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

Back to table of contents Previous article Next article EditorialsFull AccessRacial and Ethnic Biases and Psychiatric Misdiagnoses: Toward More Equitable Diagnosis and TreatmentLinda A. Teplin, Ph.D., Karen M. Abram, Ph.D., María José Luna, M.S.Linda A. TeplinSearch for more papers by this author, Ph.D., Karen M. AbramSearch for more papers by this author, Ph.D., María José LunaSearch for more papers by this author, M.S.Published Online:1 Jun 2023https://doi.org/10.1176/appi.ajp.20230294AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail 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 (5–17). In five studies, clinicians were asked to evaluate vignettes of patients where only the race or ethnicity of the patient varied (8–11, 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 (5–7, 12, 14–17). Of these, seven studies found evidence of racial and ethnic bias (5–7, 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.Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago.Send correspondence to Dr. Teplin ([email protected]).The authors report no financial relationships with commercial interests.References1. 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; 180:426–436Abstract, Google Scholar2. 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, 2022Google Scholar3. 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; 231:109240Crossref, Medline, Google Scholar4. 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; 70:214–223Crossref, Medline, Google Scholar5. 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; 69:941–945Crossref, Medline, Google Scholar6. Arnold LM, Keck PE Jr, Collins J, et al.: Ethnicity and first-rank symptoms in patients with psychosis. Schizophr Res 2004; 67:207–212Crossref, Medline, Google Scholar7. 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; 69:593–600Crossref, Medline, Google Scholar8. Gordon KH, Brattole MM, Wingate LR, et al.: The impact of client race on clinician detection of eating disorders. Behav Ther 2006; 37:319–325Crossref, Medline, Google Scholar9. Kales HC, Neighbors HW, Blow FC, et al.: Race, gender, and psychiatrists’ diagnosis and treatment of major depression among elderly patients. Psychiatr Serv 2005; 56:721–728Link, Google Scholar10. 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; 53:777–784Crossref, Medline, Google Scholar11. Londono Tobon A, Flores JM, Taylor JH, et al.: Racial implicit associations in psychiatric diagnosis, treatment, and compliance expectations. Acad Psychiatry 2021; 45:23–33Crossref, Medline, Google Scholar12. 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; 29:710–719Crossref, Medline, Google Scholar13. Payne JS: Influence of race and symptom expression on clinicians’ depressive disorder identification in African American men. J Soc Soc Work Res 2012; 3:162–177Crossref, Google Scholar14. 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; 128:263–271Crossref, Medline, Google Scholar15. Sohler NL, Bromet EJ: Does racial bias influence psychiatric diagnoses assigned at first hospitalization? Soc Psychiatry Psychiatr Epidemiol 2003; 38:463–472Crossref, Medline, Google Scholar16. Strakowski SM, Keck PE Jr, Arnold LM, et al.: Ethnicity and diagnosis in patients with affective disorders. J Clin Psychiatry 2003; 64:747–754Crossref, Medline, Google Scholar17. Whaley AL: Cultural mistrust and the clinical diagnosis of paranoid schizophrenia in African American patients. J Psychopathology Behav Assess 2001; 23:93–100Crossref, Google Scholar18. US Census Bureau: QuickFacts: United States. https://www.census.gov/quickfacts/fact/table/US/RHI725221. Suitland, MD, US Census BureauGoogle Scholar19. 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-healthGoogle Scholar FiguresReferencesCited byDetailsCited byFocusing on Substance Use Disorders, Opioids, and CravingNed H. Kalin, M.D.1 June 2023 | American Journal of Psychiatry, Vol. 180, No. 6 Volume 180Issue 6 June 01, 2023Pages 402-403 Metrics KeywordsAlcohol Use DisorderDrug Use DisordersRacismStigma/DiscriminationDiagnosis and ClassificationPDF download History Accepted 14 April 2023 Published online 1 June 2023 Published in print 1 June 2023