Episode 143: Overdiagnosis of Schizophrenia in Black Patients

Chantel Fletcher, Danielle Hairston, M.D., David Puder, M.D.

Introduction 

For decades, Black patients have been consistently diagnosed with schizophrenia more than their white counterparts despite epidemiological data not supporting a true disparity (Gara, et a., 2019; Gara, et al., 2012; Olbert, et al., 2018; Whaley, 2001). Still, the exact causes and solutions have not been firmly established (Gara, et a., 2019; Gara, et al., 2012; Olbert, et al., 2018; Whaley, 2001). There is currently an overdiagnosis of schizophrenia in Black male patients, especially. 

In addition to Black patients being diagnosed with schizophrenia at higher rates than white patients, they also are more likely to receive high doses of antipsychotics and depot antipsychotics (Arnold, et al., 2004). Exact causes and solutions for this problem are also not firmly established (Arnold, et al., 2004). 

Inaccurate diagnosis of schizophrenia and/or missed diagnosis of affective disorders can lead to inappropriate and inadequate treatment; worsened outcomes can follow. Because schizophrenia is a complex condition with a broad range of signs and symptoms that also occur in other mental disorders, it can be difficult to differentiate it from other serious mental disorders, especially mood disorders. Notably, these other conditions should actually be ruled out before arriving at a diagnosis of schizophrenia.

Furthermore, erroneously diagnosing schizophrenia can dampen expectations of a good prognosis. Additionally, antipsychotics can cause significant side effects and prescribing them inappropriately can lead to undue burden on patients. As a historically marginalized group, receiving inappropriate diagnoses and subsequent inadequate treatment further adds to the difficulties that Black patients face.  

It is imperative that psychiatrists do their part to avoid adding to existing health disparities and that they practice in ways that actively counter these disparities. 

Historical Context

Inappropriate diagnoses of Black populations can be traced back to slavery in this country. Historically, a diagnosis called “drapetomania” was used to pathologize enslaved Black people’s desire to be free. Receiving this diagnosis could actually lead to placement in insane asylums. 

In the 1960s, schizophrenia shifted from commonly being assigned to “weak-minded” white women who suffered from what was labeled “hysteria” and could not take care of their families to being assigned to Black men who wanted to voice their needs and their distrust of the system in the civil rights era. It became a diagnosis of “belligerent” and “aggressive” Black men. Around this time, advertisements for Haldol emerged as a drug that can treat belligerent people who need to be controlled. 

Disparities in Schizophrenia Diagnosis

As previously stated, Black patients are diagnosed with schizophrenia more often than their white counterparts, which is in contrast to epidemiological findings (Gara, et al., 2019; Gara, et al., 2012; Olbert, et al., 2018; Whaley, 2001). Exact figures vary. 

• Olbert, et al. found that Black patients are diagnosed with schizophrenia 2.4 times more frequently than white patients (OR=2.42, 95% CI [1.59, 3.66]) (Olbert, 2018). This was the case when using both structured (OR=2.43, 95% CI [1.59, 3.72]) and unstructured (OR=1.77, 95% diagnostic assessments) (Olbert, 2018). 

• Gara, et al. found that Black patients had higher rates of clinical diagnoses of schizophrenia than non-Latino white patients did, even after controlling for covariates like serious affective disorders (Gara, et al., 2012).

  • When schizophrenia was narrowly defined, a significant ethnicity/race effect was found even after controlling for all other predictors (