicians, regardless of their race or gender, are more likely to diagnosis an African American with schizophrenia. The difference in diagnosis is especially prevalent when negative symptoms are primarily used as the means of diagnosis. For this reason, it will be especially important to increase clinician training on means of recognizing negative symptoms of OVERDIAGNOSIS OF SCHIZOPHRENIA IN AFRICAN AMERICANS 9 schizophrenia, and how they can be differentiated from symptoms of other mental illness, such as depression. Increasing this training will not only improve clinician understanding, but will also train new diagnosticians to take a second look, or get a second opinion, when they are diagnosing an African American that does not present with positive symptoms of schizophrenia. It is also important to note that the overdiagnosis of schizophrenia decreased when patients race and racial identifiers were redacted from their medical records. This indicates that when clinicians seek a second opinion, it may be wise to consult another professional without immediately divulging the patients race. Diagnosing in this way will undoubtedly seem strange to many clinicians, but based on the inherent, and presumably unconscious bias in diagnosticians, it may be a wise course of action. When clinicians strictly adhere to standardized tools, such as the DSM, when diagnosing, the overdiagnosis of schizophrenia decreases among African American populations (Feisthamel & Schwartz, 2009). This may indicate that when diagnosing African American populations, clinicians are more likely to stray from standard practice then when they are examining patients of European or other ethnic backgrounds. Educating clinicians on the risks associated with non standardized diagnosing practices may help mitigate some unconscious bias. While African American clinicians are as likely to over diagnosis schizophrenia as clinicians of other races, it may be that a greater diversity of socioeconomics may help mitigate racial profiling in diagnosis. Perhaps clinicians who grew up in families with lower socioeconomic status may be less likely to over diagnosis schizophrenia in underserved populations. If so, scholarship programs aimed at recruiting a diverse student base to the study of psychology and psychiatry should be bolstered. With that being said, there is not a body of OVERDIAGNOSIS OF SCHIZOPHRENIA IN AFRICAN AMERICANS 10 evidence to support or refute this hypothesis. References American Psychiatric Association (2004), Practice Guideline for the Treatment of Patients with Schizophrenia, 2nd edition, American Journal of Psychiatry, Supplement, 161:2, pp. 1 50. Arnold, L., Amicone, J., Adebimpe, V., Collins, J., Corey, K., Fleck, D., Keck, P., & Strakowski, S. (2004). Ethnicity and first-rank symptoms in patients with psychosis. Schizophrenia Research, 67, 207212.
Begg, M., Bresnahan, M., Brown, A., Insel, B., Schaefer, C., Sohler, N., Susser, E., & Vella, L. (2007). Race and risk of schizophrenia in a us birth cohort: Another example of health disparity?. International Journal of Epidemiology, 36, 751758.
Feisthamel, K., & Schwartz, R. (2009). Disproportionate diagnosis of mental disorders among african american versus european american clients: Implications for counseling theory, research, and practice. American Counseling Association, 87, 295-301.
Jarvis, E. (2008). Changing psychiatric perception of african americans with psychosis. European Journal of American Culture , 27(3), 227-252.
Mayo Foundation. (2013). Schizophrenia. Retrieved from http://www.mayoclinic.com/health/schizophrenia/DS00196/DSECTION=symptoms OVERDIAGNOSIS OF SCHIZOPHRENIA IN AFRICAN AMERICANS 11
Read, J. (2010). Can poverty drive you mad? schizophrenia, socio-economic status and the case for primary prevention. New Zealand Journal of Psychology, 39(2), 7-19.
Trierweiler, S., Neighbors , H., Binion, V., Thompson, E., Munday, C., & Jackson, J. (2006). Differences in patterns of symptom attribution in diagnosing schizophrenia between african american and non-african american clinicians. American Psychological Association, 76(2), 154-160.
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