Racism in Medical diagnoses: how racial biases disproportionately label POCs with psychotic disorders

‘Psychotic disorders’ is an umbrella term used by psychiatrists and other mental health professionals as a way to categorise mental illnesses in which the patient experiences psychosis: a warped understanding of reality including ‘confusion, hallucinations, and delusions’. The most popularised psychotic disorder is schizophrenia, but the term also encompasses bipolar disorder, catatonia, and substance abuse. Psychotic disorders are taken seriously by mental health professionals and many are treatable with the right medications.

Unfortunately, the popularisation and subsequent stigmatisation of schizophrenia has led to many problems in the field, including the furthering of systemic racism. A 2014 study published in the World Journal of Psychiatry showed that African Americans and Hispanics were over three times as likely to be diagnosed with schizophrenia than their Euro-American counterparts, with many of these diagnoses later being determined to be inaccurate. Essentially, while the illness itself is evenly distributed among racial groups, it is disproportionately diagnosed in people of colour.

While inaccurate diagnoses are commonplace in mental health due to the overlapping nature of symptoms between some mental illnesses, the extreme racial disparity in schizophrenia misdiagnoses is alarming, to say the least. Race is considered the number one factor in schizophrenia diagnosis because of how much of an impact it makes on the statistics. Several reasons have been proposed as to why this might be the case. Some studies have shown that physicians often report a lower degree of ‘honesty’ from African-American patients, which can lead to more schizophrenia diagnoses. Honesty in psychiatric diagnosis has different connotations to honesty as it is commonly known. To understand this, one must understand how psychiatrists diagnose psychotic disorders. Typically, a psychiatrist conducts a one on one interview with the patient in question. Ideally, this would lead to the patient honestly and openly discussing their experiences related to schizophrenia: hearing voices, hallucinations, etc. However, many patients with these symptoms also experience a degree of paranoia, causing them to be mistrustful and leading them to lie to their psychiatrist about their experiences. This is further complicated by the fact that the stigma surrounding schizophrenia by Hollywood as a disease that breeds serial killers and other frightening individuals can lead patients to be embarrassed about their symptoms, furthering the impulse to lie. As such, gauging honesty is an important element of schizophrenia diagnoses- an element that African-American and Hispanic people score much lower on overall.

While some of this is a perceived bias on behalf of the physicians, there is also the pervasive issue of people from lower-income areas (which are also disproportionately people of colour) being less trusting of medical personnel. Arguably, some of this is the fault of physicians themselves: it is no secret that African-American patients are often mistrusted, accused of exaggerating their pain, and more likely to be suspected of being drug addicts due to personal biases. And African-Americans who have experienced or heard of this discrimination are, in turn, less likely to trust their physicians. This creates a cycle, whereby African-American and Hispanic populations get misdiagnosed with schizophrenia, the misdiagnosis furthers the lack of trust in physicians, and the lack of trust leads them to be perceived as dishonest in psychiatric assessments, which in turn leads to more schizophrenia diagnoses.

However, another more systemic factor not often considered in past psychiatric diagnosis criteria is the cultural divides present within different ethnic groups. Many older diagnostic guidelines for psychotic disorders didn’t take cultural and contextual factors into account and were instead considered standardised for all races. For example, most American psychiatrists use the Diagnostic and Statistical Manual or DSM 5 as a criteria for diagnosing various mental illnesses. One of the points used for diagnosis in the DSM 5 is ‘disorganised speech’. Different ethnic groups can have different speech patterns distinct enough to be considered their own dialects of the English language, which, if one is unfamiliar with them, could subsequently be considered as ‘disorganised’. Furthermore, different cultural groups have different religiosity and religious systems, which can be difficult to understand in the context of schizophrenia, as one symptom of schizophrenia is religion-based hallucination. This may have led some physicians to incorrectly assess traits influenced by cultural norms as symptoms of psychotic disorders. 

Amongst all of this is the issue of POCs inadvertently being underdiagnosed with bipolar disorder, as the symptoms of the two psychotic disorders greatly overlap. Interestingly, white populations see the opposite effect. This has led some psychiatrists and researchers to point to a more insidious bias as the answer. Essentially, the theory goes that because modern media has popularised schizophrenics as ‘dangerous’ or ‘aggressive’, some non-black physicians have connected it to the African-American stereotype. This, while controversial, would explain why African-American populations are overdiagnosed with schizophrenia while white populations with the same symptoms are underdiagnosed with it. While this racial bias is likely to be mostly unconscious, it does coincide with a great deal of mistreatment that African-American and Hispanic populations often experience. With so many varying potential factors, it is unlikely that this is the sole or even main reason that POC populations are overdiagnosed with schizophrenia, but it is nevertheless an internal bias that many people still unfairly hold. 

There are several consequences to misdiagnosis. Beyond furthering the mistrust between doctor and patient, it also slows down the process of finding the correct medications for the patient. Many of the POC patients initially diagnosed with schizophrenia actually have a form of bipolar disorder. Conversely, in white cultural groups, patients are often overdiagnosed with bipolar disorder when in reality they have schizophrenia. This is an issue as while both groups require a group of medications called antipsychotics in order to be treated, patients with bipolar disorder usually need mood stabilisers to control manic episodes, and often are prescribed antidepressants as well. This means that there are African-American and Hispanic patients that need these medications that aren’t getting them, and white patients being prescribed them when they might not need them (taking mood-stabilising medications unnecessarily can actually lead to mood instability or an extreme lack of energy). In both of these disorders, having incorrect or ineffective medications can lead to circumstances where the patient ends up paranoid or unintentionally putting themselves in danger, which could in turn lead to physical injury which could potentially have been prevented. As such, it is imperative that more time and effort is put into understanding and combating the internal biases and cultural barriers that lead to misdiagnoses in the first place. 

So, what can physicians do to better assess psychotic disorders in people of color?

As a medical field, knowledge of mental illnesses and how to best diagnose them is constantly shifting. Already there have been moves to update the criteria for diagnosing psychotic disorders to be specific to different ethnic groups. But beyond that, it is important to remember that every field is made up of people, with their own experiences and biases. In order to move forward, psychiatrists need to consistently work to assess and overcome their personal biases and amplify minority voices in their field, such as promoting the Black Psychiatrists of America, Inc. and attending psychiatry conferences with African-American and Hispanic panelists and speakers. 

Ultimately, this dive into psychiatry shows that the medical field still has a long way to go to address issues of racial discrimination and that the plight to better cater to POC is a universal one. An age-old question in the medical field is how to best foster and maintain doctor-patient relationships based on mutual trust and understanding. But how can we create those relationships with POC to begin with if minority groups are constantly shown that their physicians aren’t doing enough to address their concerns and correctly identify their symptoms? All doctors, but especially psychiatrists, have an obligation to address their personal biases, learn from POC struggles, and create an environment where their patients feel comfortable and willing to open up to them. After all, how can you heal a mind if you don’t even fully understand it? 

This Post Has 16 Comments

  1. Aisha Serpedin

    This is such an interesting, well-written piece! Thank you for sharing your valuable insight Ms. Baig

  2. Esha

    A great read, very insightful!

  3. Joshua Kirkhope

    Such an incredible piece, made me think about an aspect of racism that had never even crossed my mind. I hope this piece is followed by even more pieces by this seemingly expert writer!

  4. Shahid Mirza

    Amazing write up.

  5. Zarrin

    Such well written article on such a sensitive topic. I loved how you explained things so well that a reader can understand both sides of the story.

  6. Muzna K

    A very well written article! It shows author’s passion and research towards this sensitive issue would love to read more articles by this author

  7. Anonymous

    Very eloquently written article on a topic that is highly underreported! I could see the author’s passion for the topic through her writing as well as the various examples provided for each argument. Great work!

  8. Muna

    Very well written article. Have we looked into the possibility of relationship between education level and mental illness diagnosis regardless of ethnicity? There is another problem in the US. Psychotic disorders can help one get disability and certain people feel that if they try hard, they may get a monthly stipend and free insurance. It is not just the physicians giving them wrong diagnosis, it may be patients trying to get the diagnosis. If we do this same analysis based on education level regardless of ethnicity, we may find a smaller gap. It is just a thought. I am sure in your career, you will come across every possibility of patients getting wrong diagnosis.

    1. Zoha Baig

      Thank you for your response and thoughtful question! I’m not sure if education level or socioeconomic status plays a role-it would have to be something I research further. But it’s a very interesting idea that deserves more research

  9. Asad

    Amazing write up! It definitely helped me think critically about an aspect of systemic racism that I didn’t know about before. Definitely looking forward to more articles by this author.

  10. Sana

    A very enlightening and well explained article on such a unique and sensitive issue .

  11. Ahamed Lebbe

    Excellent work! And certainly on an issue that needs to more awareness in these times! Good job Zoha, it’s very well written

  12. Kudos on a thoughtful article that streams across the value of diagnosis in Psychiatry, and the various non-clinical factors a physician would need to consider to make an accurate diagnosis. An invaluable insight surfaced from this communication is that the responsibility of a diagnosis rests on both the patient and the physician. An analogy of this relationship is that the patient ought to define as accurate a degree of pain on a scale of 0-5, so as to enable the physician to diagnose and prescribe a precise therapy. However, to strike this balance, there needs to be a harmonization or understanding of non-medical factors as well. I believe a positive outlook from both the patient and the clinician to work from a level playing field, would result in a more harmonized outcome. Keep up the noble pursuit and in your endeavors strive to develop harmonizing score cards of non-clinical and clinical criteria that will benefit both collaborators. Best wishes!

  13. Nudrat

    Nicely written article, Zoha! There are so many gaps in research when we talk about racial disparities and healthcare inequities. You will do brilliantly in your career in trying to get to potential answers to these very challenging questions. Good luck!

  14. Farha

    Well worth the read, and eye opening as well! Nicely done, Zoha.

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