DIAGNOSING MENTAL DISORDERS IN PEOPLE OF COLOR

William B. Lawson, MD, PhD, DLFAPA

Professor and Chair Department of Psychiatry

Howard University College of MedicineWashington, DC

Wblawson@howard.edu (202)865-6611

Speaker Disclosure of Financial Relationship

Grants: Envivo, Assurex,Companion DX, Health Analytics Speaker Bureau: Otsuka

Discussion of off-label or investigational use: yes

Disparities

In diagnosis In treatment In access to

care Greater than

for other ethnic groups

Increasing

Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care—Report of the Institute of Medicine of the National Academies,1 2002 US racial and ethnic minorities are

less likely to receive even routine medical procedures, and they experience a lower quality of health services

Supplemental Surgeon General’s report on mental health of minorities,2 2001 No substantial difference in

prevalence Significant illness burden Lack of access

Treatment Received

PUBLIC HEALTH DISPARITIES

Unintentional injuries, mainly motor vehicle crashes, were the fifth leading cause of death for the total population, but they were the leading cause of death for minorities aged 1 to 44 years.

The death rate for HIV/AIDS was 4.5 for the total population but 39.9 for African American men aged 25 to 44 years.

Homicide remains the number one cause of death for young African American males

Substance abuse and mental disorders associated with increased risk for all the above

Homicide

Trends in Homicide Rates Among Persons Ages 10-24 Years, by Race/Ethnicity, 1994–2010

Suicide

• Suicide was the third leading cause of death for Black Americans between the ages of 15 and 24.

Young males (ages 20-24) had the highest rate of suicide in the black population, 18.18 per 100,000.

Black Americans have a lifetime prevalence rate of attempted suicide of 4.1%, similar to the general population rate of 4.6%.2

DEPRESSIONAFFECTS GENERAL MEDICAL CONDITIONS

Association with Myocardial Infarction Depressed individuals far more likely to die from an MI

40 % OF THOSE WITH DIABETES MELLITUS

Common in obesity Risk Factor in Breast and

Other Cancers Stroke and depression

Persistent disparities

OVER DIAGNOSIS OF SCHIZOPHRENIA Bipolar Disorder, PTSD overdiagnosed as

schizophrenia SUBSTANCE ABUSE COMORBIDITY

IGNORED

Schizophrenia More Common in African Americans?

OVERDIAGNOSIS OF SCHIZOPHRENIA

Problem: Schizophrenia Over-Diagnosed in African Americans

Patients in a State Hospital

0102030405060708090

Afr Am (n = 56) White (n = 117)

Per

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t

Schizophrenia Bipolar Disorder Major Depression Other

Strakowski SM, et al. J Clin Psychiatry.1993;54:96-102.

Influence of Patient Race and Ethnicity on ClinicalAssessment in Patients With Affective Disorders

Gara MA, Vega WA, Arndt S, Escamilla M, Fleck DE, Lawson WB, Lesser I, Neighbors HW, Wilson DR, Arnold LM, Stratowski SM. Influence of patient race and ethnicity on clinical assessment in patients with affective disorders.

Arch Gen Psychiatry. 2012 Jun;69(6):593-600.

Objective: To determine whether African American individuals would continue to exhibit significantly higher rates of clinical diagnoses of schizophrenia, even after controlling for age, sex, income, site, and education, as well as the presence or absence of serious affective disorder,as determined by experts blinded to race and ethnicity.

A secondary objective was to determine if a similar pattern occurred in Latino subjects.

Gara MA, Vega WA, Arndt S, Escamilla M, Fleck DE, Lawson WB,

Lesser I, Neighbors HW, Wilson DR, Arnold LM, Stratowski SM. Influence of patient race and ethnicity on clinical assessment in patients with affective disorders. Arch Gen Psychiatry. 2012 Jun;69(6):593-600.

Prevalence of Psychotic Features in Bipolar I Disorder

68

48

01020304050607080

Patients With Bipolar I Disorder

African American

Caucasian

SAPS = Scale for Assessment of Positive Symptoms; SANS = Scale for Assessment of Negative Symptoms.Source: Lawson WB, in preparation.

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PSYCHOSIS PARANOIA

CONSPIRACY BELIEFS

In African Americans

PSYCHOSIS Thought to be more common

PARANOIA Healthy?

CONSPIRACY THEORIES Rooted in reality?

Cultural Mistrust and Psychopathology

The relationship between the cultural mistrust inventory and psychopathology as measured by the SAPS, MADRS and YMRS was examined in the 244 African American patients with severe affective disorders. 104 male and 144 female (age range 18-43) from the 6 regional site study were included. We found that the cultural mistrust inventory is significantly related to total psychosis(r=.15) hallucinations/delusions(r=.14) and depression (r=.20), (p<.05), but not mania or bizarre behavior, when controlling for demographics.

DATABASE

Emergency Room Visits California Maryland

Diagnosis of Psychiatric Patients in Emergency Room Settings

 

%In California ER

Schizophrenia Bipolar disoder

White 45.3 13.4

Black 47.9 5.6

Total N=146,960

%In Maryland ER

Schizophrenia Bipolar disorder

White 40.9 35.2

Black 58.9 18.9

Persist Despite Controlling for Demographics

Controlling for gender, family income, age, insurance payer

Odds ratio African Americans to have Schizophrenia 1.89

Bipolar 0.46

MINORITIES IN THE CORRECTIONAL SYSTEM The correctional system has become the new asylum for the mentally ill after deinstitutionalizationThe war on drugs led to an explosion in the nonviolent offender population

African Americans are disproportional in this population where mood disorders, and PTSD are often missed

More likely to be incarcerated

Percentages Meeting Criteria for Lifetime PTSD & MDD in a Primary Care Clinic

46%

33%

8%13%

NEITHERPTSD ONLYMDD ONLYPTSD & MDD

Relationship between stress and unhealthy behavior

Jackson JS, Knight KM, Rafferty JA.Am J Public Health. 2010 May;100(5):933-9. Epub 2009 Oct 21.Race and unhealthy behaviors: chronic stress, the HPA axis, and physical and mental health disparities over the life course.

Blacks

Whites s

Vicious Cycle

Self treatment with drugs Drug related violence Increased risk of traumatic experiences Increased risk of mental problems

Screening

WhatsMyM3 is a validated, three-minute tool that screens for symptoms of depression, bipolar disorder, PTSD, and anxiety, and can be used to monitor changes in symptom severity over time. A screen for alcohol is now part of the test. The tool is also available for iPhone and Android smartphones.

It differs from other mental health screening tools, such as the PHQ-9 and the MDQ, in that these are all unidimensional — they only measure one domain of symptoms, like depression or bipolar disorder. The M3 is multidimensional, measuring four areas of symptoms in one quick tool.

Furthermore, when compared to results from the standardized interview tool, the Mini International Neuropsychiatric Interview (link is external) (the MINI measures for 15 different mental illness diagnoses), WhatsMyM3 provides a total mental health score that is 83 percent sensitive in finding true positives and 76 percent specific in finding true negatives. In addition to the total score, there are four subscores, one each for depression, bipolar, PTSD, and anxiety. 

Progress in making the mental health workforce more diverse and in better

representing racial-ethnic minority groups in randomized intervention trials sincethe U.S. Surgeon General’s 2001 report Mental Health: Culture, Race,

and Ethnicity.

Between 1999 and 2006, professionals from racial-ethnic minority groups increased from 17.6% to 21.4% in psychiatry, from 8.2% to 12.9% in social work, and from 6.6% to 7.8% in psychology.

Progress in Improving Mental Health Services for Racial-Ethnic Minority Groups: A Ten-Year Perspective Catherine DeCarlo Santiago, Ph.D.; Jeanne Miranda, Ph.D. Psychiatric Services 2014; doi: 10.1176/appi.ps.201200517

Primm, A.B. and Lawson, W.B. “Disparities Among Ethnic Groups: African Americans” in Disparities in Psychiatric Care: Clinical and Cross-Cultural Perspectives; Eds. P. Ruiz and A. Primm, Wolters Kluver /Lippincott Williams & Wilkins, Baltimore, 2010, Pp19-29