‘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?