Though Whaley did not report differences in distrust between African-American men and women, others have noted that distrust of health providers may be more common in minority men.18
RACIAL STEREOTYPING
Compared with similar white men, African-American men with mental disorders are more likely to be:
- referred for mental health care through social and legal—rather than medical—systems and to be involuntarily committed
- perceived as violent—even though controlled research suggests they are not. This misperception can lead to excessive medication and restraints.22
Differential treatment of African-American men may create a cycle of distrust, hostility, and additional inappropriate treatment. Together, these factors may increase the risk that African-American men will be misdiagnosed with schizophrenia.
Past racism in biomedical and psychiatric practice and research has been documented23,24 and more recently reviewed by Lawson.19 Historically, African-Americans were perceived to have a “primitive psychic” nature that was thought to be more susceptible to schizophrenia than depression.19 Whether these or similar racist stereotypes continue to inject ethnic bias into clinical assessment requires further study.
WHERE DO WE GO FROM HERE?
Although research into methods to eliminate ethnicity bias is sparse, the work reviewed in this article suggests ways that psychiatrists can minimize this problem (Table).
Obtain comprehensive information. Use structured interviews, such as the Structured Clinical Interview for DSM-IV (SCID), and rating scales, such as the Hamilton Depression Scale, which require clinicians to ask about all types of symptoms, particularly affective symptoms.
Review treatment records. Review your practice patterns for evidence of schizophrenia over-diagnosis in African-Americans or other ethnic groups. Examine ethnic differences in legal referrals or use of restraints or seclusion, which may indicate an ethnic bias in how threats are perceived. Only by being aware of bias can one correct it.
Become familiar with cultural and ethnic differences in idioms of distress. Specifically, review research in cultural psychiatry to identify potential differences among cultural groups in how they describe psychiatric symptoms. Talk with colleagues or friends from other cultural groups, and read literature from different ethnic perspectives to increase your cultural sensitivity.
Consult with psychiatrists with expertise in cultural variability of clinical presentation when the diagnosis or threat assessment seems unclear. Consultation is recommended if a patient’s diagnosis is uncertain or if you detect bias in your practice.
These interventions require clinicians to become familiar with psychosocial differences in how patients of various cultural and ethnic groups express psychiatric symptoms. With this understanding, we can better engage wary patients, obtain valid information, and improve clinical practice and patient outcomes.
Finally, psychiatry’s diagnostic systems need to continually address how patient assessment is influenced by ethnicity, culture, gender, and other socio-demographic factors. Studies are needed to examine the contributions of multiple factors—such as symptom differences and stereotyping—that contribute to ethnic-related diagnostic disparities.
Related resources
- Paul AM. Painting insanity black: Why are there more black schizophrenics? Salon.com Dec. 1, 1999. http://www.salon.com/books/it/1999/12/01/schizo/index.html
- Alarcon RD, Westermeyer J, Foulks EF, Ruiz P. Clinical relevance of contemporary cultural psychiatry. J Nerv Ment Dis 1999;187: 465-71.
- Williams DR, Neighbors HW, Jackson JS. Racial/ethnic discrimination and health: findings from community studies. Am J Public Health 2003;93:200-8.
- Lin KM, Smith MW, Ortiz V. Culture and psychopharmacology. Psychiatr Clin North Am 2001; 24:523-38.
Acknowledgement
Preparation of this manuscript was supported in part by National Institutes of Health grant MH56352.