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Race, Culture, and Clinical Interpretations of Psychopathology

Race, Culture, and Clinical Interpretations of Psychopathology


September 17, 2012

William B. Lawson, MD


Professor and Chairman of the Department of Psychiatry and Behavioral Sciences, Howard University College of Medicine and Hospital, Washington, D.C.


First published in Psychiatry Weekly, Volume 7, Issue 18, September 17, 2012




Apart from a few notable exceptions, prevalence rates of mental illness among African Americans are generally similar to those found in the general population. Researchers have recognized for decades, however, that a disproportionately greater number of African Americans are diagnosed with schizophrenia, compared to rates in Hispanic and white populations. These elevated rates persist despite epidemiologic findings showing that African Americans have equal or lower rates of schizophrenia when diagnoses are made using standardized assessments.

Overdiagnosis of Schizophrenia

Dr. William B. Lawson has contributed to a number of studies exploring racial and ethnic disparities in psychiatric diagnosis and care.

“Studying racial and ethnic effects in mental health was not a premise that I started off with a priori,” says Dr. Lawson. “I had considered socioeconomic factors, cultural norms, individual perceptions about mental health, etc, all of which led me to begin looking at issues of race. As the data emerge, it’s clear that there’s a strong, persistent tendency to overdiagnose schizophrenia in African Americans and, at the same time, to underdiagnose affective disorders, especially bipolar disorder.”

A recent study,1 led by Michael Gara, MD, set out to systematically determine what is behind the elevated rates of schizophrenia diagnoses in African Americans.

Over 600 individuals with severe mood disorders were recruited from 6 US sites. Subjects—including African American, Hispanic, and white individuals—participated in a recorded clinical interview developed specifically for this study. The transcripts of these interviews, along with subjects’ medical records, were edited carefully off-site to remove any clues of racial, cultural, or sociodemographic identifiers and characteristics. Both sets of records, blinded and un-blinded, underwent multiple layers of analysis by diagnosticians and clinical interviewers, whose findings and reports composed the raw data for the study.

"There is a strong, persistent tendency to overdiagnose schizophrenia in African Americans and, at the same time, to underdiagnose affective disorders, especially bipolar disorder."

“Despite all this careful blinding and analysis, we still found that African Americans were overdiagnosed with schizophrenia—not only when compared to Hispanic individuals (OR=2.7; 95% CI, 1.5–5.1) but to white individuals (OR=2.5; 95% CI, 1.4–4.5), as well,” says Dr. Lawson. “This association was stronger than we had originally anticipated. A number of studies suggest that when psychotic symptoms are expressed by African Americans there is a tendency for clinicians to attribute them to schizophrenia, even though psychotic symptoms appear in a number of disorders, including affective disorders. This type of routine misdiagnosis obviously implies a greater likelihood of incorrect pharmacologic treatment in cases where psychotherapy and antidepressants or mood stabilizers would otherwise be indicated.”

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Cultural Mistrust Scale

Dr. Lawson reanalyzed these data for a presentation he gave at the May 2012 meeting of the American Psychiatric Association entitled, “Cultural Mistrust and Psychopathology in African Americans.”2

“I reanalyzed these data using an instrument we call Cultural Mistrust, an instrument examining to what extent African Americans perceive themselves as living in a racist society,” says Dr. Lawson. “We found that cultural mistrust correlated very strongly with rated psychotic symptoms (Table). Cultural mistrust may even be interpreted by clinicians as psychopathology. For example, unpublished data suggest that individuals who appear suspicious and unwilling to self-disclose during the clinical interview were perceived as being paranoid.”


Dr. Lawson says that there is a growing awareness among clinicians of the propensity toward incorrect diagnoses in some populations, and he encourages taking affective symptoms into account, and more frequent use of structured instruments.

“A big survey3 showed that clinical recognition of depression is lowest in African Americans, which suggests that many clinicians didn’t recognize the symptoms of depression or misinterpreted them,” he says. “So there is an emerging movement toward the appreciation of underrecognized mental illnesses in some racial and ethnic groups and that they must be treated.”


Disclosure: Dr. Lawson reports no affiliations with, or financial interests in, any organization that may pose a conflict of interest.

This interview was conducted on July 16, 2012 by Lonnie Stoltzfoos


1. 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 Feb 16. [Epub ahead of print]

2. Lawson WB, Gara MA, Vega WA, et al. Cultural mistrust and psychopathology in African Americans. Paper presented at: American Psychiatric Association Meeting; May 7, 2012; Philadelphia, Pa.

3. Jackson JS, Torres M, Caldwell CH, et al. The National Survey of American Life: a study of racial, ethnic and cultural influences on mental disorders and mental health. Int J Methods Psychiatr Res. 2004;13:196-207.