William B Lawson. Handbook of Racial & Ethnic Minority Psychology. Editor: Guillermo Bernai. Sage Publications. 2003.
More than a decade and a half ago, a federal report showed that African Americans and other racial and ethnic minorities have higher rates of morbidity and mortality across the life span (Malone, 1985). That report and subsequent studies have shown that these health disparities are in part a result of less access to treatment. More recently, the U.S. surgeon general released a report showing that many Americans have limited access to mental health services (U.S. Department of Health and Human Services, 1999). African Americans have less access, which could contribute to poorer outcomes (U.S. Department of Health and Human Services, 2001).
Diagnosis
Historically, African Americans have been more likely than Caucasians to receive the clinical diagnosis of schizophrenia (Adebimpe, 1981; Jones & Gray, 1986). This disorder generally has the worst prognosis of any psychiatric disorder. On the other hand, affective or mood disorders appear to be underdiagnosed in African Americans. The prognosis for these disorders is usually more favorable. These ethnic differences in diagnosis may be a consequence of “true” differences in prevalence, a consequence of misdiagnosing or diagnostic error, or a result of a difference in phenomenology rather than prevalence (i.e., African Americans with the same disorder as Caucasians may have different presenting symptoms) (Neighbors, 1984).
Currently, there are no reliable biological markers for mental disorders. Consequently, verbal report and careful observation must remain the mainstay of treatment. Nevertheless, structured interviews or assessment instruments with predetermined questions can lead to reliability and validity outcomes that are as good as many general medical treatments or outcomes. When structured interviews are used (i.e., when the interview questions are predetermined), racial differences tend to disappear (Jones & Gray, 1986). Large-scale studies such as the Epidemiological Catchment Area study (a five-city door-to-door survey using a structured interview to determine diagnoses) and the National Comorbidity Study (NCS) (a recent national randomized survey using a structured interview that could generate DSM-III-R [American Psychiatric Association, 1987] diagnoses) found few consistent ethnic differences when socioeconomic status was controlled (Kessler et al., 1994; Robins, Locke, & Regier, 1991). The NCS reported that African Americans had a lower prevalence of most mental disorders, including schizophrenia, when compared with non-Hispanic Whites (Kessler et al., 1994). However, that study did not survey institutional settings such as jails or inpatient psychiatric facilities, where minorities are often overrepresented. Most important, the differences, although statistically significant, were consistently small. Nevertheless, such findings suggest that previously reported ethnic differences in diagnoses were in large part due to diagnostic errors in prevalence.
Affective Disorders
As noted earlier, African Americans are often overdiagnosed with schizophrenia at the expense of affective disorders (Adebimpe, 1994). This practice continues despite widespread usage of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) and despite evidence from epidemiological studies cited above. Many clinicians continue to believe that affective disorders are uncommon in African Americans (Jones & Gray, 1986). Diagnosis of bipolar affective disorder is often missed in African Americans, leading to a delay in the initiation of appropriate antimanic treatment. African Americans with clear evidence of bipolar disorder are more likely to receive a diagnosis of schizophrenia and less likely to receive lithium therapy (Bell & Mehta, 1980, 1981; Mukherjee, Shukla, & Woodlme, 1983). Depressive disorders are often underdiagnosed as much as 50% of the time (Brown, Feroz, Gary, & Milburn, 1995; Skaer, Selar, Robison, & Galin, 2000; Sussman, Robins, & Earls, 1987).
Many of these individuals may also be misdiagnosed. African Americans with psychotic depression are more likely to be misdiagnosed with schizophrenia (Raskin, Crook, & Herman, 1975). We also reported that Latinos with psychotic depression are at increased risk for being misdiagnosed as having schizophrenia (Lawson, 1990; Lawson, Herrera, & Costa, 1992). African Americans tend to score differently on the Minnesota Multiphasic Personality Inventory (MMPI), showing more paranoid-type symptoms (Adebimpe, Gigardet, & Harris, 1979). More suspiciousness is seen compared to non-Hispanic White populations, which some have interpreted as a “healthy paranoia” (Jones & Gray, 1986). Affective disorders are more likely to present with psychotic symptoms, mania may present with more irritable symptoms, and depression may present with suspiciousness (Adebimpe, 1981; Adebimpe, Hedlund, Cho, & Wood, 1982). African Americans with bipolar disorder are more likely to show psychotic symptoms such as hallucinations (Strakowski, McElroy, Keck, & West, 1996).
Manic subtypes such as mixed mania, rapid cyclers, and mania with psychotic features may be more common than pure mania (Bowden, 1995). The underrecognition of these may certainly play a role in misdiagnosis. Bipolar I, which is characterized by irritability and impulsivity as much as euphoria, will often lead to correctional referrals as well as misdiagnosis. Bipolar II, which is characterized by major depressive disorders but hypomanic rather then manic episodes, may be diagnosed as major depression and treated by non-mental health medical and nonmedical providers. Unfortunately, there is virtually no literature on these subtypes in African Americans.
Cultural factors may play a role in misdiagnosis by confusing the unwary clinician. Cultural differences may be interpreted as psychopathology (Adebimpe, 1994). Africans and perhaps African Americans are less likely to complain of guilt when they have an affective disorder (German, 1972).
Guilt appears to be a western European concept that focuses on individual responsibility and assumes a more individualistic view of the world. People from tribal cultures emphasize communal rather than individual responsibility. Shame rather than guilt is more likely to be experienced (German, 1972). Often, the diagnosis of major depression is missed in African Americans. African Americans with major depression are diagnosed only 50% of the time (Brown et al., 1995; Sussman et al., 1987). Probably a much smaller percentage is adequately treated. Part of the reason may be a failure to recognize symptoms as psychopathology or as depression. African Americans often may not express sadness when depressed (Jones & Gray, 1986). Rather, somatic symptoms or anger may be expressed rather then depressive complaints, although vegetative signs may be the same, regardless of ethnicity. Another factor may be an unwillingness of African Americans to express depressive symptoms because of a fear of hospitalization (Sussman et al., 1987).
African Americans may have a similar prevalence of mental disorders but could present with different symptoms that would contribute to the misdiagnosis of schizophrenia and increased likelihood of antipsychotic use. A consistent finding is the greater likelihood of psychotic symptoms in African Americans for a range of different affective and anxiety disorders. Mania may also present with more irritable symptoms, which could be misinterpreted as psychosis. African Americans with depression may show more paranoid symptoms on the MMPI (Adebimpe et al, 1979). Suspiciousness is often seen compared with non-Latino White populations, which some have interpreted as a “healthy paranoia” (Jones & Gray, 1986). Consequently, antipsychotics may be used more frequently in African Americans because they are seen as being needed to treat psychotic symptoms.
Anxiety Disorders
Disorders of anxiety are also likely to be misdiagnosed in African Americans. Panic disorder and phobic disorders are often underdiagnosed in African Americans (Brown, Eaton, & Sussman, 1990; Neal & Turner, 1991; Paradis, Hatch, & Friedman, 1994). Epidemiological studies suggest that these disorders may have the same prevalence or may occur more frequently in ethnic minorities (Kessler et al, 1994; Robins et al, 1991). Obsessive-compulsive disorder is rarely diagnosed in African Americans (Friedman, Paradis, & Hatch, 1994; Paradis et al, 1994). Obsessions can be easily mistaken for hallucinations or delusions, and compulsions may be considered the result of command hallucinations. Posttraumatic disorder, the anxiety disorder that results from exposure to a stressful event or series of events, is often underdiagnosed in African Americans despite studies of combat veterans showing that African Americans may be more likely to report post-traumatic stress disorder (Allen, 1986, 1996; Penk, Robinowitz, Dorsett, Bell, & Black, 1988). The symptoms of posttraumatic stress disorder (PTSD) have been mistaken for psychotic symptoms. Flashbacks in PTSD may be mistaken for hallucinatory experiences. The emotional blunting may be mistaken for a flattened affect or the hyperreactivity for psychotic excitement. As a result, patients are at risk for being misdiagnosed with schizophrenia (Allen, 1986).
Symptom presentation may differ in African Americans with combat-related PTSD (Allen, 1986, 1996; Parson, 1985; Penk & Allen, 1991). As with affective disorders, African Americans have scored higher on the MMPI scales for paranoid and psychotic symptoms (Penk et al., 1988; Penk et al., 1989). A later study found higher levels of psychotic symptoms and paranoid ideation for Blacks versus Whites with PTSD using the MMPI-2. The original MMPI was criticized for being normed on midwestern Caucasians, but the MMPI-2 was normed on diverse ethnic groups (Frueh, Smith, & Libet, 1996).
Schizophrenia
As noted earlier, schizophrenia tends to be over-dignosed in African Americans (Adebimpe, 1994). Moreover, paranoid schizophrenia often is the subtype diagnosed most often (Lawson, Yesavage, & Werner, 1984). Presumably, the tendency to see African Americans as overly suspicious extends to the subtyping of schizophrenia. African Americans with schizophrenia may be seen as more violent when they are actually not (Lawson et al., 1984). The reasons are unknown but may include an overgeneralization of the high African American homicide rate or confusion over the “healthy paranoia” for hostility. Finally, many African Americans may have their illness confused with criminality and being jailed. As noted above, the prison system has become a major provider of mental health services, and African Americans are disproportionately in that system (Lawson, 1986b).
Treatment
African Americans with schizophrenia or other severe mental disorders are often treated differently in the mental health system. They are more likely to be hospitalized, to be involuntarily committed, and to be placed in seclusion or restraints (Flaherty & Meagher, 1980; Lawson, Hepler, Holladay, & Cuffel, 1994; Lindsey, Paul, & Manotto, 1989; Paul & Menditto, 1992; Soloff & Turner, 1982; Strakowski et al., 1995). Most studies do not find differences in behavior or psychopathology that may account for these differences.
Medication is also prescribed differently. African Americans are more likely than Caucasians to receive, per nurses’ request, medication and higher doses of antipsychotic medication (Chung, Mahler, & Kakuna, 1995; Flaherty & Meagher, 1980; Lawson, 1986a; Strakowski, Shelton, & Kolbrener, 1993). We noted earlier that African Americans with nonpsychotic illness often receive antipsychotics (Strickland et al., 1991). Antidepressants, however, are prescribed less often for African Americans (Blazer, Hybels, Simonsick, & Hanlon, 2000; Olfson et al., 1998; Skaer et al., 2000). The underprescribing of antidepressants is due in part to the underdiagnosis of depression (Skaer et al., 2000). Certainly, the overdiagnosis of psychosis plays a role, whether from different presentations of the illness, lack of cultural competence, or misinterpretation of nonpsychotic symptoms as psychosis. African Americans are more likely to be on depot (i.e., long-acting injectable) medication, suggesting a history of noncompliance and lack of investment in mental health treatment (Price, Glazer, & Morgenstern, 1985; Segal, Bola, & Watson, 1996).
Therapist attitudes may directly affect prescribing. Segal and associates (1996) reported that therapists’ feelings about the patients affected their prescribing of medication for patients with schizophrenia. Consistent with previous reports, African Americans were found to receive more psychiatric medication, more doses of antipsychotic medications, more injections of antipsychotic medication, and higher 24-hour dosages compared to Caucasians. However, prescribing patterns were related to a rating of the physician’s willingness to engage patients in treatment. In contrast, rated unwillingness to engage was associated with excessive medicating. Presumably, social distance (i.e., most of the providers were Caucasian) increased the likelihood that patients would get more medication.
Inappropriate medication may have adverse consequences. Pharmacokinetic and clinical studies suggest that African Americans may need less antidepressant, antipsychotic, and antimanic medications (Rudorfer & Robins, 1982; Ziegler & Biggs, 1977). As a result, they may experience more side effects when given doses appropriate for Caucasians. Antidepressants may not be as well tolerated either (Mendoza, Smith, & Lin, 1999). More side effects are reported with usual therapeutic doses and blood levels of lithium (Strickland, Lin, Fu, Anderson, & Zheng, 1995). The sometimes irreversible movement disorder of tardive dyskinesia is seen up to twice as often in African Americans (Glazer, Morgenstern, & Doucette, 1994; Morgenstern & Glazer, 1993).
African Americans may not have access to certain treatments. Newer medications appear to have fewer side effects and to be better tolerated by African Americans (Tran, Lawson, Andersen, & Shavers, 1999). Consequently, some of the problems with medications’ side effects can be avoided with newer treatments. However, access to newer medications is limited. African Americans are less likely to have access to the atypical antipsychotic clozapine, which has a superior efficacy and movement disorder side effect profile compared to typical antipsychotics (Moeller, Chen, & Steinberg, 1995). Contrary to popular beliefs, African American children are less likely to be prescribed stimulants for attention deficit disorder, although inappropriate use is still possible (Hoagwood, Jensen, Feil, Vitiello, & Bhatara, 2000; Safer & Malever, 2000). Specific serotonin reuptake inhibitors (SSRIs), which are generally safer and better tolerated then older tricyclic antidepressants, are also less likely to be prescribed to African Americans (Melfi, Croghan, & Hanna, 1999; Melfi, Croghan, Hanna, & Robinson, 2000).
Availability of psychotherapy may also be limited for African Americans. African Americans are more likely to be referred for medication alone (Flaherty & Meagher, 1980). They are terminated sooner from treatment by Caucasian therapists, especially if the therapist is racially biased (Chung et al., 1995; Flaherty & Meagher, 1980; Yamamoto, James, Bloombaum, & Hattem, 1967). Conversely, patients with African American providers stay in treatment longer, suggesting that therapist attitude and social distance can affect outcome (Rosenheck, Fontana, & Cottrol, 1995).
General Issues of Access
As noted earlier, the experience of African Americans in the mental health system often appears to be punitive rather than therapeutic. Consequently, fear of treatment should not be surprising. Fear of hospitalization probably contributes to delayed treatment for depression (Sussman et al., 1987). Fear of psychostimulants also may play a role in the lack of availability of these agents, perhaps to the detriment of African American parents (Safer & Krager, 1992). The social distance described above certainly contributes to the unwillingness of African Americans to seek initial treatment in the mental health system for mental disorders (Neighbors, 1984). Another factor is the widespread awareness of the Tuskegee study (Roy, 1995), which was a federally sponsored study begun in the 1930s in which African American men diagnosed with syphilis had treatment withheld without their knowledge. Only newspaper exposes in the 1970s ended the study. Partially as a consequence, psychotropic medication and mental health treatment are often viewed with suspicion.
Costs are a significant barrier for African Americans. New treatments tend to be more costly than standard agents as pharmaceutical manufactures try to recoup development costs for drugs that are patent protected. Such costs can limit their availability (Griffith, 1990). African Americans often have limited incomes or are underinsured. African Americans’ median income is 60% and family wealth is one tenth of Caucasians’, and nearly a quarter of African Americans live below the poverty line (O’Hare, Pollard, & Mann, 1991). As a result, African Americans are more likely to be uninsured, depend on public facilities for care, or depend on public insurance programs such as state disability or Medicaid (Snowden & Cheung, 1990). Medicaid and public facilities tend to have restrictive formularies that can limit the availability of psychotherapy and newer pharmaceutical agents.
There is now general agreement that disparities in health care exist for racial and ethnic minorities. Clearly, disparities in access to care exist in mental health as well. Improved treatments in psychotherapy and medications have greatly improved the outcome of mental disorders and removed some ethnic disparities. Bold efforts are needed to further improve the access of African Americans to quality mental health care. Despite extensive efforts, diagnostic deficiencies and limited access to treatment continue to exist for African Americans.