African Americans with severe depression are more likely to be misdiagnosed as having schizophrenia than white patients, a new study from Rutgers University found.
The finding builds on years of evidence that clinicians’ racial biases — whether conscious or unconscious — affect the types of mental-health diagnoses African American patients receive. From teens being underdiagnosed for depression to adults being overdiagnosed for schizophrenia, research has demonstrated a persistent trend of misdiagnosis for this community.
“This is rampant and widespread,” said Alfiee Breland-Noble, a professor of psychiatry at Georgetown University Medical Center who researches depression in African Americans but who was not associated with the Rutgers study. “It is a pervasive problem in the health-care system.”
In the study, which was published in the journal Psychiatric Services, researchers examined the medical records of more than 1,600 people at a community behavioral clinic. About 600 were African American and about 1,000 were non-Latino whites.
The review was done retroactively based on data that are routinely gathered at the clinic, so researchers would not influence clinicians or patients.
They found about 20 percent of African Americans diagnosed with schizophrenia also screened positive for major depression — nearly six times the percentage of white patients with schizophrenia who screened positive for major depression.
That suggests some of the African American patients may have been misdiagnosed, said Michael Gara, coauthor of the study and a professor of psychiatry at Rutgers’ Robert Wood Johnson Medical School.
Schizophrenia is a diagnosis of exclusion, he explained. Clinicians must rule out other potential causes of symptoms first, such as mood disorders, before the diagnosis of schizophrenia is given.
But research shows there’s a tendency for clinicians to overemphasize the relevance of psychotic symptoms, such as hallucinations, and overlook symptoms of major depression in African Americans compared with other racial or ethnic groups.
“Let’s face it, people stereotype,” Gara said. “It’s not necessarily malicious. They do it implicitly. It’s automatic.”
Large population-based studies have found no significant difference in the likelihood of African Americans and whites having schizophrenia. But in practice, the diagnosis disparities persist, Gara said.
What may be happening, Gara said, is that during a clinical interview, an African American patient might report psychotic symptoms like hearing voices. “The clinician might stop right there and say, ‘He’s clearly psychotic,’ and make a diagnosis,” Gara said. “But maybe there were a lot of mood symptoms and they never looked for those.” With white patients, clinicians might be investigating further.
A previous study Gara worked on with Stephen Strakowski from the University of Texas Austin’s Dell Medical School found the diagnosis disparities for African Americans were consistent at medical centers across the country. But they did not find the same trend in Latino patients, so Gara didn’t include Latino patients in the new study.
There are scarce data on disparities in schizophrenia diagnoses among other minority groups.
The consequences of misdiagnosis
Misdiagnosis among African Americans is not limited to schizophrenia.
Previous research has shown black teens are often underdiagnosed for depression because they express different symptoms from white teens. Instead of saying they feel sad or lonely, black teens might express more anger and irritability. Depression screening tools are not designed to pick up on that, and clinicians will often diagnose them with a conduct problem instead.
People of color are also more likely to experience mental illness as physical symptoms, Breland-Noble said. Depression can present as headaches, for example, or anxiety as gastrointestinal issues. Since not all providers know to consider psychological causes for these physical symptoms, it can delay or prevent proper diagnosis.
When patients are misdiagnosed, their care suffers, the study authors wrote, putting patients at risk for worsening symptoms or suicide.
Medications for schizophrenia can have serious side effects and those risks cannot outweigh the benefits when a diagnosis is incorrect, the authors added.
Misdiagnoses also exacerbate the mistrust many communities of color have of the medical system, Breland-Noble said. “People are less likely to come in for care because they see what happens to the people around them,” she said.
The study authors recommended that screening for major depression be required when assessing African American patients for schizophrenia.
“It takes just a minute to screen and then the psychiatrist would look and say: ‘He might have major depression. Let me see if that better accounts for his symptoms,' ” Gara said.
It still may turn out that the patient has schizophrenia, but pausing and giving it a second thought might decrease the likelihood of misdiagnosis, he said.
Breland-Noble suggests cultural competence training plays a large role in addressing disparities such as this. While the study didn’t assess how a provider’s race or background affected diagnosis, she said it’s likely clinicians who know how to listen and observe with more cultural understanding would make better diagnoses.
For example, if patients say they’re talking to God, a culturally competent provider might recognize that faith and mental health are strongly linked in many communities. It would lead them to expand their line of questioning.
“Are they literally talking to God, seeing him standing next to them? Or are they saying internally they have this dialogue with God?” Breland-Noble said.
Without that cultural competence, clinicians might just assume the patient is out of touch with reality and jump to a schizophrenia diagnosis.