Schizophrenia Among African Americans

For some years, researchers have known that African American patients are more likely to receive a diagnosis of schizophrenia—with the results of serious treatment, personal, and social effects—compared with white patients. [Trierweiler 2000, Neighbors 2003] Receipt of a schizophrenia diagnosis by an African American patient may be more likely in circumstances such as:

  • The patient has another mental disorder that may manifest with psychotic features.
  • The patient is not in fact experiencing a mental
    disorder, but the diagnosing clinician has misinterpreted cultural idioms of emotional distress
    as schizophrenic symptoms.
  • The patient’s symptoms are not actually those of schizophrenia but rather of a systemic medical condition that may involved psychotic symptoms, such as substance abuse (eg, cocaine, methamphetamine, or hallucinogen) or a neurologic disorder associated with advanced HIV disease.

Minimizing the risk of an inappropriate diagnosis of schizophrenia—and the negative health and other consequences that may accompany it—will require healthcare organizations and practitioners to understand the clinician-related and patient-related factors that can contribute to such a misdiagnosis.

Strakowski and colleagues performed an analysis comparing the diagnoses of 99 patients presenting to a psychiatric emergency service with information obtained by screening the same patients using a structured clinical interview. [Strakowski 1997] The researchers reported that the diagnoses obtained by the latter method agreed with the emergency service’s diagnoses in only 42% of cases and concluded that in such situations a patient’s race may be a contributing factor in the type and quality of information elicited during screening.

And in a 1981 review study, Adebimpe concluded that clinicians’ failure to understand ethnic differences in the expression of emotional distress could be a contributing factor to the psychiatric misdiagnosis of African American patients and stressed the importance of the development of more appropriate diagnostic criteria for African American patients. [Adebimpe 1981, Strakowski 2003] In addition, without the careful use of structured screening techniques, along with clinical judgment, to determine the most accurate assignment of DSM criteria, practitioners have often tended to overemphasize the diagnostic importance of psychotic symptoms in African American patients, with the risk of overdiagnosing schizophrenia in this population. [Trierweiler 2000, Neighbors 2003]

Furthermore, patient-related factors—that is, culture-specific manifestation or description of symptoms—present another challenge to diagnosticians in appropriately eliciting from patients the information necessary to accurately diagnose, or rule out, schizophrenia. These factors can include:

  • Culturally idiomatic differences in expression of symptoms [Strakowski 1997, Strakowski 2003, Neighbors 1989]
  • Patient protective wariness regarding the clinical encounter—misinterpreted by the diagnostician as paranoia [Strakowski 1997, Strakowski 2003]
  • Avoidance of treatment, particularly regarding mental health services [Adebimpe 1981]

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Howard University College of Medicine AIDS Education and Training Center - National Multicultural Center