Racial bias in medicine is driving the overdiagnosis of schizophrenia in Black patients

Dr. Stephanie Eng remembers the night clearly.

It was 2019. She was a first-year emergency department intern during her general psychiatry residency at the University of Chicago Medical Center. A young Black woman had come in saying she had been sexually assaulted. Overwhelmed by the amount of medical history she had to gather from the patient, Dr. Eng recalls what she did next.

“I remember registering what information felt relevant to me at the time,” she said. “I looked at what she was wearing, what her hair looked like, what her face looked like, all of those superficial physical attributes. And then I remember reading her medical chart and seeing words like: Oppositional Defiant Disorder and Conduct Disorder. The downside of diagnoses like that are that they can sometimes bias [a doctor]. They can make people think differently about patients. I remember what she looked like and I remember the words that were used to describe her in the medical chart and my first thought was, ‘I don’t believe her’.”

Later, working with the emergency department attending physician who guided her in assessing the patient, Dr. Eng ordered lab tests and imaging that confirmed that the young woman had indeed been assaulted. 

It was, she said, a very shameful experience and a startling realization that she had been making decisions on patient care, not necessarily based on objective clinical data, but rather her own implicit biases. 

Now an assistant professor of clinical psychiatry at Weill-Cornell Medicine in New York and the recipient of an American Medical Association Medical Justice in Advocacy Fellowship where she researches the impact of implicit bias on medical decision-making, Dr. Eng reflects on the role of bias in psychiatry.  

“A lot of our decision-making is subjective. We have… [tools] that can help us be more objective,” she said. “But at the end of the day it is one person’s opinion.”

The implicit bias of medical professionals is a driving factor contributing to the overdiagnosis of schizophrenia and other psychotic disorders characterized by symptoms of psychosis among Black populations, experts say. 

Research published by the American Psychological Association shows that Black patients are 2.4 times more likely to be diagnosed with schizophrenia than white patients. 

In New York City, Black patients are disproportionately diagnosed with schizophrenia and other psychotic disorders. An AmNews analysis of New York State Department of Health discharge data for New York City hospitals found that from 2019 to 2023, the most recent year of data publicly available, patients diagnosed with schizophrenia and other psychotic disorders were nearly three times more likely to be Black than white. This is despite the fact that white residents outnumber Black residents in New York City.  

The likely root cause of this disparity is clinician bias, said Dr. Stephen Strakowski, associate vice president for regional mental health and professor of psychiatry and behavioral sciences at The University of Texas at Austin Dell Medical School. 

“The most parsimonious explanation is it’s good old-fashioned structural racism,” said Dr. Strakowski. “It’s mostly misdiagnosis based on race bias, unconscious bias, and it’s systematized and trained into people,” he added.

How bias influences psychotic disorder diagnoses 

Structural racism in healthcare and medicine has a long and well-documented history.

From diabetic limb amputations to COVID-19 mortality rates to longer waits in emergency departments, Black Americans face widespread challenges when seeking quality healthcare in the United States. 

Dr. Strakowski believes the same critiques can be applied to the clinical diagnosis of schizophrenia, a serious chronic mental illness that disrupts an individual’s ability to think clearly, process emotions and manage behaviors. Often characterized by a disconnect from reality, symptoms of the condition include psychosis, marked by delusions and hallucinations as well as disorganized speech and thinking, and motor and cognitive impairment. 

Diagnosis of this condition is made utilizing the guidelines of the Diagnostic and Statistical Manual of Mental Disorders (DSM), a reference tool published by the American Psychiatric Association (APA). Widely used among the mental health practitioner community, the manual provides a framework and criteria for classifying and diagnosing mental disorders.  

According to the DSM, schizophrenia is considered a diagnosis of exclusion, meaning that clinicians should rule out other conditions in which a patient may present symptoms of psychosis, Dr. Strakowski notes. It is a guideline that he does not believe is emphasized enough as evident in the tendency among clinicians to prioritize symptoms of psychosis in Black patients when diagnosing schizophrenia. This, he said, is despite the fact that psychosis can be present in other conditions such as bipolar disorder, severe depression and even trauma. 

“It’s an unconscious [bias], but [it’s one]… in which it’s assumed… that Black people suffer from the worst things,” Dr. Strakowski said. “And so we jump to the worst outcome quickly.”  

Dr. Strakowski points to the historical diagnosis known as the protest psychosis in which Black men fighting for equal rights during the 1960s were deemed hostile and aggressive and, thus, psychotic or schizophrenic, as perpetuating the biases that contribute to the racial disparities in diagnosis today. Black Americans’ desire for freedom was pathologized a century earlier in 1851 when Dr. Samuel Cartwright coined the term drapetomania, declaring it a mental condition that caused enslaved Africans to escape from captivity.  

AmNews’ data analysis found that during the period from 2019 to 2023, more than 60% of Black patients diagnosed with schizophrenia and other psychotic disorders at hospitals serving city residents identified as male.

“We’ve inherited a legacy of psychiatry… [that has had] a very contentious relationship with people of color. And we haven’t completely shed that,” Dr. Eng said. “We’ve carried forward a lot of covert and unconscious messaging about what psychiatric symptoms mean when they’re attached to certain people.”

Dr. Eng added that bias in medicine can appear in the form of mental shortcuts that help doctors to simplify decision-making in complex environments. She notes that clinicians are predispositioned to this automatic pattern of thinking in high-stress, time-pressured environments such as the emergency department where clinicians are often meeting patients for the first time. Research published by the Society for Academic Emergency Medicine shows that mental stressors including overcrowding and high patient loads are associated with increased racial implicit bias among clinicians working in emergency departments. 

According to Dr. Adjoa Smalls-Mantey, a New York City-based emergency psychiatrist, following admittance to the emergency department, a patient is triaged by a nurse and then evaluated by the department provider such as a medical resident or attending physician. The provider may request a consultation from a psychiatrist if they assess that the patient is exhibiting symptoms of a mental disorder, but the ultimate diagnosis of a patient in the emergency department lies with the emergency department provider, she explains.

It is this aspect of the emergency medicine patient care model, she believes, can contribute to the misdiagnosis of psychotic disorders, including schizophrenia. Often, she said, emergency department providers’ most immediate concern is determining next steps in a patient’s potential treatment plan, noting that an accurate diagnosis doesn’t impact the workflow of a patient. 

“… All the ED [emergency department] wants to hear [is whether a patient is] cleared for discharge or going to be admitted and when I say ‘admitted’, [they’ll ask] ‘what’s the diagnosis?’ You can tell them, but they still might pick the wrong [diagnostic] code,” she said. “They have so much they’re dealing with they have to keep it moving,” she added.

The misdiagnosis of a psychotic disorder can be particularly detrimental to Black patients due to the potential for a diagnosis to “stick more” to them as compared to patients of other races, Dr. Smalls-Mantey points out. She said this is seen in cases where a Black patient might receive a final diagnosis of schizophrenia, whereas another patient of a differing race with similar symptoms who eventually improves is likely to have their diagnosis updated.  

She also notes how Black individuals’ negative encounters with law enforcement make them acutely vulnerable to diagnoses of psychotic disorders in the emergency department. Referencing the increased likelihood for Black patients to be transported by the authorities to the emergency department during behavioral health crises, Dr. Smalls-Mantey says their distress stemming from the situation is often immediately characterized as agitation by clinicians.

“It could just be that somebody was upset about being in handcuffs,” she added. Then all of a sudden if you’re saying, ‘If I don’t take my clothes off, put this gown on… then you’re going to give me a needle to sedate me’… you’re going to act out a little bit more …. That’s going to set the ground for people to think they have an underlying mental health issue, probably psychosis.”

The impact of a misdiagnosis

The consequences of a misdiagnosis of a psychotic disorder can result in poor patient outcomes on multiple levels. Beyond the side effects of anti-psychotics that fail to target the symptoms of a patient’s actual behavioral disorder, the negative connotations associated with psychotic disorders, including schizophrenia, may be even more severe.

The belief that individuals diagnosed with schizophrenia may be violent or aggressive can often impact their ability to maintain relationships and engage socially with others and even threaten other parts of their life, including their ability to acquire or maintain employment, said Dr. Patrice Malone, an associate professor of psychiatry at Columbia University.

“Schizophrenia is one of those diagnoses that is a little more extreme,” she said.

The interruptions to an individual’s life as a result of a schizophrenia diagnosis may be amplified due to involuntary psychiatric hospitalization. Research published in Psychiatric Quarterly shows that individuals with psychotic disorders, including schizophrenia, are more likely to be subject to involuntary psychiatric hospitalization whereas individuals with anxiety or developmental disorders are more likely to be discharged. Involuntary psychiatric hospitalization may also adversely impact patients’ familial relationships and diminish their ability to maintain steady employment. 

Dr. Smalls-Mantey adds that clinicians often have less trust in a patient’s non-psychotic complaints once they have seen a diagnosis of a psychotic disorder on their chart. 

“People just often say, ‘Oh, it’s psych related. They’re just probably depressed and … complaining about their body’, and that’s not it,” she said. “They really are feeling pain….and that may not be paid attention to.”

Psychiatry’s path forward

The approach by other medical specialties to confront long-standing inequities in patient care and treatment within their own respective fields can serve as a framework for change in psychiatry. 

For example, heart disease was long believed to be a disease that primarily impacted men. However, beginning with the 1986 National Heart, Lung and Blood Institute Workshop on Coronary Heart Disease, perceptions of how heart disease impacted women began to change. Further research challenged the beliefs that heart disease did not affect women until later in life nor as seriously as men. The passing of federal legislation in 1993 requiring the equitable inclusion of women and minorities in government-funded clinical trials helped shed more light on the presentation and risk factors of the disease in women.  

Cardiology’s eventual recognition that heart disease presents differently in men than women also helped spur the development of diagnostic testing guidelines targeting women suspected of having the disease. Research published by the American Heart Association (AHA) found that in cases of heart attacks, female patients are more likely to present with additional symptoms besides chest pain, such as indigestion and jaw pain, as compared to male patients. In 2014, the AHA released a consensus statement outlining recommendations for non-invasive testing, such as echocardiography, for women with suspected heart disease. 

Such initiatives by the cardiology field are believed to have contributed to a decline in heart disease mortality rates among women. The rate of decline among women surpassed that of men during the same time period. While heart disease continues to be the leading cause of death among both men and women in the United States, cardiology’s approach to reducing inequities in treating women illustrates how American medicine can reduce disparities when it commits to the task.

The work of Dr. Roberto Lewis-Fernández is integral to helping the field of psychiatry with similar efforts. 

A professor of clinical psychiatry and interim vice chair of psychiatric research at Columbia University, Dr. Lewis-Fernández conducts research rooted in understanding how culture impacts individuals’ lived experience with mental disorders and integrating it into the psychiatric diagnostic evaluation process. 

He utilized this expertise in his role leading the development of the Cultural Formulation Interview (CFI) for publication in the DSM-5 in 2013. Comprising a series of questionnaires, the CFI is an evidence-based tool designed to inform psychiatric diagnosis and treatment planning by helping clinicians better understand a “patient’s own narrative of illness” in the context of cultural factors including identity, support and stressors.

Dr. Lewis-Fernández believes that when applied correctly, the CFI is a mechanism which can help mitigate clinician misdiagnosis.  The first step, he said though, is recognition of self-biases by doctors. 

“What kind of world would we live in if we weren’t influenced by external influences?” he asks.

“There’s the awareness of the bias, the learning of the contextual thinking to understand the world in which a person lives, and the adjustment of the diagnosis,” he continues. “Hallucinations might be the right symptom, but you have to decide whether it’s a hallucination or not, whether it’s a dream or an idea, an illusion, any number of things.”

In addition to providing training to clinicians on how to utilize the CFI, Dr. Lewis-Fernández is engaged in identifying improved methods to incorporate social determinants of health, factors such as education and healthcare access as well as economic stability, into the psychiatric evaluation process. Emphasizing the need for clinicians to understand the experiences of their patients not through just the lens of cultural competency, but structural competency too, Dr. Lewis-Fernández notes the pervasive role of structural racism.

“If you discuss mistrust among African Americans, but you forget the fact that they’ve been badly treated and are still badly treated for a long time by society, and they get access to relatively limited health care choices, and they live in very vulnerable situations, in neighborhoods,” he explains. “[If] you forget all that, it sounds as though African Americans have a trust problem, when, in fact, [during evaluations] they’re responding naturally to being badly treated.”

It is a sentiment shared by Dr. Danielle Hairston, a director of residency training in the Department of Psychiatry at Howard University College of Medicine and a former president of the Black Caucus of the APA. Relaying her experiences while serving as a member of the 2020-2021 APA Presidential Task Force to Address Structural Racism Throughout Psychiatry, she believes that doctors’ inability to recognize their own racial biases and their lack of consideration of generational trauma during their psychiatric assessments results in a gross injustice to their patients.

“If you’re saying ‘I don’t see color,’ you’re missing an important part of how someone’s presenting or what their fears are or what they’re willing to tell you and express, or what is actually a normal response to mistrust versus calling them ‘paranoid’,” she explains.

It is one of the reasons, she said, she felt it was important for her to be a member of the Ethnoracial Equity and Inclusion Workgroup for Text Revision of the DSM-5 which was released in 2022. Co-chairing the group alongside Dr. Lewis-Fernández, Dr. Hairston and colleagues were tasked, among many responsibilities, with ensuring that DSM explanations of symptom appearance in patients accounted for personal experiences with racism and discrimination as well as cultural, racial and ethnic factors. Their work led to a number of updates in the DSM, including diagnosis criteria encouraging clinicians to acknowledge the overdiagnosis of schizophrenia in Black males. The impact of the revisions remains to be seen, Dr. Hairston said.

“Has [it] really changed the way that people have practiced? Has [it] really changed the way people engage with their patients, with their assessments, with their interviews, with [the] treatment options they give?” she asks, noting that more research is needed.

A study published by the World Psychiatric Association in 2021 found that clinicians lent greatest importance to the presentation of a patient’s symptoms as compared to other clinical information when assessing and treating psychotic disorders. The DSM-5 diagnosis was considered the least important clinical information for patient assessment and treatment. 

Additional research examining how clinicians utilize the DSM could also help shed light on other factors, beyond clinician misdiagnosis, that drive the disproportionate diagnosis of psychotic disorders among Black patients. Recent studies show that racial discrimination and social disadvantage are associated with an increased risk of psychosis among Black and Latino individuals in the United States.  

Developing opportunities for clinicians to step into the shoes of their patients may also help combat bias and reduce misdiagnosis. Dr. Hairston believes that studying a standardized patient case that illustrates the experiences of a Black male attempting to obtain psychiatric services could offer medical residents and students vital insights into patient care and treatment. It is a virtual reality simulation-based initiative that Dr. Hairston and her co-investigators are piloting through Microsoft’s AI for Accessibility Grant Program.  

“You have standardized patient cases for everything else, why not this?,” she asks. “Everyone should have some empathy about what it’s like for their patients to attempt to seek services.”

More thoughtful training is needed

Dr. Smalls-Mantey adds that additional intensive training in psychiatry for front line providers including emergency department, family medicine and internal medicine physicians, would help inform their clinical decision-making skills when seeing patients with psychiatric disorders. Noting that these hospital staff often see patients with psychiatric disorders before a psychiatrist does, she believes residency rotations in outpatient clinics are not sufficient to equip frontline providers with the experience needed to accurately assess and diagnose psychiatric disorders. Spending time in an inpatient psychiatric unit is critical to gaining the best understanding of a psychiatric illness, she said.  

“You’re seeing someone day after day. You’re seeing them improve. You’re seeing them maybe even get worse if they’re not on the right medications,” she said. 

Implicit bias training can also play a role in reducing racial disparities in psychotic disorder diagnoses. Several states are currently engaged in efforts to pass legislation mandating the completion of implicit bias training as part of continuing medical education requirements. In New York, State Senator James Sanders Jr. is the sponsor of Senate Bill S911 which would amend the education law to require physicians to complete a diversity, inclusion and elimination of bias training every two years. 

New York State Assemblymember Karines Reyes is also leading legislative measures to integrate implicit bias training into medical education. If passed, Assembly Bill A4116 would require anti-bias training to be included as part of orientation training for medical schools, medical residency programs and physician assistant programs based in the state.   

“A lot of data points to biases within the medical community that are driving poor outcomes for our community,” Assemblymember Reyes, a nurse by training, said. “So we thought that perhaps if we try and tackle this problem from an educational lens to make sure we are bringing awareness and highlighting the ways that implicit and explicit biases can contribute or influence how patients are treated, then maybe we can make some inroads with those statistics,” she added.

Dr. Jessica Isom, an assistant clinical professor in the Department of Psychiatry at the Yale School of Medicine who also served as a member of the Ethnoracial Equity and Inclusion Workgroup for DSM-5-TR, believes that the utility of implicit bias training is rooted in how it is structured. Far too often, she said, it allows an individual or institution to simply define what bias is and reference impact measurement limitations in existing research literature. She attributes this largely to an inability of people to move from talking about structural racism to implementing solutions to it.

“It’s not pervasive enough beyond rhetoric,” she said. “It hasn’t translated into structural interventions that are really a part of what evidence-based practice is supposed to be.”   

In Dr. Isom’s view, the key to addressing systemic structural racism starts not from convincing people to be less racist, but rather by implementing larger structural changes embedded in how the field of medicine operates. One example of this, she explains, is in which a medical department could introduce a new policy that requires clinicians, as part of quality improvement measures, to ask patients about their cultural background during the psychiatric evaluation process. 

It is an approach that she likens to putting accountability first and then shifting culture –– and one that she is confident can have a lasting impact on psychiatry.

“We know we can change things. We do it all the time,” she said. “Any change creates conflict and tension, and just requires enough resources and persistence to make it work.”