Problems in diagnosing schizophrenia and affective disorders among blacks

Whose Signals Are Being Amplified? Toward a More Equitable Clinical Psychophysiology

Research using psychophysiological methods holds great promise for refining clinical assessment, identifying risk factors, and informing treatment. Unfortunately, unique methodological features of existing approaches limit inclusive research participation and, consequently, generalizability. This brief overview and commentary provides a snapshot of the current state of representation in clinical psychophysiology, with a focus on the forms and consequences of ongoing exclusion of Black participants. We illustrate issues of inequity and exclusion that are unique to clinical psychophysiology, considering intersections among social constructions of Blackness and biased design of current technology used to measure electroencephalography, skin conductance, and other signals. We then highlight work by groups dedicated to quantifying and addressing these limitations. We discuss the need for reflection and input from a wider variety of stakeholders to develop and refine new technologies, given the risk of further widening disparities. Finally, we provide broad recommendations for clinical psychophysiology research.

Examining the Impact of Race on Motivational Interviewing Implementation and Outcomes with HIV+ Heavy Drinking Men Who Have Sex with Men

Motivational interviewing (MI)-based interventions focus on changing behavior through building client motivation. It is unknown how racial mismatch between clients and providers may impact MI implementation and subsequent behavior. We used a mixed methods approach to examine differences in Motivational Interviewing Skill Code (MISC) coded sessions and post-session outcomes between a sample of HIV-positive cisgender men who have sex with men (MSM) participants of an MI-based intervention to reduce heavy drinking who identified as persons of color (POC; n = 19) and a matched sample of White participants (n = 19). We used quantitative methods to analyze how providers implemented the intervention (i.e., MISC codes) and post-session drinking. We used qualitative analyses of session transcripts to examine content not captured by MISC coding. Quantitative analyses showed that providers asked fewer open-ended questions and had a lower ratio of complex reflections to simple reflections when working with POC participants, but no significant differences were observed in drinking post-intervention between participants. Qualitative analyses revealed that participants discussed how racial and sexual orientation discrimination impacted their drinking. Allowing clients to share their experiences and to explore individually meaningful reasons for behavioral change may be more important than strict adherence to MI techniques.

Psychiatric Disorders and Alcohol Consumption Among Low-Income African Americans:Gender Differences

Background: Although cooccurrence of nonsubstance use disorders (non-SUDs) and substance use is well-established in the literature, most of what we know in this regard is derived from studies that have recruited predominantly White sample populations. As a result, there is a gap in knowledge on this link among low-income African Americans (AAs). There is also a need to understand how low-income AA men and women differ in these associations. Objective: To study whether there is an association between number of non-SUDs and amount of alcohol consumption by AA adults, and whether this association varies between AA men and women. Methods: This cross-sectional study recruited a nonrandom sample of 150 AA adults with non-SUDs (i.e., major depression, bipolar disorders, obsessive–compulsive disorder, paranoid disorder, panic disorder, posttraumatic stress disorder (PTSD), and schizoaffective disorder). The independent variable was the number of non-SUDs. The dependent variable was the amount of alcohol consumption. Age, socioeconomic status (educational attainment and household income), and self-rated health were covariates. Gender was the moderator. Linear regression models were used to analyze the data. Results: A higher number of non-SUDs was not associated with a higher amount of alcohol use in the pooled sample of AA adults. We, however, found a significant interaction between gender and number of non-SUDs on the amount of alcohol use, suggesting a stronger effect of non-SUDs on alcohol consumption in AA men than in AA women. Gender-stratified linear regression models showed a positive association between number of non-SUDs and amount of alcohol consumption in AA men but not in AA women. Conclusion: Non-SUDs impact alcohol use of AA men but not women. Future research should test whether AA men may have a higher tendency to turn to alcohol to regulate their emotions and cope with psychological pain due to multiple non-SUDs. The results also suggest that integration of services for SUDs and non-SUDs may be more relevant to provision of mental health services for AA men than AA women.

Attitudes of mental health clinicians toward perceived inaccuracy of a schizophrenia diagnosis in routine clinical practice

BACKGROUND

Mental health clinicians have previously been reported to express reservations regarding the utility and accuracy of the psychiatric classification systems. In this study we aimed to examine clinicians' experiences with instances of perceived inaccuracy of a schizophrenia diagnosis.

METHODS

Mental health clinicians (N = 175) participated in an online survey assessing prevalence and perceived reasons for inaccuracies of a schizophrenia diagnosis. Respondents included psychiatric ward directors (13.1%), senior psychiatrists and psychologists (40.5%), and psychiatry and clinical psychology residents (36%).

RESULTS

Fifty-three percent of respondents reported encountering instances where a schizophrenia diagnosis was assigned even though clinical presentation did not match diagnostic criteria. Seventy-three percent of senior psychiatrists in a position to determine a diagnosis declared assigning schizophrenia even when controversial among clinical staff, and 15% of them declared doing so frequently. The likelihood of frequently assigning a schizophrenia diagnosis even when clearly controversial was predicted by the perception that an inaccurate diagnosis is assigned due to the presence of negative symptoms (OR 2.20, 95% CI 1.04-4.66, p = 0.039) and due to patient-related factors, such as the need to facilitate rehabilitation (OR 1.77, 95% CI 1.07-2.90, p = 0.024).

CONCLUSIONS

Although a schizophrenia diagnosis is considered relatively stable and clear, our study indicates that, in clinical practice, the assignment of this diagnosis is frequently controversial. These controversies are associated with the perception that an inaccurate diagnosis is assigned due to diagnostic considerations, or due to the possibility that patients might benefit from such a diagnosis. Implications and limitations for psychiatric practice and discourse are discussed.

Racial-Ethnic Differences in Psychiatric Diagnoses and Treatment Across 11 Health Care Systems in the Mental Health Research Network

OBJECTIVE

The objective of this study was to characterize racial-ethnic variation in diagnoses and treatment of mental disorders in large not-for-profit health care systems.

METHODS

Participating systems were 11 private, not-for-profit health care organizations constituting the Mental Health Research Network, with a combined 7,523,956 patients age 18 or older who received care during 2011. Rates of diagnoses, prescription of psychotropic medications, and total formal psychotherapy sessions received were obtained from insurance claims and electronic medical record databases across all health care settings.

RESULTS

Of the 7.5 million patients in the study, 1.2 million (15.6%) received a psychiatric diagnosis in 2011. This varied significantly by race-ethnicity, with Native American/Alaskan Native patients having the highest rates of any diagnosis (20.6%) and Asians having the lowest rates (7.5%). Among patients with a psychiatric diagnosis, 73% (N=850,585) received a psychotropic medication. Non-Hispanic white patients were significantly more likely (77.8%) than other racial-ethnic groups (odds ratio [OR] range .48-.81) to receive medication. In contrast, only 34% of patients with a psychiatric diagnosis (N=548,837) received formal psychotherapy. Racial-ethnic differences were most pronounced for depression and schizophrenia; compared with whites, non-Hispanic blacks were more likely to receive formal psychotherapy for their depression (OR=1.20) or for their schizophrenia (OR=2.64).

CONCLUSIONS

There were significant racial-ethnic differences in diagnosis and treatment of psychiatric conditions across 11 U.S. health care systems. Further study is needed to understand underlying causes of these observed differences and whether processes and outcomes of care are equitable across these diverse patient populations.

Validation study of HSCL-10, HSCL-6, WHO-5 and 3-key questions in 14-16 year ethnic minority adolescents

BACKGROUND

There is a lack of validated instruments for detection of depression in ethnic minority adolescent patients in primary care. This study aimed to compare a subgroup of the bilingual, ethnic minority adolescents with the rest of the population using Hscl-10, Hscl-6, WHO-5 and 3-Key Questions for detection of depression in primary care.

METHOD

This is a cross-sectional, multicenter study conducted in General Practice in Norway and Denmark. A minor bilingual non-aggregated heterogenic ethnic minority group from non-European countries was compared with a major ethnic group of Norwegian/Danish adolescents. Participants completed questionnaires which were either mailed to them or found on our website. The Composite International Diagnostic Interview was used as gold standard. Depression classified by the International Classification of Diseases - 10. The Internal and external validity of the four questionnaires were examined. Optimal cut-off point for major depressive disorder was calculated using the Youden Index.

RESULTS

294 (77%) were interviewed; mean age was 15 years. The ethnic group comprised 44 (64% girls and 36% boys). Chronbach's alpha was above 0. 70 and area under curve was 0.80 or above for all instruments in the ethnic minority group. Cut-off points for major depressive disorder had sensitivities of 81% (Hscl-10), 82% (Hscl-6), 91% (Who-5) and 81% (3-key questions) in the ethnic minority group. Corresponding specificities were 80% (Hscl-10), 77% (Hscl-6), 80% (Who-5) and 67% (3-key questions). Cut-off points were the same Hscl-10, Who-5, the 3-key questions but differed for Hscl-6.

CONCLUSION

Hscl-10, Hscl-6, WHO-5 and 3-key questions seem to be valid instruments for detection of depression in bilingual, ethnic minority adolescents in primary care.

Psychiatric morbidity, phenomenology and management in hospitalized female foreign domestic workers in Lebanon

40 million female domestic workers worldwide experience the inhumane conditions associated with this unregulated occupation, a situation that induces psychiatric morbidities in many. The case in Lebanon is not any better where it is estimated that one foreign domestic worker (FDW) commits suicide weekly. 33 female FDW and 14 female Lebanese (control group, CG) were enrolled. Brief Psychotic Rating Scale (BPRS) and Clinical Global Impression (CGI) scales were administered on admission and discharge and socio-demographic, living conditions, mental health care data and phenomenological observations were collected. Sexual, physical, and verbal abuses were detected in FDW (12.5, 37.5, and 50.0 %. respectively). 66.7 % of them were diagnosed with brief psychotic episode. The mean duration of hospital stay (13.1 days) was significantly lower in the FDW group. The mean cumulative antipsychotic dose of the FDW was 337.1 mg of chlorpromazine equivalent and the mean BPRS total pre-score of FDW was 66.4 with a much improved state on the CGI global improvement scale, all of which were nonsignificantly different from the CG. Striking phenomenological findings among FDW were acute anorexia (39.4 %), nudity (30.3 %), catatonic features (21.2 %), and delusion of pregnancy (12.1 %). Inpatient FDW are more diagnosed with psychotic than affective disorders and receive approximately similar treatment as controls in spite of the trend to rapidly discharge and deport the worker to limit the costs. Both groups presented with similar severity, although the FDW had peculiar phenomenological observations.

Correlates of schizophrenia spectrum disorders in children and adolescents cared for in community settings

BACKGROUND: This study examined the prevalence and correlates of schizophrenia spectrum disorders (SSD) among a national sample of 9006 children. METHODS: Clinician-assigned diagnoses were used to divide the sample into two groups: children with SSD and children with other Axis I disorders. RESULTS: Three percent of the sample had a SSD diagnosis. African American (OR=1.71, 95% CI: 1.11, 2.65) and Hispanic race/ethnicity (OR=1.96, 95% CI: 1.31, 2.94), a greater number of comorbid psychiatric diagnoses (three diagnoses, OR=2.22, 95% CI: 1.49, 3.31), a history of attempting suicide (OR=1.45; 95% CI: 1.05, 2.02), and past residential treatment (OR=1.59; 95% CI: 1.11, 2.28) were all associated with increased odds of SSD diagnosis. CONCLUSIONS: Although schizophrenia spectrum disorders in youth are rare, children with these disorders present with a distinct risk profile that may inform service planning and delivery and assist in identifying individuals early in the course of their illness.

Ethnicity and diagnostic patterns in veterans with psychoses

BACKGROUND

Differential diagnosis of schizophrenia and bipolar disorder is a challenging but important task. These conditions often exhibit overlapping clinical symptomatology, but have different prognoses and pharmacological management strategies. Factors other than clinical presentation may influence diagnosis. Past studies suggest that ethnicity is one such factor, with variations observed in diagnostic rates of serious mental illness (SMI). With increasing attention paid to provider cultural competency, we investigate current diagnostic practices within a veteran population.

METHOD

Controlling for patient need characteristics and illness severity, we examine whether ethnic differences in diagnosis continue to exist. If so, race may adversely enter the evaluation process. A national database of all SMI veterans explores the relationship between ethnicity and diagnosis. The role of symptomatology is also examined. Given minimal variation in veteran socioeconomic status, the Department of Veterans Affairs (VA) provides a natural setting to address this confounding factor. The 1999 National Psychosis Registry provides a sample of 134,523 veterans diagnosed with schizophrenia, schizoaffective disorder, or bipolar disorder. Multinomial logistic regression yielded odds ratios (OR) for being diagnosed with schizophrenia versus bipolar disorder; the schizoaffective versus bipolar risk was likewise assessed, exploring theoretical aspects of a psychosis-affective 'continuum'.

RESULTS

Small effects were observed for being male, single or rural resident. However, the demographic characteristic most strongly associated with a schizophrenia diagnosis was race. The OR for African Americans was 4.05, and 3.15 for Hispanics. Similar though less dramatic results were revealed for schizoaffective disorder.

CONCLUSIONS

This study confirms continued ethnic disparities in diagnostic patterns, and highlights the importance of recognizing ethnic differences in symptom presentation while emphasizing greater cultural competency.

Panic disorder in African-Americans: symptomatology and isolated sleep paralysis

While attention has been paid to the study of panic disorder (PD) with or without agoraphobia among Caucasians, surprisingly little empirical research within the United States has looked at the phenomenology of PD among minority groups. In this paper we present data we have collected and review other research on the phenomenology, social supports, and coping behavior among African-Americans with panic disorder. Our studies indicate that, in comparison to Caucasians, African-Americans with PD reported more intense fears of dying or going crazy, as well as higher levels of numbing and tingling in their extremities. African-Americans reported higher rates of comorbid post traumatic disorder and more depression. African-Americans also used somewhat different coping strategies (such as religiosity and counting one's blessings), less self-blame, and were somewhat more dissatisfied with social supports. The incidence of isolated sleep paralysis was, as per previous reports, higher in African-Americans. These findings, results of other research, and the implications for assessment and treatment are discussed within a semantic network analysis of panic (Hinton and Hinton 2002, this issue).

Ethnic populations in public mental health: services choice and level of use

BACKGROUND

Barriers to access and use of mental health care by Asians, Blacks, and Hispanic Americans have been a source of concern for many years. Limitations in our knowledge base persist regarding patterns of use in public sector programs of certain services. Using a sample of almost 27,000 persons, this study examined access and level of use by ethnic minority groups of emergency services, inpatient care, individual outpatient visit, and case management.

METHODS

Data from the management information systems of San Francisco and Santa Clara counties were analyzed for fiscal year 1987/1988. Multivariate models were evaluated at two stages, reflecting whether or not a service had been used, and if used, the level of use.

RESULTS

Asians and Hispanics used less emergency and inpatient but more outpatient care than did Whites; Blacks used more emergency and less outpatient care.

CONCLUSIONS

Ethnicity continues to play a role in understanding the utilization of mental health services. Regarding emergency and inpatient care, Asian and Hispanic patterns of use appear relatively favorable, whereas the patterns of Blacks continue to be problematic.

Community mental health and ethnic minority populations

National trends in minority utilization of mental health services are reviewed, and recommendations are made for needed research. In relation to their representation in the population, blacks use services more than expected, and Asian American/Pacific Islanders use services less; Hispanics and Native American/Alaska Islander use varies according to type of service. Hospitalization accounts for part of the increase in minority utilization; this trend is problematic. Disruptions in service continue to plaque minority clients, possibly stemming from inadequacies in the organization and financing of care, and from cultural incongruity. Much more must be learned about these problems in utilization, as well as about other key issues.

The influence of racial factors on psychiatric diagnosis: a review and suggestions for research

Research on race and diagnosis initially focused on black-white differences in depression and schizophrenia. Statistics showing a higher treated prevalence of schizophrenia and a lower prevalence of depression for blacks seemed to support the claim that blacks did not suffer from depression. Others argued, however, that clinicians were misdiagnosing depression in blacks. This article reviews empirical studies of racial differences in individual symptoms and summarizes the evidence on misdiagnosis. It argues that more attention must be paid to resolving two contradictory assumptions made by researchers working in the area of race and diagnostic inference: (1) blacks and whites exhibit symptomatology similarly but diagnosticians mistakenly assume that they are different; (2) blacks and whites display psychopathology in different ways but diagnosticians are unaware of or insensitive to such cultural differences. The article concludes with suggested research directions and a discussion of critical research issues.