Ethnicity and diagnosis in patients with affective disorders

• Published in: The journal of clinical psychiatry Vol. 64; no. 7; pp. 747 - 754
• Main Authors: STRAKOWSKI, Stephen M, KECK, Paul E, ARNOLD, Lesley M, COLLINS, Jacqueline, WILSON, Rodgers M, FLECK, David E, COREY, Kimberly B, AMICONE, Jennifer, ADEBIMPE, Victor R
• Format: Journal Article
• Language: English
• Published: Memphis, TN Physicians Postgraduate Press 01-07-2003
• Subjects: Adult; Adult and adolescent clinical studies; African Americans - psychology; Biological and medical sciences; Culture; Diagnosis, Differential; Diagnostic and Statistical Manual of Mental Disorders; Diagnostic Errors; European Continental Ancestry Group - psychology; Female; Humans; Logistic Models; Male; Medical sciences; Miscellaneous; Mood disorders; Mood Disorders - diagnosis; Mood Disorders - ethnology; Mood Disorders - psychology; Psychology. Psychoanalysis. Psychiatry; Psychopathology. Psychiatry; Psychotic Disorders - diagnosis; Psychotic Disorders - ethnology; Psychotic Disorders - psychology; Schizophrenia - diagnosis; Schizophrenia - ethnology; Schizophrenic Psychology; Severity of Illness Index; Socioeconomic Factors; Surveys and Questionnaires; United States; North America; America; Social environment; Human; Mood disorder; Evaluation; Hallucination; Mental health; Delusion; Clinical form; Schizophrenia; Error; Ethnic group; Psychosis; Thought disorder; Symptomatology; Sociodemographic factor; Hospital consultation; Risk factor; Diagnosis; Caucasoid; Comparative study; Public health; African American
• ISSN: 0160-6689; 1555-2101
• DOI: 10.4088/JCP.v64n0702

Clinically, African American psychiatric patients are disproportionately diagnosed with schizophrenia compared with white patients. Why this occurs is unknown. Extending prior work, the authors hypothesized that first-rank symptoms distract clinicians so that they fail to identify affective disorders in African Americans.
195 African American and white patients with at least 1 psychotic symptom (delusions, hallucinations, or prominent thought disorder) at admission were recruited from January 1, 1998, through May 31, 2001. Each patient received 3 independent DSM-IV diagnoses: a clinical diagnosis, a structured-interview diagnosis, and an expert-consensus diagnosis. The expert-consensus diagnoses were derived from the structured interviews, which were audiotaped and transcribed, and medical records. After reviewing edited transcripts and medical records from which ethnic cues had been eliminated, 2 psychiatrists assigned expert-consensus diagnoses and first-rank symptom ratings. For the 79 patients who received an expert-consensus diagnosis of an affective disorder, clinical variables, diagnoses, and first-rank symptoms were compared between African American (N = 39) and white (N = 40) patients.
Seventy-nine (41%) of 195 patients were diagnosed with an affective disorder by expert consensus. African American men with an expert-consensus affective disorder were significantly (p <.03) more likely than other patients to be diagnosed with a schizophrenia spectrum disorder by clinical assessment and structured interview. Although first-rank symptoms were more commonly identified in African American men, this finding did not explain the difference in diagnoses. Post hoc analyses suggested that African American men diagnosed with a schizophrenia spectrum disorder were more likely than other patients to have been identified during structured interview as having psychotic symptoms in the absence of affective symptoms.
The apparent misdiagnosis of schizophrenia in African-Americans with mood disorders cannot be ascribed to differences in first-rank symptoms. However, it may be due to a perception that psychotic symptoms are more chronic or persistent than affective symptoms in these patients.