Evidence-Based Reviews

How to avoid ethnic bias when diagnosing schizophrenia

Current Psychiatry. 2003 June;2(6):72-82

References

1. Robins LN, Regier DA (eds). Psychiatric disorders in America: the Epidemiologic Catchment Area study. New York: The Free Press. 1991.

2. Simon RJ, Fleiss JL, Gurland BJ, et al. Depression and schizophrenia in hospitalized black and white mental patients. Arch Gen Psychiatry 1973;28:509-12.

3. Mukherjee S, Shukla S, Woodle J, et al. Misdiagnosis of schizophrenia in bipolar patients: a multiethnic comparison. Am J Psychiatry 1983;140:1571-4.

4. Strakowski SM, Shelton RC, Kolbrener ML. The effects of race and comorbidity on clinical diagnosis in patients with psychosis. J Clin Psychiatry 1993;54:96-102.

5. Strakowski SM, Lonczak HS, Sax KW, et al. The effects of race on diagnosis and disposition from a psychiatric emergency service. J Clin Psychiatry 1995;56:101-7.

6. Lawson WB, Hepler N, Holladay J, Cuffel B. Race as a factor in inpatient and outpatient admissions and diagnosis. Hosp Comm Psychiatry 1994;45:72-4.

7. Hoffman H, Kupper Z, Kunz B. Hopelessness and its impact on rehabilitation outcome in schizophrenia—an exploratory study. Schizophr Res 2000;43:147-58.

8. Walkup JT, McAlpine DD, Olfson M, et al. Patients with schizophrenia at risk for excessive antipsychotic dosing. J Clin Psychiatry 2000;61:344-8.

9. Segal SP, Bola JR, Watson MA. Race, quality of care, and antipsychotic prescribing practices in psychiatric emergency services. Psychiatr Serv 1996;47:282-6.

10. Flaskerud JH, Hu L. Racial/ethnic identity and amount and type of psychiatric treatment. Am J Psychiatry 1992;149:379-84.

11. Adebimpe VR, Klein HE, Fried J. Hallucinations and delusions in black psychiatric patients. J Natl Med Assoc 1981;73:517-20.

12. Adebimpe VR, Chu CC, Klein HE, Lange MH. Racial and geographic differences in the psychopathology of schizophrenia. Am J Psychiatry 1982;139:888-91.

13. Fabrega H, Jr, Mezzich J, Ulrich RF. Black-white differences in psychopathology in an urban psychiatric population. Compr Psychiatry 1988;29:285-97.

14. Strakowski SM, Flaum M, Amador X, et al. Racial differences in the diagnosis of psychosis. Schizophr Res 1996;21:117-24.

15. Schneider K. Clinical psychopathology (translated by Hamilton MW). New York: Grune and Stratton, 1959.

16. Strakowski SM, McElroy SL, Keck PE, Jr, West SA. Racial influence on diagnosis in psychotic mania. J Aff Disord. 1996;39:157-62.

17. Strakowski SM, Hawkins JM, Keck PE, Jr, et al. The effects of race and information variance on disagreement between psychiatric emergency service and research diagnoses in first-episode psychosis. J Clin Psychiatry 1997;58:457-63.

18. Jones BE, Gray BA. Problems in diagnosing schizophrenia and affective disorders among blacks. Hosp Comm Psychiatry 1986;37:61-5.

19. Neighbors HW, Jackson JS, Campbell L, Williams D. The influence of racial factors on psychiatric diagnosis: A review and suggestions for research. Comm Ment Health J 1989;25:301-11.

20. Lawson WB. Racial and ethnic factors in psychiatric research. Hosp Comm Psychiatry 1986;37:50-4.

21. Whaley AL. Ethnicity/race, paranoia, and psychiatric diagnoses: Clinician bias versus sociocultural differences. J Psychopathol Behav Assess 1997;19:1-20.

22. Lawson WB, Yesavage JA, Werner RD. Race, violence, and psychopathology. J Clin Psychiatry 1984;45:294-7.

23. Spurlock J. Psychiatric states. In: Williams RA (ed). Textbook of black-related diseases. New York: McGraw-Hill, 1975.

24. Thomas A, Sillen S. Racism and psychiatry. New York: Brunner/Mazel, 1972.

Box 2

Major depressive episode with psychotic features: Characteristic symptoms

MAJOR DEPRESSIVE EPISODE

Five or more of the following symptoms present during the same 2-week period and representing a change from previous functioning; must include either depressed mood or loss of interest or pleasure.

Depressed mood
Markedly diminished interest or pleasure
Significant weight loss
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue
Feelings of worthlessness or excessive guilt
Diminished ability to concentrate

SEVERE MAJOR DEPRESSION WITH PSYCHOTIC FEATURES

Mood-congruent

Delusions or hallucinations whose content is entirely consistent with the typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment

Mood-incongruent

Delusions or hallucinations whose content does not involve typical depressive themes. Includes symptoms such as persecutory delusions, thought insertion, thought broadcasting, and delusions of control

Source: DSM-IV-TR

African-American patients also are more likely than whites to exhibit so-called Schneiderian first-rank symptoms of schizophrenia,¹⁵ including:

delusions of thought broadcasting or insertion
auditory hallucinations of voices conversing about the patient in the third person.

These symptoms were once used to diagnose schizophrenia, but their lack of specificity has been well documented.^2,16 First-rank symptoms of schizophrenia depend on the specific form of the hallucination or delusion, are likely to be influenced by a patient’s culture, and may be misleading in multicultural populations. Though first-rank symptoms now occupy a minor role in U.S. diagnostic systems, they might continue to sway clinicians—even when using structured diagnostic interviews—to inappropriately diagnose schizophrenia in lieu of affective disorders in minority patients.¹⁵

To extend this finding, our group¹⁶ studied rates and severity of affective and psychotic symptoms—particularly first-rank symptoms—in 100 patients with psychotic mania who met DSM-III-R criteria for bipolar disorder (80%) or schizoaffective disorder, bipolar type (20%) as determined by structured diagnostic interview. No differences in affective symptoms between African-American and white patients were seen. African-Americans were more likely to endorse auditory hallucinations and to report severe auditory hallucinations of voices commenting on their behavior—the only first-rank symptom on which they differed from whites.

Though their affective symptoms were similar, African-Americans were significantly more likely than whites to have been diagnosed with a schizophrenia-spectrum disorder. Because misdiagnosis of African-Americans could not be explained by psychotic symptoms—which were as severe as those of white patients—these findings suggest other mechanisms were at work.

UNIDENTIFIED AFFECTIVE SYMPTOMS

Underidentification of mood disorders in African-American patients may also lead to over-diagnosis of schizophrenia. In a sample of 99 patients, colleagues and I¹⁷ compared clinical diagnoses made in a psychiatric emergency service with those by research investigators using a structured clinical interview. Reasons for diagnostic differences were identified and divided into two categories:

the same symptoms were recorded but applied differently to diagnostic criteria (criterion variance)
different information was recorded, which led to diagnostic discrepancies (information variance).

Differences occurred significantly more often in African-American than in white patients, but only information variance was associated with ethnicity. This suggests that clinicians are less likely to elicit appropriate information from African-American than from white psychiatric patients. The fact that researchers obtained this information during diagnostic interviews suggests that the patients could provide it when given appropriate prompts. Specifically, affective symptoms were less likely to be elicited by clinicians than by researchers.

PATIENT WARINESS

Minority patients, when interacting with clinicians of the majority population, may project “protective wariness.”¹⁸ Specific behaviors include hesitancy or reluctance to fully engage with the care provider as a precaution against being exploited or harmed. Cultural misunderstandings¹⁹ and patient concerns about past reports of minorities receiving substandard or unethical health care²⁰ may contribute to this behavior.

Whaley²¹ compared nonpathologic distrust and paranoia in 404 community-living African-Americans and whites. Some were healthy, and some had diagnoses of schizophrenia or depression. African-Americans—particularly those with psychiatric disorders—showed higher levels of distrust than whites. Distrust was also associated with depression in African-Americans but not in whites. Whaley concluded that:

depressed African-Americans may exhibit more distrust toward clinicians than do whites
this distrust puts African-Americans at risk of being perceived as paranoid and being misdiagnosed with paranoid schizophrenia.

Table

Remedial actions to avoid ethnic bias in diagnosing schizophrenia

Problem	Remedies
Failure to recognize differences in symptom expression	Become familiar with ethnic differences in how patients describe symptoms Incorporate structured interviews or rating scales into the clinical assessment
Failure to elicit affective symptoms	Incorporate structured interviews or rating scales into the clinical assessment Maintain a high index of suspicion for affective symptoms (see Box 2)
Misinterpreted protective wariness	Clarify the patient’s degree of suspicion; consider this in the historical context of abuses toward minorities by majority populations Become familiar with ethnic differences in how symptoms are described
Covert and overt stereotyping and cultural insensitivity	Review practice patterns Consult with culturally sensitive clinicians as necessary