Racial Differences in Treatment of Adolescents With Bipolar Disorder

Previous studies have demonstrated that patient ethnicity influences clinical decision making in psychiatry. Specifically, studies report that African American psychiatric patients are more likely to be treated with “as needed” medication and to be placed in seclusion or restraints, and they receive more antipsychotic medication and at higher doses than similar Caucasian patients (1, 2). To our knowledge, there have been no studies examining the relationship between race and the psychopharmacological treatment of adolescents with bipolar disorder. The aim of our study was to compare the medications received by Caucasian and African American adolescents hospitalized for bipolar disorder.

We retrospectively reviewed the hospital records of all adolescents with a discharge diagnosis of bipolar disorder who were hospitalized at Cincinnati Children’s Hospital Medical Center’s Adolescent Psychiatry Unit between July 1995 and June 1998 (N=74) for demographic and clinical variables. All of the psychiatrists treating children and adolescents were Caucasian. There were no differences between the African American (N=14) and Caucasian (N=60) adolescents diagnosed with bipolar disorder in age, sex, co-occurring diagnoses (including substance use disorders, conduct disorder, oppositional defiant disorder, and attention deficit hyperactivity disorder), length of hospitalization, treatment with lithium, treatment with sodium divalproex, number of episodes of seclusion or restraint, or number of as-needed medications received.

All of the adolescents received at least one mood stabilizer. The groups also did not differ in reported psychotic symptoms: 14% (two of 14) of the African American and 18% (11 of 60) of the Caucasian adolescents were clinically diagnosed with hallucinations, delusions, or thought disorder. Nonetheless, African American adolescents with bipolar disorder were nearly twice as likely to receive treatment with an antipsychotic as were Caucasians (86%, N=12, and 45%, N=27, respectively) (χ²=7.5, df=1, p=0.006).

The results of this preliminary study suggest that there are ethnic differences in the pharmacological treatment of hospitalized adolescents with a clinical diagnosis of bipolar disorder. Lewis and colleagues (3) reported that African American adolescents are more likely to be incarcerated, rather than hospitalized, than similar Caucasian adolescents, which suggests that African American patients are perceived by Caucasian clinicians as more threatening and disruptive than similar Caucasian adolescents. Perhaps this perception may explain the racial differences in the use of antipsychotics in this group. The differences in treatment may also be secondary to actual racial differences in the rates of psychotic spectrum symptoms in adolescents with bipolar disorder. Whaley (4) reported that mild forms of paranoia are more prominent in African Americans than Caucasians, which suggests that differences in the diagnosis and treatment of African Americans and Caucasians may be linked to the misinterpretation of African American, culturally based paranoia as a psychotic symptom.

Our findings may be confounded by variables not controlled in the present study, including racial differences in the clinical diagnosis of bipolar disorder, the rates of hospitalization, and socioeconomic status. Despite these limitations, our results suggest that further systematic investigations of the effects of race on the psychiatric diagnosis and treatment of adolescents, using structured diagnostic interviews to evaluate the accuracy of clinical diagnosis, are warranted.