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Published Online: 1 June 2023

Racial and Ethnic Biases and Psychiatric Misdiagnoses: Toward More Equitable Diagnosis and Treatment

Publication: American Journal of Psychiatry
Psychiatrists and other medical professionals use diagnostic nomenclature to communicate information about the mental health needs of patients and to make critical decisions regarding treatment. An accurate and precise diagnosis can help patients access appropriate treatments and avoid contraindicated or potentially harmful treatments. Psychiatric misdiagnosis can have both beneficial and harmful effects. For example, overdiagnosis can make it easier for patients to access services and to have those services covered by insurance; but a psychiatric diagnosis can also expose patients to stigma and discrimination. Underdiagnosis avoids exposure to stigma but increases barriers to care. Either form of misdiagnosis can promote mistrust in psychiatry and deter people from seeking services.
In this issue of the Journal, Vickers-Smith and colleagues (1) report on an investigation of racial and ethnic bias, discrimination, and psychiatric diagnoses. Their article provides timely findings on racial and ethnic disparities in the diagnosis of alcohol use disorder (AUD) among U.S. veterans receiving services at Veterans Health Administration sites. Approximately 40% of U.S. veterans have a lifetime diagnosis of AUD, and 10% have a past-year diagnosis of AUD (2, 3). The authors leveraged data from the Million Veteran Program (N=700,012) (4), a research program established to evaluate how genetic characteristics, behaviors, and environmental factors affect health outcomes. Vickers-Smith et al. extracted the following information from electronic health records: race, ethnicity, past-year alcohol consumption (participant’s highest score on the consumption subscale of the Alcohol Use Disorders Identification Test [AUDIT-C]), clinical diagnoses (alcohol use, substance use, and mental disorders), and other alcohol-related medical conditions. The authors hypothesized that Black and Hispanic veterans would have higher rates of AUD diagnosis than White veterans, despite similar levels of alcohol consumption.
The authors found striking racial and ethnic disparities in AUD diagnosis, especially among male veterans. For example, Black male veterans were two times more likely than White male veterans to receive an AUD diagnosis when the two groups reported the same level of alcohol consumption. Notably, the higher odds for Black male veterans of receiving an AUD diagnosis remained the same after the investigators adjusted for comorbid mental disorders and other alcohol-related medical conditions. The authors suggest that clinicians’ racial and ethnic bias may have accounted for the observed disparities in the diagnosis of AUD.
These findings must be considered in light of the study’s limitations, several of which were noted by the authors. First, although the characteristics of the sample matched those of the population of veterans receiving care, the generalizability of these findings is nevertheless unknown. The participants were not randomly sampled, but instead volunteered to participate in the Million Veteran Program. Second, the AUDIT-C is an imperfect gold-standard measure of AUD because it assesses alcohol consumption, which is only one aspect of AUD. An AUD diagnosis also requires symptoms of abuse, dependence, and impairment. Third, the authors could not explore causal mechanisms. What is the source of racial and ethnic disparities in AUD diagnosis? Is the disparity attributable to racial and ethnic differences or to misdiagnosis? If the clinicians exhibited bias, we do not know the cause. The investigators did not assess, for example, the clinicians’ explicit and implicit racial and ethnic biases or their levels of clinical experience, education, and training.
Despite these limitations, Vickers-Smith and colleagues highlight a critical problem in the field of psychiatry. To put the authors’ findings into perspective, we searched the literature for studies of racial and ethnic bias in psychiatric diagnosis that met three criteria: 1) studied adults, 2) was published in a peer-reviewed journal since 2000, and 3) investigated the relationship between race and ethnicity (the independent variable) and diagnosis (the dependent variable). We excluded studies that examined racial and ethnic differences in prevalence but did not address racial and ethnic bias. We found 13 studies, all of which used one of two methodological approaches (517). In five studies, clinicians were asked to evaluate vignettes of patients where only the race or ethnicity of the patient varied (811, 13). Of these, three studies found evidence of racial and ethnic bias (8, 11, 13). In eight studies, clinicians’ diagnoses of patients (often obtained from the medical record) were compared with race- and ethnicity-blinded research diagnoses based on transcripts of diagnostic interviews that included assessments such as the Brief Psychiatric Rating Scale and the Structured Clinical Interview for DSM-5 (57, 12, 1417). Of these, seven studies found evidence of racial and ethnic bias (57, 12, 14, 16, 17). (A table summarizing these findings is available from the authors.)
Findings from the study by Vickers-Smith et al. and our review point to several important directions for future research. First, Vickers-Smith and colleagues, and most of the studies identified in our literature search, did not assess the influence of socioeconomic variables, although these factors are highly correlated with race and ethnicity and can affect diagnostic decisions (2, 3). Future studies should evaluate how the intersection of race and ethnicity, socioeconomic disadvantage, and gender affects diagnostic decision making.
Second, nearly all the studies in our review investigated patients admitted to psychiatric inpatient settings and focused on schizophrenia and mood disorders. Thus, we know little about how racial and ethnic bias may affect the diagnosis of other disorders, such as posttraumatic stress disorder, anxiety disorders, and substance use disorders. Moreover, we do not know how diagnostic biases affect the largest patient population: persons treated in outpatient settings.
Third, future investigations should study diagnostic bias in more diverse patient populations. Nearly all the investigations we found compared Black and non-Hispanic White persons. We need to study other racial and ethnic groups, such as Native North American and Asian American populations. Hispanic populations are particularly important to study because they now constitute the largest minority group in the United States, comprising 18.9% of the U.S. population (18).
Racial and ethnic bias in psychiatric diagnosis is a challenging problem to study. Studies like the one conducted by Vickers-Smith et al. will provide the empirical basis needed to improve diagnostic accuracy, clinical decision making, and treatment planning. Access to quality and equitable health care is among the key social determinants of health highlighted in Healthy People 2030 (19). The field of psychiatry must rise to the challenge to provide equitable and culturally sensitive diagnosis and treatment.

References

1.
Vickers-Smith R, Justice AC, Becker WC, et al: Racial and ethnic bias in the diagnosis of alcohol use disorder in veterans. Am J Psychiatry 2023; 180:426–436
2.
Substance Abuse and Mental Health Services Administration: 2020 National Survey on Drug Use and Health: Veterans. Rockville, MD, Substance Abuse and Mental Health Services Administration, 2022
3.
Panza KE, Kline AC, Na PJ, et al: Epidemiology of DSM-5 alcohol use disorder in US military veterans: results from the National Health and Resilience in Veterans Study. Drug Alcohol Depend 2022; 231:109240
4.
Gaziano JM, Concato J, Brophy M, et al: Million Veteran Program: a mega-biobank to study genetic influences on health and disease. J Clin Epidemiol 2016; 70:214–223
5.
Anglin D, Malaspina D: Ethnicity effects on clinical diagnoses compared to best-estimate research diagnoses in patients with psychosis: a retrospective medical chart review. J Clin Psychiatry 2008; 69:941–945
6.
Arnold LM, Keck PE Jr, Collins J, et al: Ethnicity and first-rank symptoms in patients with psychosis. Schizophr Res 2004; 67:207–212
7.
Gara MA, Vega WA, Arndt S, et al: Influence of patient race and ethnicity on clinical assessment in patients with affective disorders. Arch Gen Psychiatry 2012; 69:593–600
8.
Gordon KH, Brattole MM, Wingate LR, et al: The impact of client race on clinician detection of eating disorders. Behav Ther 2006; 37:319–325
9.
Kales HC, Neighbors HW, Blow FC, et al: Race, gender, and psychiatrists’ diagnosis and treatment of major depression among elderly patients. Psychiatr Serv 2005; 56:721–728
10.
Kales HC, Neighbors HW, Valenstein M, et al: Effect of race and sex on primary care physicians’ diagnosis and treatment of late‐life depression. J Am Geriatr Soc 2005; 53:777–784
11.
Londono Tobon A, Flores JM, Taylor JH, et al: Racial implicit associations in psychiatric diagnosis, treatment, and compliance expectations. Acad Psychiatry 2021; 45:23–33
12.
Marx BP, Engel-Rebitzer E, Bovin MJ, et al: The influence of veteran race and psychometric testing on Veterans Affairs posttraumatic stress disorder (PTSD) disability exam outcomes. Psychol Assess 2017; 29:710–719
13.
Payne JS: Influence of race and symptom expression on clinicians’ depressive disorder identification in African American men. J Soc Soc Work Res 2012; 3:162–177
14.
Schwartz EK, Docherty NM, Najolia GM, et al: Exploring the racial diagnostic bias of schizophrenia using behavioral and clinical-based measures. J Abnorm Psychol 2019; 128:263–271
15.
Sohler NL, Bromet EJ: Does racial bias influence psychiatric diagnoses assigned at first hospitalization? Soc Psychiatry Psychiatr Epidemiol 2003; 38:463–472
16.
Strakowski SM, Keck PE Jr, Arnold LM, et al: Ethnicity and diagnosis in patients with affective disorders. J Clin Psychiatry 2003; 64:747–754
17.
Whaley AL: Cultural mistrust and the clinical diagnosis of paranoid schizophrenia in African American patients. J Psychopathology Behav Assess 2001; 23:93–100
18.
US Census Bureau: QuickFacts: United States. https://www.census.gov/quickfacts/fact/table/US/RHI725221. Suitland, MD, US Census Bureau
19.
Healthy People, 2030. US Department of Health and Human Service, Office of Disease Prevention and Health Promotion. https://health.gov/healthypeople/objectives-and-data/social-determinants-health

Information & Authors

Information

Published In

Go to American Journal of Psychiatry
Go to American Journal of Psychiatry
American Journal of Psychiatry
Pages: 402 - 403
PubMed: 37259513

History

Accepted: 14 April 2023
Published online: 1 June 2023
Published in print: June 01, 2023

Keywords

  1. Alcohol Use Disorder
  2. Drug Use Disorders
  3. Racism
  4. Stigma/Discrimination
  5. Diagnosis and Classification

Authors

Details

Linda A. Teplin, Ph.D. [email protected]
Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago.
Karen M. Abram, Ph.D.
Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago.
María José Luna, M.S.
Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago.

Notes

Send correspondence to Dr. Teplin ([email protected]).

Competing Interests

The authors report no financial relationships with commercial interests.

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