Painting insanity black

Why are there more black schizophrenics?

By Annie Murphy Paul

Dec 1, 1999 | It took only a few weeks on the job for William Lawson to notice that there was something very strange going on. The psychiatrist had just joined the staff of the John L. McClellan Veterans Hospital in North Little Rock, Ark., and already he had seen patient after patient -- dozens of them, as it turned out -- with the same ill-fitting diagnosis. All African-American men, all veterans of combat in the Vietnam War, they suffered from terrifying nightmares, gut-twisting anxiety, flashbacks of fighting -- classic symptoms of post-traumatic stress disorder (PTSD). Yet they'd been assigned a very different condition: schizophrenia.

Lawson immediately took the men off the anti-psychotic medication they'd been prescribed, replacing it with the psychotherapy and antidepressants that have proven effective in relieving PTSD. Under the new treatment regime, most of the patients made a quick recovery.

Mistakes like the ones he discovered may be odd, but they're far from uncommon, says Lawson, now a professor at Indiana University and the co-editor of "Cross-Cultural Psychiatry" (Wiley, 1999). Studies going back to the 1960s show that African-Americans are significantly more likely to be diagnosed with schizophrenia than whites, a discrepancy due at least in part to clinician error. The rates of such mislabeling vary with the type of facility -- they're much lower, for example, in hospitals affiliated with universities -- but Lawson estimates that in overburdened community mental-health centers, as many as 30 percent of black patients diagnosed with schizophrenia actually have some other illness.

Of course, whites are also misdiagnosed at times, but far less frequently. According to Stephen Strakowski, M.D., a psychiatrist at the University of Cincinnati who has studied the issue, blacks are two to five times more likely than whites to be misidentified as schizophrenic. Ethnicity affects the diagnosis of other mental illnesses as well; clinicians sometimes miss the signs of major depression and bipolar disorder in blacks, for example, thereby leading to underdiagnosis. But schizophrenia presents special problems.

For one thing, it's precisely these bipolar and depressive patients who are likely to be misdiagnosed with schizophrenia. Each disease is treated with a different type of medication and the drugs used to manage schizophrenia have unfortunate side effects, including the involuntary (and sometimes permanent) twitching of facial muscles known as tardive dyskinesia. "The worst side effects accrue as you get more medicine over time," Strakowski observes. "We really want to minimize that, and only expose people who really have to have it."

While they wait for their misdiagnoses to be corrected, patients who actually have a different illness may be getting sicker, increasing the risk that they will attempt suicide and decreasing the odds that they'll eventually get better. (The more untreated episodes of mania and depression experienced by bipolar patients, for example, the tougher they are to treat when they do get appropriate care.) No less of a concern is the stigma attached to schizophrenia, a severe and probably partly inherited disorder of the brain that bears heavy social baggage. People diagnosed with schizophrenia are frequently feared or shunned by others, and have difficulty finding employment and housing. Studies suggest that schizophrenics often receive substandard medical care for illnesses like diabetes or high blood pressure because their physical complaints are dismissed as a product of their craziness.

But why would black people be more likely to be tagged as schizophrenics? Experts have some ideas; the first is simple racism. While clinicians are hesitant to burden middle- or upper-class whites with a devastating diagnosis like schizophrenia, Rosemary Farmer, Ph.D., assistant professor of social work at Virginia Commonwealth University, observes, such considerations don't always apply to minorities. "With an African-American, especially a lower socioeconomic-status African-American, people don't care as much, somehow," she says. "It's like, 'Oh well, what difference does it make, we'll label them anything.'"

Such careless -- or deliberate -- labeling has a long and ugly history. In the years before the Civil War, inflated estimates of mental illness among free blacks were used by anti-abolitionists to "prove" that blacks were better off as slaves. Even into the 1950s, American psychiatry maintained that blacks were too psychologically simple or too "jovial" to be depressed -- and so diagnosed the bulk of their mental illness as schizophrenia.

Next Page: But what if the differences can't all be chalked up to racism?

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