Bias in mental health diagnosis gets in the way of treatment

Howard N. Garb

psyche.co

Originally posted 2 MAR 22

Here is an excerpt:

What about race-related bias? 

Research conducted in the US indicates that race bias is a serious problem for the diagnosis of adult mental disorders – including for the diagnosis of PTSD, depression and schizophrenia. Preliminary data also suggest that eating disorders are underdiagnosed in Black teens compared with white and Hispanic teens.

The misdiagnosis of PTSD can have significant economic consequences, in addition to its implications for treatment. In order for a US military veteran to receive disability compensation for PTSD from the Veterans Benefits Administration, a clinician has to diagnose the veteran. To learn if race bias is present in this process, a research team compared its own systematic diagnoses of veterans with diagnoses made by clinicians during disability exams. Though most clinicians will make accurate diagnoses, the research diagnoses can be considered more accurate, as the mental health professionals who made them were trained to adhere to diagnostic criteria and use extensive information. When veterans received a research diagnosis of PTSD, they should have also gotten a clinician’s diagnosis of PTSD – but this occurred only about 70 per cent of the time.

More troubling is that, in cases where research diagnoses of PTSD were made, Black veterans were less likely than white veterans to receive a clinician’s diagnosis of PTSD during their disability exams. There was one set of cases where bias was not evident, however. In roughly 25 per cent of the evaluations, clinicians administered a formal PTSD symptom checklist or a psychological test to help them make a diagnosis – and if this additional information was collected, race bias was not observed. This is an important finding. Clinicians will sometimes form a first impression of a patient’s condition and then ask questions that can confirm – but not refute – their subjective impression. By obtaining good-quality objective information, clinicians might be less inclined to depend on their subjective impressions alone.

Race bias has also been found for other forms of mental illness. Historically, research indicated that Black patients and sometimes Hispanic patients were more likely than white patients to be given incorrect diagnoses of schizophrenia, while white patients were more often given correct diagnoses of major depression and bipolar disorder. During the past 20 years, this appears to have changed somewhat, with the most accurate diagnoses being made for Latino patients, the least accurate for Black patients, and the results for white patients somewhere in between.

The info is here.

Structural Competency Meets Structural Racism: Race, Politics, and the Structure of Medical Knowledge

Jonathan M. Metzl and Dorothy E. Roberts
Virtual Mentor. 2014;16(9):674-690.
doi: 10.1001/virtualmentor.2014.16.9.spec1-1409.

Here is an excerpt:

The Clinical Implications of Addressing Race from a Structural Perspective

These brief case examples illustrate the complex ways that seemingly clinically relevant “cultural” characteristics and attitudes also reflect structural inequities, medical politics, legal codes, invisible discrimination, and socioeconomic disparities. Black men who appeared schizophrenic to medical practitioners did so in part because of the framing of new diagnostic codes. Lower-income persons who “refused” to eat well or exercise lived in neighborhoods without grocery stores or sidewalks. Black women who seemed to be uniquely harming their children by using crack cocaine while pregnant were victims of racial stereotyping, as well as of a selection bias in which decisions about which patients were reported to law enforcement depended on the racial and economic segregation of prenatal care. In this sense, approaches that attempt to address issues—such as the misdiagnosis of schizophrenia in black men, perceived diet “noncompliance” in minority populations, or the punishment of “crack mothers”—through a heuristic aimed solely at enhancing cross-cultural communication between doctors and patients, though surely well intentioned, will overlook the potentially pathologizing impact of structural factors set in motion long before patients or doctors enter exam rooms.

Structural factors impact majority populations as well as minority ones, and structures of privilege or opulence also influence expressions of illness and health. For instance, in the United States, research suggests that pediatricians disproportionately overdiagnose ADHD in white school-aged children. Until recently, medical researchers in many global locales assumed, wrongly, that eating disorders afflicted only affluent persons.

Yet of late, medicine and medical education have struggled most with addressing ways that structural forces impact and disadvantage communities of color. As sociologist Hannah Bradby rightly explains it, hypothesizing mechanisms that include the micro-processes of interactions between patients and professionals and the macro-processes of population-level inequalities is a missing step in our reasoning at present…. [A]s long as we see the solution to racism lying only in educating the individual, we fail to address the complexity of racism and risk alienating patients and physicians alike.

The info is here.

Stigmatized Schizophrenia Gets a Rebrand

By Elizabeth Picciuto
The Daily Beast
Originally published March 26, 2015

Here are two excerpts:

The word “schizophrenia” was coined in the early 20th century, deriving from the Greek word for “split mind.” The term conveyed the idea that people with schizophrenia experienced a splitting of their personality—that they no longer had unified identities.

Considering all the words for mental illness, both those used by medical doctors and those that are cruel slurs used by the general public, it is striking how many of them have connotations of being broken or disorganized: deranged, crazy (which means cracked— itself a derogatory term), unglued, having a screw loose, unhinged, off the wall.

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“The first lesson from the Japanese experience is that a change is possible and that the change may be beneficial for mental health users and their careers, for professionals and researchers alike,” said Lasalvia. “An early effect of renaming schizophrenia, as proven by the Japanese findings, would increase the percentage of patients informed about their diagnosis, prognosis, and available interventions. A name change would facilitate help seeking and service uptake by patients, and would be most beneficial for the provision of psychosocial interventions, since better informed patients generally display a more positive attitude towards care and a more active involvement in their own care programs.”

The entire article is here.

Don't Execute Schizophrenic Killers

By Sally L. Satel
Bloomberg View
Originally posted December 1, 2014

Is someone who was diagnosed with schizophrenia years before committing murder sane enough to be sentenced to death?

The government thinks so in the case of Scott L. Panetti, 56, who will die on Wednesday by lethal injection in Texas unless Governor Rick Perry stays the execution.

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This is unjust. It is wrong to execute, even to punish, people who are so floridly psychotic when they commit their crimes that they are incapable of correcting the errors by logic or evidence.

Yet Texas, like many other states, considers a defendant sane as long as he knows, factually, that murder is wrong. Indeed, Panetti’s jury, which was instructed to apply this narrow standard, may have been legally correct to reject his insanity defense because he may have known that the murders were technically wrong.

The entire article is here.

When Hearing Voices Is a Good Thing

A new study suggests that schizophrenic people in more collectivist societies sometimes think their auditory hallucinations are helpful.

By Olga Khazan
The Atlantic
Originally posted July 23, 2014

Here are two excerpts:

But a new study suggests that the way schizophrenia sufferers experience those voices depends on their cultural context. Surprisingly, schizophrenic people from certain other countries don't hear the same vicious, dark voices that Holt and other Americans do. Some of them, in fact, think their hallucinations are good—and sometimes even magical.

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The Americans tended to described their voices as violent—"like torturing people, to take their eye out with a fork, or cut someone's head and drink their blood, really nasty stuff," according to the study.

The entire article is here.

Who’s to blame for inaccurate media coverage of study of therapy for persons with schizophrenia?

By James C. Coyne
jcoynester blog
Originally published March 7, 2014

“I’m in competition with literally hundreds of stories every day, political and economic stories of compelling interest…we have to almost overstate, we have to come as close as we came within the boundaries of truth to dramatic, compelling statement. A weak statement will go no place.”                                 Journalist interviewed for JA Winsten, Science and Media: The Boundaries of Truth

Hyped, misleading media coverage of a study in Lancet of CBT for persons with unmedicated schizophrenia left lots of clinicians, policymakers, and especially persons with schizophrenia and their family members confused.

Did the study actually showed that psychotherapy was as effective as medication for schizophrenia? NO!

Did the study demonstrate that persons with schizophrenia could actually forgo medication with nasty side effects and modest effectiveness and just get on with their life with the help of CBT? NO!

The entire blog post is here.

Sanity of Psychologist’s Killer Is Again at Issue

By JAMES C. McKINLEY Jr.
The New York Times
Published: January 2, 2014

The mental health of a man accused of killing a psychologist in her Upper East Side office was once again in question on Thursday, just as a judge in Manhattan was about to set a date for a new trial because the first one ended in a hung jury.

Lawyers for the man, David Tarloff, 45, said during a hearing on Thursday that a court-appointed psychiatrist at Bellevue Hospital Center had found him unfit to stand trial during an examination in November.

The entire story is here.

Antipsychotics: Taking the Long View

By Thomas Insel
NIMH Director's Blog
Originally published on August 28, 2013

Here is an excerpt:

An article recently posted online in JAMA-Psychiatry tells an interesting story about medications and recovery.1 Wunderink and colleagues from the Netherlands report on a seven-year follow-up of 103 people with schizophrenia and related disorders who had experienced a first episode of psychosis between 2001 and 2002. After six months of symptomatic remission following antipsychotic treatment, patients were randomly assigned to either maintenance antipsychotic treatment or a tapering-off and discontinuation of the drug. As expected, the group that stopped taking their medications experienced twice the relapse rates in the early phase of the follow-up. But these rates evened out after a few years, as some patients in the maintenance group also stopped taking their medication. Most important, by seven years, the discontinuation group had achieved twice the functional recovery rate: 40.4 percent vs. only 17.6 percent among the medication maintenance group. To be clear, this study started with patients in remission and only 17 of the 103 patients—21 percent of the discontinuation group and 11 percent of the maintenance group—were off medication entirely during the last two years of follow-up. An equal number were taking very low doses of medication—meaning that roughly one-third of all study patients were eventually taking little or no medication.

Emphasis added.

The entire blog post is here.

Thanks to Tom Fink for this story.

Successful and Schizophrenic

By ELYN R. SAKS
The New York Times - Opinion
Published: January 25, 2013

THIRTY years ago, I was given a diagnosis of schizophrenia. My prognosis was “grave”: I would never live independently, hold a job, find a loving partner, get married. My home would be a board-and-care facility, my days spent watching TV in a day room with other people debilitated by mental illness. I would work at menial jobs when my symptoms were quiet. Following my last psychiatric hospitalization at the age of 28, I was encouraged by a doctor to work as a cashier making change. If I could handle that, I was told, we would reassess my ability to hold a more demanding position, perhaps even something full-time.

Then I made a decision. I would write the narrative of my life. Today I am a chaired professor at the University of Southern California Gould School of Law. I have an adjunct appointment in the department of psychiatry at the medical school of the University of California, San Diego, and am on the faculty of the New Center for Psychoanalysis. The MacArthur Foundation gave me a genius grant.

Although I fought my diagnosis for many years, I came to accept that I have schizophrenia and will be in treatment the rest of my life. Indeed, excellent psychoanalytic treatment and medication have been critical to my success. What I refused to accept was my prognosis.

The entire article is here.

A Schizophrenic on Death Row

The Opinion Pages
The New York Times
Originally published Ocotber 17, 2012

The Florida Supreme Court decided on Wednesday that the state can proceed with the execution next week of a 64-year-old inmate named John Ferguson. His lawyers immediately said that they will ask the United States Supreme Court to stay the execution and to review the case on grounds that Mr. Ferguson is mentally incompetent and that executing him would violate his constitutional rights as defined by the court in two earlier decisions.

The court must review the case. At issue are not only Mr. Ferguson’s life but also two differing interpretations of what constitutes competence: one Florida’s, the other the Supreme Court’s.

The entire story is here.