> washingtonpost.com
>
> Racial Disparities Found in Pinpointing Mental Illness
>
> By Shankar Vedantam
> Washington Post Staff Writer
> Tuesday, June 28, 2005; A01
>
>
>
> John Zeber recently examined one of the nation's largest databases of
> psychiatric cases to evaluate how doctors diagnose schizophrenia, a
> disorder that often portends years of powerful brain-altering drugs,
> social ostracism and forced hospitalizations.
>
> Although schizophrenia has been shown to affect all ethnic groups at
> the same rate, the scientist found that blacks in the United States
> were more than four times as likely to be diagnosed with the disorder
> as whites. Hispanics were more than three times as likely to be
> diagnosed as whites.
>
> Zeber, who studies quality, cost and access issues for the U.S.
> Department of Veterans Affairs, found that differences in wealth, drug
> addiction and other variables could not explain the disparity in
> diagnoses: "The only factor that was truly important was race."
>
> The analysis of 134,523 mentally ill patients in a VA registry is by
> far the largest national sample to show broad ethnic disparities in
> the diagnosis of serious mental disorders in the United States.
>
> The data confirm the fears of experts who have warned for years that
> minorities are more likely to be misdiagnosed as having serious
> psychiatric problems. "Bias is a very real issue," said Francis Lu, a
> psychiatrist at the University of California at San Francisco. "We
> don't talk about it -- it's upsetting. We see ourselves as unbiased
> and rational and scientific."
>
> As the ranks of America's patients and doctors become more diverse,
> psychiatrists such as Lu are spearheading a movement to address the
> problem. Clinicians need to be trained in "cultural competence," they
> say, to prevent misdiagnosis and harm.
>
> Psychiatrist Heather Hall, a colleague of Lu's, said she had to
> correct the diagnoses of about 40 minorities over a two-year period.
> She estimated that one in 10 patients referred to her came with a
> misdiagnosis such as schizophrenia, a disorder characterized by social
> withdrawal, communication problems, and psychotic symptoms such as
> delusions and hallucinations.
>
> Unlike AIDS or cancer, mental illnesses cannot be diagnosed with a
> brain scan or a blood test. The impressions of doctors -- drawn from
> verbal and nonverbal cues -- determine whether a patient is healthy or
> sick.
>
> "Because we have no lab test, the only way we can test if someone is
> psychotic is, we use ourselves as the measure," said Michael Smith, a
> psychiatrist at the University of California at Los Angeles who
> studies the effects of culture and ethnicity on psychiatry. "If it
> sounds unusual to us, we call it psychotic."
>
> When hospitals diversified their staffs to include Spanish-speaking
> doctors, many cases of psychotic behavior were reassessed, he said:
> "Half the cases were rediagnosed as depression. Some doctors think if
> you don't make eye contact, you can be diagnosed. In some communities,
> eye contact is a sign of disrespect."
>
> Zeber and a team of other researchers said they do not know why
> doctors were more likely to diagnose schizophrenia among blacks and
> Hispanics. Perhaps diagnostic measures developed primarily with white
> patients in mind do not automatically apply to other groups, said
> Zeber, who published his results in the journal Social Psychiatry and
> Psychiatric Epidemiology.
>
> "Race appears to matter and still appears to adversely pervade the
> clinical encounter, whether consciously or not," Zeber and his
> colleagues wrote in their October 2004 report.
>
> Darrel Regier, director of the division of research at the American
> Psychiatric Association and U.S. editor of the journal, said the study
> had been carefully conducted. He agreed that cultural differences
> between patients and doctors could result in misdiagnosis.
>
> "I believe bias exists, and there is a risk a psychiatrist with a
> different cultural experience than a patient can misinterpret the
> expression of a psychiatric symptom," he said. "If you have a very
> religious group of patients and a very secular psychiatrist who thinks
> beliefs in spirits or hearing the voice of God is not normal, you are
> going to have misses."
>
> But he added that Zeber's study did not explain what caused the
> diagnostic disparity among the veterans. Regier also questioned
> whether the veterans in the study were representative of the general
> population, or even representative of all veterans. Different ethnic
> groups seek care in different ways within and outside the VA, he said,
> and blacks tend to seek care when they are sicker than white patients.
>
> While agreeing that even more comprehensive analyses are possible,
> Zeber stood by his findings. The study had carefully eliminated a host
> of confounding variables, he said, and the analysis had not found that
> black patients were any sicker than whites. "Access issues or
> selection bias are unlikely to account for our findings," the paper
> concluded.
>
> "If you have an African American patient presenting with elevated
> paranoia, that has been referred to in some quarters as healthy
> paranoia based on how they perceive society," said Zeber, who works at
> the Veterans Affairs Department's Health Services Research and
> Development center in San Antonio. "If you base your diagnosis on that
> symptom, you can be misled."
>
> Zeber's argument is supported by a panel of academic experts who
> helped draft a research agenda in 2002 for the next edition of
> psychiatry's manual of mental disorders.
>
> They wrote: "Misdiagnosis due to a different cultural perspective of
> bizarreness is rather frequent." Inattention to the role that social
> standards and cultural factors play in diagnosis has caused patients
> to be stereotyped, they added, "with obvious negative consequences for
> diagnosis and treatment."
>
> Rethinking a Diagnosis
>
> The patient was a young black man named Kevin Moore. He had been
> picked up by police -- after his mother called 911 and said he was
> making threats. The police brought him to San Francisco General
> Hospital.
>
> Moore already had a diagnosis from previous stints at other hospitals:
> schizophrenia.
>
> But psychiatrist Heather Hall thought something was wrong. Patients
> with schizophrenia can seem to shrink into their own world.
>
> Superficially, Moore matched that description. He was uncommunicative.
> But when Hall looked closer, she noticed something else.
>
> "A schizophrenic would be flat, he would be staring blankly into
> space," Hall said in an interview about Moore's case, given with his
> permission. "His expression wasn't moving, but he wasn't blank. He
> looked really, really sad."
>
> After a thorough evaluation, Hall changed Moore's diagnosis to
> depression and reconfigured his medication regimen. She spent hours
> with Moore, coaxing him to talk. Within weeks, he began opening up
> about a host of interpersonal problems.
>
> Moore said he was first diagnosed with schizophrenia when he was 16 or
> 17. In an interview at the San Francisco hospital, he was dressed in a
> baggy sweat shirt and sported his hair in cornrows. His braces made
> him seem younger than his age -- 24 at the time.
>
> He said the police had picked him up because he had talked of getting
> a gun. A quarrel with a friend had escalated into a fight, and his
> mother had called the police. Moore thought his mother had
> overreacted, and he was sullen and uncommunicative when the police
> forcibly took him to the hospital.
>
> "I probably didn't want to talk to any people," he said. "I didn't
> want to be there."
>
> The particularly close attention that Hall paid to Moore was not the
> only unusual thing about his treatment. Moore was treated at one of
> the hospital's "focus units" -- inpatient psychiatric centers that
> focus on how culture and ethnicity influence psychiatric diagnosis and
> treatment.
>
> The units pay attention to everything -- the decor as well as the
> treatment: The Black Focus Unit, for example, had African and African
> American art and icons on the walls. The occupational therapy room had
> photos of Vanessa Williams, Maya Angelou and Oprah Winfrey. The
> hospital also had an HIV-AIDS and a Lesbian, Gay, Bisexual and
> Transgender Focus Unit, as well as a Latino/Women's Focus Unit. The
> Asian Focus Unit had bulletins printed in multiple Asian languages.
>
> The specialized units have been hailed as an innovative way to put
> patients at ease, but they have also faced criticism.
>
> Psychiatrist Sally Satel described them as a type of "apartheid."
> Satel, who is affiliated with the American Enterprise Institute and is
> the author of "PC, M.D.: How Political Correctness Is Corrupting
> Medicine," said such divisions can prompt patients to avoid examining
> the real source of their mental problems.
>
> "In its worst form, it is not really counseling," she said of what she
> called multicultural therapy. "It is a support group between two
> people who want to blame the outside world."
>
> Moore and psychiatrist Hall are both black, but the hospital does not
> match doctors and patients by ethnicity. Every unit had staff members
> and patients from diverse backgrounds, and psychiatrist Lu said the
> wishes of patients and special needs such as language and prior
> history determined where patients were assigned. Every unit had
> specialized training -- staff members at the Asian Focus Unit, for
> example, spoke 14 languages.
>
> Hall said Moore was a perfect example of why the Black Focus Unit is
> important: "Maybe because I am an African American psychiatrist, maybe
> he was able to show me a little more of himself for me to make an
> accurate diagnosis and change his treatment to a more accurate
> treatment."
>
> She added, "Because the people who work on our unit are sensitive to
> the issues of African Americans, we are much more likely to look at
> our patients with eyes that aren't clouded by preconceived notions."
>
> The psychiatrist recalled another case of a black man diagnosed as
> delusional. The man had talked about going to another city and getting
> revenge on people who had killed his son.
>
> "The treatment plan was filled out by someone who was not part of our
> focus unit," she said. "She assumed it was a delusion -- she said,
> 'This man has a delusion that his son was killed in a hate crime.' "
> Hall checked out the man's account. It turned out to be true.
>
> "People say minorities don't follow up" in psychiatric care, Hall
> said. "Maybe on their first session they are not heard. Why would they
> come back? If I tell a therapist I am being brutalized and he thinks I
> am delusional, why would I come back?"
>
> Other clinicians echo such views. UCLA's Smith, who speaks Spanish,
> said that while making rounds with residents, he once asked an
> interpreter to check whether a Spanish-speaking patient wanted to
> commit suicide: "The patient said, 'I feel so bad I could die.' " But
> rather than convey the sense that the patient was in distress and felt
> terrible, Smith said, the interpreter told the residents, "She's
> suicidal."
>
> Carl Bell, a Chicago psychiatrist, said he once went through the
> medical records of minority patients at Jackson Park Hospital in
> Chicago and found many misdiagnoses. One 30-year-old woman was talking
> fast, was calling people at all hours and did not seem to need sleep
> -- classic symptoms of bipolar disorder, or manic-depression. But her
> charts showed she had been hospitalized for schizophrenia and treated
> with injectable medications, which suggested that her doctors thought
> her schizophrenia was particularly severe.
>
> "How does a woman with a college education, a job . . . she has
> euphoria, pressured speech, decreased need for sleep -- how do you get
> schizophrenia, chronic schizophrenia?" asked Bell, still incredulous.
>
> Advocates for cultural competence say both clinicians and patients are
> unwilling to acknowledge that race might matter: "In a cross-cultural
> situation, race or ethnicity is the white elephant in the room," said
> Lillian Comas-Diaz, a psychotherapist in Washington, who added that
> she always brings up the subject with patients as a way to get hidden
> issues into the open -- and increase trust.
>
> "I say, 'You happen to be Pakistani, and I am not -- how do you feel
> about that?' Sometimes they say, 'Oh, it's not important,' but when
> certain things happen [later] in therapy, people remember you opened
> the door and they come inside," she said.
>
> Tina Tong Yee, a psychologist in charge of ensuring San Francisco's
> mental health services are culturally competent, said Western
> medicine's secular notions of normality are sometimes an uneasy fit in
> a deeply religious and increasingly diverse America.
>
> "Seeing ghosts in my family was part of growing up," she said. "If I
> brought it up in therapy, you don't want someone to make that
> delusional."
>
> Behavioral problems are different than other kinds of ailments, she
> added: "What you are reading is not a pulse, but how people act and
> behave and how you react to it. In a cross-cultural setting, it's ripe
> for misunderstanding."
>
> (c) 2005 The Washington Post Company
>


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