Running Head: OVERDIAGNOSIS OF SCHIZOPHRENIA IN AFRICAN AMERICANS 1

The Overdiagnosis of Schizophrenia in African American Populations:

A Discussion of Diagnostic Bias in the Untied States
Anna Allison
University of San Francisco

OVERDIAGNOSIS OF SCHIZOPHRENIA IN AFRICAN AMERICANS
2

Introduction
Over the past decade, increased attention has been paid how racial and ethnic differences
affect clinical diagnosis of mental illness. Race and ethnicity have a role to play in the allocation
of resources, the method of treatment, and even the diagnosis itself. African Americans are more
likely to be recommended to inpatient care while European Americans are often treated with less
invasive and stigmatizing out-patient care (Feisthamel & Schwartz, 2009). Similar studies found
that African Americans are more likely to be first admitted and then readmitted to hospitals for
mental illness. During diagnosis, African Americans are more likely to be diagnosed with
specific psychotic disorders, such as schizophrenia while European Americans are more likely to
be diagnosed with mood disorders (Feisthamel & Schwartz, 2009). There is, in fact, an under
diagnosis of mood disorders among African Americans, despite the fact that mood disorders are
often considered a safer diagnosis due to improved prognosis and less invasive interventions
(Feisthamel & Schwartz, 2009). One study found that African Americans were as much as three
times more likely to be diagnosed with schizophrenia than European Americans (Begg,
Bresnahan, Brown, Insel, Schaefer, Sohler, Susser & Vella, 2007).
Diagnostic bias can be seen in both counseling and non-counseling professions and are
applied to African American children as well as adults (Feisthamel & Schwartz, 2009). Once
diagnosed with schizophrenia, African Americans are 13 times more likely to experience forced
hospitalizations than non-diagnosed individuals. Once diagnosed, these hospitalizations are also
much longer than they otherwise would be (Feisthamel & Schwartz, 2009). As children,
misbehavior among African Americans is more likely to be seen a symptomatic of ADHD or
ODD, whereas similar behavior of European American children is viewed as the normal
OVERDIAGNOSIS OF SCHIZOPHRENIA IN AFRICAN AMERICANS
3
rambunctiousness of childhood (Feisthamel & Schwartz, 2009). While not specifically related to
schizophrenia, this indicates that African American children are more likely to be considered
mentally ill than counterparts from other racial groups.
Poor access to mental health services, inadequate insurance and low quality care may all
affect how an individual is diagnosed and treated. However, clinician bias is well established and
plays a significant role in the diagnostic disparity among African Americans. This bias has a
significant impact on the patient, caregiver and community (Feisthamel & Schwartz, 2009).
When hospitalization is long and drawn out, it leads to more missed days of work, increased
stigma, and deepened distrust of medical providers. This indicates a clear need for increased
multicultural training, diversity in the field, and adherence to standardized diagnostic tools such
as the DSM.
History of Diagnostic Bias
After the abolition of slavery, medical reports began to speak of a rapid and general decline
of African American health (Jarvis, 2008). Before 1883, the rate of psychosis among African
Americans was believed to be nearly non-existent. The behavioral controls placed on slaves
supposedly shielded them from mental illness, as such afflictions were believed to only occur
among the upper class society (Jarvis, 2008). However, by the end of the 19th century, reports of
psychosis among African Americans had increased significantly. Moreover, medical reports
indicated that African Americans were more likely to be aggressive, destructive and disruptive
than European Americans when psychotic (Jarvis, 2008). In a complete reversal of earlier
beliefs, scientists of the time believed African Americans were predisposed to severe forms of
mental illness, and more likely to experience psychosis than European Americans. Ironically,
OVERDIAGNOSIS OF SCHIZOPHRENIA IN AFRICAN AMERICANS
4
this psychosis supposedly manifested in African Americans irrational suspicion and fear of
bodily harm. These reports represent the obvious bias that lingered, and still linger, long after the
abolition of slavery. While institutionalized racism may not be as pronounced as it once was,
current diagnostic bias mimics much of the prejudice that permeated the 19th century.
The Civil Rights Movement sparked a review of current medical literature, and the obvious
bias of previous studies were exposed, leading to a general discrediting of many of the beliefs
surrounding African American psychosis. Even at that time, there was some attention paid to
unusual rates of schizophrenia among African Americans compared to the Black British. In
1972, Cooper et al. reported that the, New York concept of schizophrenia is much broader than
that used in London and embraces many patients who would be regarded by British psychiatrists
as suffering from depressive illnesses, neurotic illnesses or personality disorders, and nearly all
those who would be regarded as suffering from mania (Jarvis, 2008). This anecdote speaks to
the overdiagnosis of psychosis and under diagnosis of mood disorders that was already occurring
among African Americans. In 1972, American psychologists ability to diagnosis schizophrenia
was already being called into question. However, many British psychiatrists believed American
psychiatrists to be unfit to diagnosis, regardless of the race of their patient. In the same article,
Cooper et al. stated, the New York concept of schizophrenia is not a useful one and is likely to
inhibit fruitful research if it is widely adopted (Jarvis, 2008). The severity of this statement may
reflect international anti-Americanism as much as it represents American diagnostic bias towards
African Americans.
As more reliable information was published, psychiatrists reported equal rates of
schizophrenia among African and European Americans. Instead of reporting elevated rates of
disorder, they began to report elevated rates of diagnosis. In 2004, the American Psychiatric
OVERDIAGNOSIS OF SCHIZOPHRENIA IN AFRICAN AMERICANS
5
Association released a statement, officially calling attention to diagnosing bias in the United
States:
Compared with Caucasians, African Americans, especially men, are less likely to receive a
diagnosis of a mood disorder and more likely to receive a diagnosis of schizophrenia . . .
These remarkably consistent findings suggest that clinicians should be mindful of the
extent to which cultural factors influence their diagnostic approach (American Psychiatric
Association, 2004).
Since then, diagnostic bias as been a consistent theme for African American patients with
schizophrenia. Observed bias may be conscious or unconscious and may be a mix of racial bias
as well as poverty bias. Teasing out the cause of overdiagnosis is not a cut and dry procedure as
several factors are likely to feed into it.
Remaining Biases
While prejudiced literature of the 19th century has been discredited, similar themes are still
seen in modern day studies. Arnold et al. found that African American patients were more likely
to be identified as having first-rank symptoms of schizophrenia, regardless of their actual
diagnosis (Arnold, Amicone, Adebimpe, Collins, Corey, Fleck, Keck & Strakowski, 2004). The
perceived presence of first-rank schizophrenia symptoms led many psychologists to assign
African Americans a diagnosis of schizophrenia, even when patients had been previous
diagnosed with a mood disorder. When clinicians participated in a blinded trial, where a
diagnosis of the patient was made based on redacted medical histories, and their race kept
hidden, there was a lower rate of diagnosis among African Americans. However, men of any
race were still more likely to be diagnosed with schizophrenia than women (Arnold et al., 2003).
OVERDIAGNOSIS OF SCHIZOPHRENIA IN AFRICAN AMERICANS
6
This indicates that racial bias is skewing clinician diagnosis, rather than actual differences
between African American and European American patients.
In several clinical trials, African American patients were diagnosed with schizophrenia at
rates of 10 to 40 percent higher than European American patients (Trierweiler, Neighbors ,
Binion, Thompson, Munday & Jackson, 2006). In 2000 and again in 2006, S.J. Trierweiler et. al
found that when nearly 3000 adult inpatients were studied at two different psychiatric hospitals,
62 percent of African Americans were diagnosed with schizophrenia while only 40 percent of
European Americans received a diagnosis of schizophrenia (S.J. Trierweiler et. al, 2006).
European Americans not diagnosed with schizophrenia often received a diagnosis of major
depressive disorder, or another mood disorder (S.J. Trierweiler et. al, 2006).
Trierweiler et. al hypothesized any difference in population rates of schizophrenia for
African American and non-African American patients should correspond to differences in rates
of the symptom attributions clinicians make in support of their diagnoses (S.J. Trierweiler et. al,
2006). They believed that it was possible that clinicians link particular attributions to a
schizophrenia diagnosis differently for African American patients than for non-African
American patients (S.J. Trierweiler et. al, 2006). Throughout their course of study, they found
that clinicians were not more likely to observe positive symptoms of schizophrenia in African
Americans, but they were more likely to observe negative symptoms (S.J. Trierweiler et. al,
2006). Among non-clinicians, positive symptoms are more closely associated with schizophrenia
than negative symptoms as these symptoms included an excess or distortion of normal functions
(Mayo Foundation, 2013). Positive symptoms include delusions, hallucinations and disorganized
behavior. Negative symptoms, on the other hand, are a diminishment or absence of normal
functioning. These symptoms include loss of interest in everyday activities, appearing to lack
OVERDIAGNOSIS OF SCHIZOPHRENIA IN AFRICAN AMERICANS
7
emotion, social withdrawal and neglect of personal hygiene (Mayo Foundation, 2013). Many of
the negative symptoms of schizophrenia can also be attributed to other mental illness, such as
depression (Mayo Foundation, 2013). However, when these symptoms are present in an African
American patient, clinicians are more likely to see it as schizophrenia, rather than depression.
Among European American patients, and patients of other ethnic groups, these symptoms are
more often diagnosed as depression.
The findings of Trierweilers 2006 trial remained consistent with findings in 2000,
indicating that clinician bias remained, and remains a deciding factor in the diagnosis of
schizophrenia in African Americans. However, this bias was not solely found in clinicians of a
specific ethnic or gender group (S.J. Trierweiler et. al, 2006). An important component of
Trierweilers trial were the clinicians utilized in the trail. Each clinician was either a third or
fourth year psychiatry resident, and each one had a minimum of two years working with
inpatient populations. The clinician group was comprised of five African Americans and five
European Americans. Each ethnic group consisted of two females and three males. Diagnosis of
schizophrenia was dispersed evenly throughout the group, meaning that a European American
woman was as likely to diagnosis an African American with schizophrenia as an African
American man was, and vice versa (S.J. Trierweiler et. al, 2006). This is an important indication
that better cultural competency training is needed, regardless of the diagnosticians race or
gender.
Socio-cultural Factors of Diagnosis
Many factors can influence an individuals mental status. Genetics, socioeconomics, and
the environment all play an important role in shaping mental health. There was a slight
OVERDIAGNOSIS OF SCHIZOPHRENIA IN AFRICAN AMERICANS
8
correlation between socioeconomic status and schizophrenia diagnosis, regardless of race. This
indicates that factors such as maternal education, paternal occupation, total family income, and
maternal marital status does play a role in affecting an individuals likelihood of being diagnosed
with schizophrenia (Begg et. al, 2007). However, socioeconomic status cannot mitigate the
affects of race on a diagnosis of schizophrenia. Children of African American mothers were still
three times more likely to be diagnosed with schizophrenia than children of European American
mothers with similar socioeconomic status (Begg et. al, 2007).
Separating the effects of race and socioeconomics on a diagnosis of schizophrenia is very
difficult. In 2010, and in several earlier studies, poverty is found to be a powerful predictor of
psychosis, and that poverty is more closely tied to schizophrenia than other forms of mental
illness (Read, 2010). However, since African Americans are more likely to live in poverty than
European Americans, it is difficult to determine whether the elevated risk of schizophrenia is due
to race or poverty. In all likelihood, both play a role. However, elevated diagnosis of
schizophrenia was found in European Americans living in poverty as well (Read, 2010). This
indicates that greater cultural competency is needed when dealing with impoverished
populations, as well as African American populations.
Possible Solutions
There is an apparent and well documented bias permeating diagnostic practices of
clinicians. Clinicians, regardless of their race or gender, are more likely to diagnosis an African
American with schizophrenia. The difference in diagnosis is especially prevalent when negative
symptoms are primarily used as the means of diagnosis. For this reason, it will be especially
important to increase clinician training on means of recognizing negative symptoms of
OVERDIAGNOSIS OF SCHIZOPHRENIA IN AFRICAN AMERICANS
9
schizophrenia, and how they can be differentiated from symptoms of other mental illness, such
as depression. Increasing this training will not only improve clinician understanding, but will
also train new diagnosticians to take a second look, or get a second opinion, when they are
diagnosing an African American that does not present with positive symptoms of schizophrenia.
It is also important to note that the overdiagnosis of schizophrenia decreased when
patients race and racial identifiers were redacted from their medical records. This indicates that
when clinicians seek a second opinion, it may be wise to consult another professional without
immediately divulging the patients race. Diagnosing in this way will undoubtedly seem strange
to many clinicians, but based on the inherent, and presumably unconscious bias in
diagnosticians, it may be a wise course of action.
When clinicians strictly adhere to standardized tools, such as the DSM, when diagnosing,
the overdiagnosis of schizophrenia decreases among African American populations (Feisthamel
& Schwartz, 2009). This may indicate that when diagnosing African American populations,
clinicians are more likely to stray from standard practice then when they are examining patients
of European or other ethnic backgrounds. Educating clinicians on the risks associated with non
standardized diagnosing practices may help mitigate some unconscious bias.
While African American clinicians are as likely to over diagnosis schizophrenia as
clinicians of other races, it may be that a greater diversity of socioeconomics may help mitigate
racial profiling in diagnosis. Perhaps clinicians who grew up in families with lower
socioeconomic status may be less likely to over diagnosis schizophrenia in underserved
populations. If so, scholarship programs aimed at recruiting a diverse student base to the study of
psychology and psychiatry should be bolstered. With that being said, there is not a body of
OVERDIAGNOSIS OF SCHIZOPHRENIA IN AFRICAN AMERICANS
10
evidence to support or refute this hypothesis.
References
American Psychiatric Association (2004), Practice Guideline for the Treatment of Patients with
Schizophrenia, 2nd edition, American Journal of Psychiatry, Supplement, 161:2, pp. 1
50.
Arnold, L., Amicone, J., Adebimpe, V., Collins, J., Corey, K., Fleck, D., Keck, P., & Strakowski,
S. (2004). Ethnicity and first-rank symptoms in patients with psychosis. Schizophrenia
Research, 67, 207212.

Begg, M., Bresnahan, M., Brown, A., Insel, B., Schaefer, C., Sohler, N., Susser, E., & Vella, L.
(2007). Race and risk of schizophrenia in a us birth cohort: Another example of health
disparity?. International Journal of Epidemiology, 36, 751758.

Feisthamel, K., & Schwartz, R. (2009). Disproportionate diagnosis of mental disorders among
african american versus european american clients: Implications for counseling theory,
research, and practice. American Counseling Association, 87, 295-301.

Jarvis, E. (2008). Changing psychiatric perception of african americans with psychosis.
European Journal of American Culture , 27(3), 227-252.

Mayo Foundation. (2013). Schizophrenia. Retrieved from
http://www.mayoclinic.com/health/schizophrenia/DS00196/DSECTION=symptoms
OVERDIAGNOSIS OF SCHIZOPHRENIA IN AFRICAN AMERICANS
11

Read, J. (2010). Can poverty drive you mad? schizophrenia, socio-economic status and the case
for primary prevention. New Zealand Journal of Psychology, 39(2), 7-19.

Trierweiler, S., Neighbors , H., Binion, V., Thompson, E., Munday, C., & Jackson, J. (2006).
Differences in patterns of symptom attribution in diagnosing schizophrenia between
african american and non-african american clinicians. American Psychological
Association, 76(2), 154-160.