Is schizophrenia over-diagnosed?

Researchers at Johns Hopkins Medicine conducted a short study of individuals referred to the Early Psychosis Intervention Clinic (EPIC) and found that around half of the participants referred to the clinic with a schizophrenia diagnosis did not have schizophrenia. Schizophrenia is a persistent, severe, and disabling condition characterized by abnormal thoughts, feelings, and behavior. Hearing voices or experiencing anxiety were two of the most common reasons for people to be misdiagnosed. “Because we’ve focused attention in recent years on emerging and early indicators of psychosis, diagnosis of schizophrenia is like a new trend,” says Krista Baker, L.C.P.C., manager of adult outpatient schizophrenia services at Johns Hopkins Medicine. “Diagnostic errors can be disastrous for individuals, particularly when a mental disease is misdiagnosed,” she says.[1]

What exactly is over-diagnosis? Overdiagnosis refers to the diagnosis of a medical illness that would never have generated any symptoms or difficulties in the first place. Psychological stress and excessive therapies might result from this type of diagnosis, which can be damaging.’ The consequences of overdiagnosis can be harmful to patients since they can result in overtreatment with potential side effects, diagnosis-related anxiety or despair, and labeling, as well as financial hardship.

Several studies conducted over several decades have revealed that Black individuals are diagnosed with schizophrenia at a higher incidence than white counterparts. Researchers discovered that Black individuals are 2.4 times more likely than white folks to be diagnosed with schizophrenia in a 2018 study of data from 52 distinct studies. According to other research, black people are diagnosed at a rate that is three to four times higher than that of white individuals. A number of studies have demonstrated the existence of the phenomena, according to William Lawson, M.D., Ph.D., chairperson of the Department of Psychiatry and Behavioral Sciences at Howard University Health Sciences. The overdiagnosis of schizophrenia is by far the most prevalent among black individuals. This phenomenon has been documented despite the paucity of genetic evidence demonstrating a true increase in incidence in this population. [2]

African Americans continued to have significantly higher rates of clinical diagnoses of schizophrenia after controlling for age, gender, income, location, and education, as well as the presence or absence of serious affective disorder, as determined by experts who were blinded to race and ethnicity, according to a study published in the journal JAMA Psychiatry in June 2012. After controlling for confounders such as major affective illness, Lawson and colleagues discovered that African Americans had considerably higher rates of clinical schizophrenia diagnoses than non-Latino white respondents. In addition, the researchers discovered that, despite these diagnostic disparities, African-American and white individuals did not differ significantly in blinded expert judgments of affective symptoms, but that African-American subjects did obtain greater ratings of psychosis than white respondents. Researchers found that “these data show that psychotic symptoms in African-American subjects may be overestimated by clinicians, skewing diagnoses toward schizophrenia-spectrum illnesses, even though affective symptoms are comparable to those in white subjects.”[3]

Hold on, don’t we all have prejudices? As a matter of fact, we all carry some sort of prejudice, whether we are aware of it or not. Others have a high level of self-awareness and will readily catch judgment before it exits its abode; nonetheless, our facial expressions or perhaps non-verbal signals can occasionally betray our true feelings and intentions. The thing is, by the time you misdiagnose someone based on their skin color, you’ve gone too far. Isn’t it, in some ways, a death sentence? Isn’t the goal of the healthcare sector to aid people, not to condemn them to an early grave? Perhaps not for people of color, but for everyone else—I’m so perplexed; aren’t we all human? I simply cannot fathom the fact that individuals are either overtreated, undertreated, or not treated at all based on their skin color.

My mind is spinning at the moment. Let’s meet on a patio and talk about this absurdity while sitting as comfortably as possible. We may be here for a while, so get a cup of coffee. This is a racial issue—I’m not going to sugarcoat it. This wilderness has no beginning, middle, or end, but we can nonetheless get started someplace. Consider the evidence that reveals that persons of color are less likely to seek and receive professional mental health care. I suppose they’re afraid for their own safety. Isn’t that so? I mean– If a black person goes to see a mental health professional because they are depressed or anxious, they may be diagnosed with schizophrenia. There is so much prejudice and discrimination that it scares people away from seeking professional treatment.

For some strange reason, all diagnoses — genuine or fraudulent — disappear when there is a court issue and requests for documentation of mental disorders with black people for a pass in jail and go to a mental facility. You are a robot without emotions in this arena (court and jail), and the court will lean toward the worst penalty imaginable, regardless of whether you deserve it or not. However, in the real world, you are portrayed as a mental case, whether or not that is the case. Either way, you have been tacitly sentenced to death. On the other hand,  You’re more likely to be mentally impaired if you’re a white person who’s on a trial or if you’re facing possible jail time hence sent to a mental facility despite the lethality of the crime.  And, in the normal world, you have the option and the ability to dictate what you believe is more fitting. To be continued…

Data shows that doctors utilize different symptom criteria when diagnosing schizophrenia among Black people[4] and that the use of a structured clinical interview does not alleviate this problem[5]. Additional research indicates that elevated diagnosis appears to be equally common among African Americans and white practitioners. [6] Patients with Black African ancestry appear to be perceived by clinicians as more paranoid and suspicious in general, which may contribute to the higher than average likelihood of psychotic diagnoses. Actually, much of contemporary popular literature has focused on how schizophrenia became known as a “black” diagnosis, in part because of cultural mistrust and perceived obstinance on the part of white people[7].

How about we make a point of agreeing to disagree? If there are overdiagnoses of African Americans in the normal world, why not apply the same standard while facing possible jail time? At the very least, there will be an opportunity to flee midway between prejudice and a probable death sentence…right? oh no, I forgot that if you’re sent to a mental facility, they’ll put you in such a drug-induced stupor that you’ll forget your name and pronoun. Please make some suggestions for possible actions, as that is by far the intended definition of “fucked” for a predominantly black man living in America.

So, what’s the deal, folks? Should individuals of color seek mental health care despite the high likelihood and risk of misdiagnosis, overdiagnosis, and underdiagnosis? Or should they remain put and perhaps devise a means of regaining a semblance of normalcy?

There are opportunities for cultural education and competence, for increasing the representation of persons of color in mental health professions, and so on. Even so, how soon will these measures become effective? The reality is that everyone needs equitable access to, at the very least, health care services. Everyone has the right to visit the doctor, and they shall be treated with dignity and respect as fellow people. Everyone deserves a chance at life, free from the threat of an implicit death sentence. Everyone, after all, is a human being!

References

[1] “Study Suggests Overdiagnosis of Schizophrenia.” Johns Hopkins Medicine Newsroom, 22 Apr. 2019, https://www.hopkinsmedicine.org/news/newsroom/news-releases/study-suggests-overdiagnosis-of-schizophrenia.

[2] Schwartz, Robert C, and David M Blankenship. “Racial Disparities in Psychotic Disorder Diagnosis: A Review of Empirical Literature.” World Journal of Psychiatry, Baishideng Publishing Group Inc, 22 Dec. 2014, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4274585/v.

[3] Moran, Mark, and Search for more papers by this author. “Overdiagnosis of Schizophenia Said to Be Persistent among Black Patients.” Psychiatric News, 29 Dec. 2014, https://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2015.1a17.

[4]Neighbors HW, Trierweiler SJ, Ford BC, et al. Racial differences in DSM diagnosis using a semi-structured instrument: the importance of clinical judgment in the diagnosis of African Americans. Journal of Health and Social Behavior. 2003;44:237–256.  

[5]Neighbors HW, Trierweiler SJ, Munday C, et al. Psychiatric diagnosis of African Americans: diagnostic divergence in clinician-structured and semistructured interviewing conditions. Journal of the National Medical Association. 1999;91:601–612. 

[6]Trierweiler SJ, Neighbors HW, Thompson EE, et al. Differences in Patterns of Symptom Attribution in Diagnosing Schizophrenia Between African American and Non-African American Clinicians. American Journal of Orthopsychiatry. 2006;76:154–160. 

[7]Whaley AL. Cultural mistrust and the clinical diagnosis of paranoid schizophrenia in African American patients. Journal of Psychopathology and Behavioral Assessment. 2001;23:93–100. 

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