Clinician attributions associated with the diagnosis of schizophrenia in African American and non-African American patients

Cultural Competemility Training and Use of a Standardized Assessment Tool in Reducing Misdiagnosis of Black Patients with Schizophrenia Spectrum Disorders and Psychotic Disorders

INTRODUCTION

Research studies have highlighted disparities in diagnosing schizophrenia between Black and White patients, with Black individuals being diagnosed at rates three to five times higher than their White counterparts. Moreover, studies have postulated that a lack of cultural awareness and biases leads to providers' misinterpretation and misdiagnosis of these patients.

AIMS

This quality-improvement project aimed (a) to enhance cultural competemility, the synergistic process between cultural humility and cultural competence in health care providers (HCPs) serving Black patients, promoting cultural sensitivity among providers serving all patients; (b) to introduce the Brief Psychiatric Rating Scale (BPRS-24) as a standardized tool for evaluating suspected schizophrenia spectrum disorders and psychotic disorders across all patients; and (c) to reduce the disparities in schizophrenia spectrum disorders and psychosis diagnostic rates across all patients, with a focus on enhancing accuracy for Black patients.

METHOD

HCPs completed the Inventory for Assessing the Process of Cultural Competemility Among Healthcare Professionals (IAPCC-HCP) before and after training based on Campinha-Bacote's model of cultural competemility (CCM). In addition, they received training in the use of the BPRS-24. After training, HCPs incorporated the BPRS-24 into clinical practice for assessing patients initially diagnosed with schizophrenia spectrum disorders or psychosis.

RESULTS

After introducing the BPRS-24 in clinical practice, it was used in 87.5% of assessments, with improved cultural skills and knowledge among HCPs.

CONCLUSION

Using the BPRS-24 and cultural competemility training, misdiagnosis was identified in 48.4% of the sample, regardless of race.

Race and self-reported paranoia: Increased item endorsement on subscales of the SPQ

There is a dearth of research examining how individual-level and systemic racism may lead to elevated diagnostic and symptom rates of paranoia in Black Americans. The present study employed item response theory methods to investigate item- and subscale-level functioning in the Schizotypal Personality Questionnaire (SPQ) in 388 Black and 450 White participants across the schizophrenia-spectrum (i.e., non-psychiatric controls, individuals with schizophrenia, schizoaffective disorder, or schizotypal personality disorder). It was predicted that (1) Black participants would score significantly higher than Whites on the Suspiciousness and Paranoid Ideation subscale of the SPQ, while controlling for total SPQ severity and relevant demographics and (2) Black participants would endorse these subscale items at a lower latent severity level (i.e., total SPQ score) compared to Whites. Generalized linear modeling showed that Black participants endorsed higher scores on subscales sampling paranoia (e.g., Suspiciousness and Paranoid Ideation), while White participants endorsed higher rates within disorganized/positive symptomatology subscales (e.g., Odd or Eccentric Behavior). IRT analyses showed that Black individuals also endorse items within the Suspiciousness and Paranoid Ideation subscale at lower latent severity levels, leading to inflated subscale scores when compared to their White counterparts. Results indicate prominent race effects on self-reported paranoia as assessed by the SPQ. This study provides foundational data to parse what could be normative endorsements of paranoia versus indicators of clinical risk in Black Americans. Implications and recommendations for paranoia research and assessment are discussed.

Remote Assessment of Negative Symptoms of Schizophrenia

In contrast to the validated scales for face-to-face assessment of negative symptoms, no widely accepted tools currently exist for remote monitoring of negative symptoms. Remote assessment of negative symptoms can be broadly divided into 3 categories: (1) remote administration of an existing negative-symptom scale by a clinician, in real time, using videoconference technology to communicate with the patient; (2) direct inference of negative symptoms through detection and analysis of the patient's voice, appearance, or activity by way of the patient's smartphone or other device; and (3) ecological momentary assessment, in which the patient self-reports their condition upon receipt of periodic prompts from a smartphone or other device during their daily routine. These modalities vary in cost, technological complexity, and applicability to the different negative-symptom domains. Each modality has unique strengths, weaknesses, and issues with validation. As a result, an optimal solution may be more likely to employ several techniques than to use a single tool. For remote assessment of negative symptoms to be adopted as primary or secondary endpoints in regulated clinical trials, appropriate psychometric standards will need to be met. Standards for substituting 1 set of measures for another, as well as what constitutes a "gold" reference standard, will need to be precisely defined and a process for defining them developed. Despite over 4 decades of progress toward this goal, significant work remains to be done before clinical trials addressing negative symptoms can utilize remotely assessed secondary or primary outcome measures.

Psychotic Misdiagnosis of Racially Minoritized Patients: A Case-Based Ethics, Equity, and Educational Exploration

The overdiagnosis and misdiagnosis of racially minoritized groups as having a primary psychotic disorder is one of psychiatry's longest-standing inequities born of real-time clinician racial bias. Evidence suggests that providers assign a diagnosis of schizophrenia and/or schizoaffective disorder according to race more than any other demographic variable, and this inequity persists even in the absence of differences in clinician symptom ratings. This case report describes the journey of one young Black woman through her racialized misdiagnosis of schizophrenia and the process by which interdisciplinary, health equity-minded providers across the spectrum of medical education and practice joined together to provide a culturally informed, systematic rediagnosis of major depressive disorder and post-traumatic stress disorder. Expert discussion is provided by three Black academic psychiatrists with expertise in social justice and health equity. We provide an evidence-based exploration of mechanisms of clinician racial bias and detail how the psychosis misdiagnosis of racially minoritized groups fails medical ethics and perpetuates iatrogenic harm to patients who truly need help with primary mood, trauma, and substance use disorders.

Computerized analysis of facial expressions in serious mental illness

Blunted facial affect is a transdiagnostic component of Serious Mental Illness (SMI) and is associated with a host of negative outcomes. However, blunted facial affect is a poorly understood phenomenon, with no known cures or treatments. A critical step in better understanding its phenotypic expression involves clarifying which facial expressions are altered in specific ways and under what contexts. The current literature suggests that individuals with SMI show decreased positive facial expressions, but typical, or even increased negative facial expressions during laboratory tasks. While this literature has coalesced around general trends, significantly more nuance is available regarding what components facial expressions are atypical and how those components are associated with increased severity of clinical ratings. The present project leveraged computerized facial analysis to test whether clinician-rated blunted affect is driven by decreases in duration, intensity, or frequency of positive versus other facial expressions during a structured clinical interview. Stable outpatients meeting criteria for SMI (N = 59) were examined. Facial expression did not generally vary as a function of clinical diagnosis. Overall, clinically-rated blunted affect was not associated with positive expressions, but was associated with decreased surprise and increased anger, sadness, and fear expressions. Blunted affect is not a monolithic lack of expressivity, and increased precision in operationally defining it is critical for uncovering its causes and maintaining factors. Our discussion focuses on this effort, and on advancing digital phenotyping of blunted facial affect more generally.

Racial/Ethnic Disparities in Depression Treatment for Caregivers Investigated by the US Child Welfare System

OBJECTIVE

To determine whether there are racial/ethnic differences in depression treatment for caregivers investigated by the US child welfare system.

METHODS

This cross-sectional study used baseline data from the Second National Survey of Child and Adolescent Well-being, a nationally representative sample of children and caregivers investigated by US child welfare agencies (February 2008-April 2009). We included permanent caregivers who met criteria for major depression and had available covariate data (n = 908). In multivariable logistic regression models, we estimated the associations between caregiver race/ethnicity and past-year receipt of: any depression treatment, minimally adequate depression treatment, and depression treatment from 4 sectors (general medical, psychiatry, nonpsychiatry mental health, and human services). We controlled for clinical need and access variables according to the Institute of Medicine's definition of health care disparities.

RESULTS

Black caregivers had the lowest rates of treatment receipt of any racial/ethnic group, with 42.2% receiving any depression treatment and 17.2% receiving minimally adequate depression treatment in the past year. In multivariable analyses controlling for clinical need and access variables, Black caregivers were less likely than White caregivers to receive any depression treatment (odds ratio [OR] = 0.49 [95% CI: 0.24-0.97]), minimally adequate depression treatment (OR = 0.37 [95% CI: 0.16-0.85]), and depression treatment from the general medical sector (OR = 0.40 [95% CI: 0.18-0.89]) in the past year (all P< .05).

CONCLUSIONS

Future research should examine the underlying mechanisms of Black-White disparities in depression treatment for caregivers involved with the US child welfare system and develop targeted interventions to promote equitable mental health care for this highly vulnerable population.

Clinicians' Racial Bias Contributing to Disparities in Electroconvulsive Therapy for Patients From Racial-Ethnic Minority Groups

Patients from racial-ethnic minority groups undergo disparate electroconvulsive therapy (ECT) treatment compared with Caucasian peers. One leading hypothesis is that clinicians may unknowingly display racial bias when considering ECT for patients of color. Studies have consistently shown that patients of color face numerous racially driven, provider-level interpersonal and perceptual biases that contribute to clinicians incorrectly overdiagnosing them as having a psychotic-spectrum illness rather than correctly diagnosing a severe affective disorder. A patient's diagnosis marks the entry to evidence-based service delivery, and ECT is best indicated for severe affective disorders rather than for psychotic disorders. As a consequence of racially influenced clinician misdiagnosis, patients from racial-ethnic minority groups are underrepresented among those given severe affective diagnoses, which are most indicated for ECT referral. Evidence also suggests that clinicians may use racially biased treatment rationales when considering ECT after they have given a diagnosis of a severe affective or psychotic disorder, thereby producing secondary inequities in ECT referral. Increasing the use of gold-standard treatment algorithms when considering ECT for patients of color is contingent on clinicians transcending the limitations posed by aversive racism to develop culturally unbiased, clinically indicated diagnostic and treatment rationales.

Students' perceptions on race in medical education and healthcare

Major racial disparities continue to exist in our healthcare education, from the underrepresentation of ethnic minorities when teaching about clinical signs to health management in primary and secondary care. A multi-centre group of students discuss what needs to change in medical education to cultivate physicians who are better prepared to care for patients of all backgrounds. We argue that the accurate portrayal of race in medical education is a vital step towards educating medical students to consider alternative explanations to biology when considering health inequities.

Implicit bias of encoded variables: frameworks for addressing structured bias in EHR-GWAS data

The 'discovery' stage of genome-wide association studies required amassing large, homogeneous cohorts. In order to attain clinically useful insights, we must now consider the presentation of disease within our clinics and, by extension, within our medical records. Large-scale use of electronic health record (EHR) data can help to understand phenotypes in a scalable manner, incorporating lifelong and whole-phenome context. However, extending analyses to incorporate EHR and biobank-based analyses will require careful consideration of phenotype definition. Judgements and clinical decisions that occur 'outside' the system inevitably contain some degree of bias and become encoded in EHR data. Any algorithmic approach to phenotypic characterization that assumes non-biased variables will generate compounded biased conclusions. Here, we discuss and illustrate potential biases inherent within EHR analyses, how these may be compounded across time and suggest frameworks for large-scale phenotypic analysis to minimize and uncover encoded bias.

Improving Research Quality to Achieve Mental Health Equity

Inequities and the resulting disparities that exist in mental health for a variety of socially disadvantaged groups have roots in the history and ongoing processes of medical and mental health research, as well as in persisting implicit bias in our society and health care system. The inclusion of historically excluded communities in the research to practice pipeline is vital to ensuring that treatments and interventions are developed to increase equity in mental health. A research framework is proposed based on the integration of community-based participatory research and human-centered design as an avenue for removing inequities and barriers in mental health.

Race, History of Abuse, and Homelessness Are Associated With Forced Medication Administration During Psychiatric Inpatient Care

OBJECTIVE

Although previous research has suggested that racial disparities exist in the administration of forced medication (FM) in psychiatric inpatients, data remain scarce regarding other contributing variables. Therefore, this study examined sociodemographic and clinical variables associated with FM administration in psychiatric inpatients.

METHODS

Electronic medical records from 57,615 patients admitted to an academic psychiatric hospital between 2010 and 2018 were reviewed to identify patients who received FM. These records indicated that FM petitions were requested and approved for ∼6200 patients. Patients were excluded from the analysis if they met the following exclusion criteria: under 18 years of age, presence of intellectual/developmental disability, dementia, or other neurological condition, or primary diagnosis of a nonpsychiatric medical condition or a substance-induced mood or psychotic disorder. After data on those patients were excluded, the final sample included records from 2569 patients (4.5% of the total records) in which the administration of FM was petitioned for and approved. The FM group was compared with a control group of 2569 patients matched in terms of age, sex, and admission date (no-forced medication group; NFM) via propensity scoring matching. Group comparisons (FM vs. NFM group) examined sociodemographic factors (race, age, sex, living situation), clinical features (diagnosis, substance abuse, history of abuse), and outcomes (length of stay, readmission rate). Regression analyses examined the association between FM and sociodemographic, clinical, and outcome variables.

RESULTS

Compared with the NFM group, the FM group contained significantly more African Americans (P<0.001), homeless individuals (P<0.001), and individuals with histories of abuse (P<0.001). Having received FM was a significant predictor of a longer length of stay (P<0.001) and higher readmission rates (P<0.001).

DISCUSSION

These results suggest that FM is more likely to be instituted in psychiatric inpatients who are of a minority race (African American), are in a homeless living situation, and/or have a history of abuse. Moreover, FM may be associated with poorer clinical outcomes at least as measured by the length of stay and higher readmission rates. We discuss possible reasons for these results and the importance of culturally competent and trauma-focused care.

Terminology and assessment tools of psychosis: A systematic narrative review

AIM

Phenomena within the psychosis continuum that varies in frequency/duration/intensity have been increasingly identified. Different terms describe these phenomena, however there is no standardization within the terminology. This review evaluated the definitions and assessment tools of seven terms - (i) 'psychotic experiences'; (ii) 'psychotic-like experiences'; (iii) 'psychotic-like symptoms'; (iv) 'attenuated psychotic symptoms'; (v) 'prodromal psychotic symptoms'; (vi) 'psychotic symptomatology'; and (vii) 'psychotic symptoms'.

METHODS

EMBASE, MEDLINE, and CINAHL were searched during February-March 2019. Inclusion criteria included 1989-2019, full text, human, and English. Papers with no explicit definition or assessment tool, duplicates, conference abstracts, systematic reviews, meta-analyses, or no access were excluded.

RESULTS

A total of 2238 papers were identified and of these, 627 were included. Definitions and assessment tools varied, but some trends were found. Psychotic experiences and psychotic-like experiences were transient and mild, found in the general population and those at-risk. Psychotic-like symptoms were subthreshold and among at-risk populations and non-psychotic mental disorders. Attenuated psychotic symptoms were subthreshold but associated with distress, risk, and help-seeking. Prodromal psychotic symptoms referred to the prodrome of psychotic disorders. Psychotic symptomatology included delusions and hallucinations within psychotic disorders. Psychotic symptoms was the broadest term, encompassing a range of populations but most commonly involving hallucinations, delusions, thought disorder, and disorganization.

DISCUSSION

A model for conceptualizing the required terms is proposed and future directions needed to advance this field of research are discussed.

Demographic, psychosocial, clinical, and neurocognitive baseline characteristics of Black Americans in the RAISE-ETP study

This study compared baseline characteristics of Black Americans and Caucasians with first-episode psychosis in the Recovery After an Initial Schizophrenia Episode Early Treatment Program (RAISE-ETP). Black American (N=152) and Caucasian (N=218) participants were compared on demographic, psychosocial, clinical, and neurocognitive measures. Results indicated several notable racial differences in baseline characteristics: a greater proportion of Black Americans than Caucasians were female, and Black Americans reported less personal and parental education than Caucasians. Black Americans were also less likely to have private insurance, more likely to be homeless or transient, had significantly poorer quality of life, more severe disorganized symptoms, worse neurocognition, and were less likely to abuse alcohol than Caucasians. The implications of these findings are discussed, and suggestions are provided for future avenues of treatment and research on racial disparities in first-episode psychosis.

An Examination of Polygenic Score Risk Prediction in Individuals With First-Episode Psychosis

BACKGROUND

Polygenic risk scores (PRSs) have successfully summarized genome-wide effects of genetic variants in schizophrenia with significant predictive power. In a clinical sample of first-episode psychosis (FEP) patients, we estimated the ability of PRSs to discriminate case-control status and to predict the development of schizophrenia as opposed to other psychoses.

METHODS

The sample (445 case and 265 control subjects) was genotyped on the Illumina HumanCore Exome BeadChip with an additional 828 control subjects of African ancestry genotyped on the Illumina Multi-Ethnic Genotyping Array. To calculate PRSs, we used the results from the latest Psychiatric Genomics Consortium schizophrenia meta-analysis. We examined the association of PRSs with case-control status and with schizophrenia versus other psychoses in European and African ancestry FEP patients and in a second sample of 248 case subjects with chronic psychosis.

RESULTS

PRS had good discriminative ability of case-control status in FEP European ancestry individuals (9.4% of the variance explained, p < 10^-6), but lower in individuals of African ancestry (R² = 1.1%, p = .004). Furthermore, PRS distinguished European ancestry case subjects who went on to acquire a schizophrenia diagnosis from those who developed other psychotic disorders (R² = 9.2%, p = .002).

CONCLUSIONS

PRS was a powerful predictor of case-control status in a European sample of patients with FEP, even though a large proportion did not have an established diagnosis of schizophrenia at the time of assessment. PRS was significantly different between those case subjects who developed schizophrenia from those who did not, although the discriminative accuracy may not yet be sufficient for clinical utility in FEP.

Racism as a Unique Social Determinant of Mental Health: Development of a Didactic Curriculum for Psychiatry Residents

INTRODUCTION

Mental health disparities based on minority racial status are well characterized, including inequities in access, symptom severity, diagnosis, and treatment. For African Americans, racism may affect mental health through factors such as poverty and segregation, which have operated since slavery. While the need to address racism in medical training has been recognized, there are few examples of formal didactic curricula in the psychiatric literature. Antiracism didactics during psychiatry residency provide a unique opportunity to equip physicians to address bias and racism in mental health care.

METHODS

With advocacy by residents in the Massachusetts General Hospital/McLean Psychiatry residency program, the Division of Public and Community Psychiatry developed a curriculum addressing racial inequities in mental health, particularly those experienced by African Americans. Four 50-minute interactive didactic lectures were integrated into the required didactic curriculum (one lecture per postgraduate training class) during the 2015-2016 academic year.

RESULTS

Of residents who attended lectures and provided anonymous feedback, 97% agreed that discussing racism in formal didactics was at least "somewhat" positive, and 92% agreed that it should "probably" or "definitely" remain in the curriculum. Qualitative feedback centered on a need for more time to discuss racism as well as a desire to learn more about minority mental health advocacy in general.

DISCUSSION

Teaching about racism as part of required training conveys the explicit message that this is core curricular material and critical knowledge for all physicians. These lectures can serve as a springboard for dissemination and provide scaffolding for similar curriculum development in medical residency programs.

Black-White Disparities in Criminal Justice Referrals to Drug Treatment: Addressing Treatment Need or Expanding the Diagnostic Net?

Slightly more than half of admissions to U.S. publicly-funded treatment for marijuana use are referred by the criminal justice system; this pattern has remained for at least 20 years. Nationally, Blacks comprise nearly a third of treatment admissions for marijuana use. This article explores the interplay between race and criminal justice referrals to treatment for marijuana use. Using data from the (U.S.) 2011 Treatment Episode Data Set, we examine the relationship between race and diagnosis of cannabis use disorder (dependence versus abuse) among referrals to community-based treatment in North Carolina. We compare Black/White differences in cannabis diagnoses across four referral sources: the criminal justice system, healthcare providers, self, and other sources. Race was significantly related to type of diagnosis across all four referral sources, however, the nature of the relationship was distinctly different among criminal justice referrals with Whites being more likely than Blacks to be diagnosed with cannabis dependence. Moreover, the marijuana use profiles of criminal justice referrals differed substantially from individuals referred by other sources. The findings suggest that diagnoses of cannabis abuse (rather than dependence) may have worked to widen the diagnostic net by “capturing” individuals under control of the criminal justice system who manifested few problems with marijuana use, other than their involvement in the criminal justice system. The potential for a net-widening effect appeared to be most pronounced for Blacks.

Examining patient race and area predictors of inpatient admission for schizophrenia among hospital users in California

According to international research African-Caribbean and Black African populations have increased risk of hospitalization for schizophrenia, compared to Whites. Less is known about admission risk for other racial-ethnic groups. This study investigated racial-ethnic differences in hospital admission for schizophrenia in California. It also investigated the influence of area social factors (racial-ethnic neighborhood composition, and per capita income) and health service factors (presence of primary care clinics). The study sample included individuals admitted to a California hospital during 1990-2005 with a primary appendicitis related diagnosis, and without a prior or concurrent indication of schizophrenia. The adjusted logistic model examined how patient racial-ethnicity (White, Black, Hispanic, Other), other personal, area social characteristics and presence of primary care clinics influenced hospital admissions for schizophrenia. Black individuals were almost twice as likely as Whites to be admitted while Hispanics and Other race individuals were less to be admitted. In addition, male sex, having more comorbidities and living in areas with greater proportions of non-Whites increased risk. The increased risk for Blacks compared to Whites was consistent with the existing literature. However, this is among the first studies to report that Hispanics had a reduced risk of admission for schizophrenia, compared to Whites. Future studies may want to include a broader range of health services to better understand patterns of care use among individuals with schizophrenia.

Race Matters? Examining and Rethinking Race Portrayal in Preclinical Medical Education

Critical examination of "health disparities" is gaining consideration in medical schools across the United States, often as elective curricula that supplement required education. However, there is disconnect between discussions of race and disparities in these curricula and in core science courses. Specifically, required preclinical science lecturers often operationalize race as a biological concept, framing racialized disparities as inherent in bodies. A three- and five-month sampling of lecture slides at the authors' medical school demonstrated that race was almost always presented as a biological risk factor.This presentation of race as an essential component of epidemiology, risk, diagnosis, and treatment without social context is problematic, as a broad body of literature supports that race is not a robust biological category. The authors opine that current preclinical medical curricula inaccurately employ race as a definitive medical category without context, which may perpetuate misunderstanding of race as a bioscientific datum, increase bias among student-doctors, and ultimately contribute to worse patient outcomes.At the authors' institution, students approached the medical school administration with a letter addressing the current use of race, urging reform. The administration was receptive to proposals for further analysis of race in medical education and created a taskforce to examine curricular reform. Curricular changes were made as part of the construction of a longitudinal race-in-medicine curriculum. The authors seek to use their initiatives and this article to spark critical discussion on how to use teaching of race to work against racial inequality in health care.

PARANOID INDIVIDUALS WITH SCHIZOPHRENIA SHOW GREATER SOCIAL COGNITIVE BIAS AND WORSE SOCIAL FUNCTIONING THAN NON-PARANOID INDIVIDUALS WITH SCHIZOPHRENIA

Paranoia is a common symptom of schizophrenia that may be related to how individuals process and respond to social stimuli. Previous investigations support a link between increased paranoia and greater social cognitive impairments, but these studies have been limited to single domains of social cognition, and no studies have examined how paranoia may influence functional outcome. Data from 147 individuals with schizophrenia were used to examine whether actively paranoid and non-paranoid individuals with schizophrenia differ in social cognition and functional outcomes. On measures assessing social cognitive bias, paranoid individuals endorsed more hostile and blaming attributions and identified more faces as untrustworthy; however, paranoid and non-paranoid individuals did not differ on emotion recognition and theory of mind tasks assessing social cognitive ability. Likewise, paranoid individuals showed greater impairments in real-world interpersonal relationships and social acceptability as compared to non-paranoid patients, but these differences did not extend to performance based tasks assessing functional capacity and social competence. These findings isolate specific social cognitive disparities between paranoid and non-paranoid subgroups and suggest that paranoia may exacerbate the social dysfunction that is commonly experienced by individuals with schizophrenia.

Racial disparities during admission to an academic psychiatric hospital in a large urban area

Multiple studies confirm that African Americans are less likely than non-Hispanic whites to receive needed mental health services. Research has consistently shown that African Americans are under-represented in outpatient mental health treatment settings and are over-represented in inpatient psychiatric settings. Further, African Americans are more likely to receive a diagnosis of schizophrenia and are less likely receive an affective disorder diagnosis during inpatient psychiatric hospitalization compared to non-Hispanic white patients, pointing to a need for examining factors contributing to mental health disparities. Using Andersen's Behavioral Model of Health Service Use, this study examined predisposing, enabling and need factors differentially associated with health service utilization among African American and non-Hispanic white patients (n=5183) during psychiatric admission. We conducted univariate and multivariate logistic regression analyses to examine both main effects and interactions. In the multivariate model, African American race at admission was predicted by multiple factors including younger age, female gender, multiple psychiatric hospitalizations, elevated positive and negative symptoms of psychosis, a diagnosis of schizophrenia and substance use, as well as having housing and commercial insurance. Additionally, screening positive for cannabis use at intake was found to moderate the relationship between being female and African American. Our study findings highlight the importance of examining mental health disparities using a conceptual framework developed for vulnerable populations (such as racial minorities and patients with co-occurring substance use).

Absence of bias in clinician ratings of everyday functioning among African American, Hispanic and Caucasian patients with schizophrenia

A substantial research literature implicates potential racial/ethnic bias in the diagnosis of schizophrenia and in clinical ratings of psychosis. There is no similar information regarding bias effects on ratings of everyday functioning. Our aims were to determine if Caucasian raters vary in their ratings of the everyday functioning of schizophrenia patients of different ethnicities, to find out which factors determine accurate self-report of everyday functioning in different ethnic groups, and to know if depression has similar effects on the way people of different ethnicities self-report their current functionality. We analyzed data on 295 patients with schizophrenia who provided their self-report of their everyday functioning and also had a Caucasian clinician rating their functionality. Three racial/ethnic groups (African American (AA), Hispanic and Caucasian) were studied and analyzed on the basis of neurocognition, functional capacity, depression and real-world functional outcomes. No differences based on racial/ethnic status in clinician assessments of patients' functionality were found. Differences between racial groups were found in personal and maternal levels of education. Severity of depression was significantly correlated with accuracy of self-assessment of functioning in Caucasians, but not in AAs. Higher scores on neurocognition and functional capacity scales correlated with reduced overestimation of functioning in AAs, but not in Hispanics. This data might indicate that measurement of everyday functionality is less subject to rater bias than measurement of symptoms of schizophrenia.

Clinician reasoning in the use of cultural formulation to resolve uncertainty in the diagnosis of psychosis

We examined how the process of cultural formulation contributes to diagnostic assessment of patients with psychotic disorders at a specialized Cultural Consultation Service (CCS). Specifically, we investigated the reasoning process used to resolve uncertainty of psychotic disorder diagnosis in African immigrant patients referred to the CCS for assessment of possible psychotic disorder. Qualitative thematic analysis of 23 clinical case conference transcripts was used to identify clinicians' reasoning styles. Use of the CF appears to facilitate the emergence of a rule-governed reasoning process that involved three steps: (i) problematize the diagnosis of the intake 'psychosis' symptoms or behavior; (ii) elaborate explanations as to why the symptoms or behavior may or may not be psychosis; and (iii) confirm the diagnosis of psychosis or re-interpret as non-psychosis. Prototypes and exemplars drawn from previous experience in intercultural work featured prominently in clinicians' reasoning. Prototypes were crucial in diagnostic decision-making and appear to be important sources of both clinician expertise and bias, and may need to be targeted specifically in cultural competence training.

Race and psychiatric diagnostic patterns: understanding the influence of hospital characteristics in the National Hospital Discharge Survey

Historically, blacks have been more frequently diagnosed with schizophrenia and less frequently diagnosed with mood disorders than whites. Our understanding of why these disparities exist has primarily focused on patient and clinician characteristics and failed to examine the influence of social contextual factors such as hospital characteristics on diagnostic patterns. We analyzed data from the 2007 National Hospital Discharge Survey, a large national database of hospital inpatient stays. The paper examines whether race influences inpatient diagnoses before and after adjustment for select patient and hospital characteristics. Results indicate that blacks were 3-fold more likely to be diagnosed with schizophrenia (odds ratio [OR], 3.68; 95% confidence interval [CI], 2.96-4.57) or a psychotic disorder (OR, 3.39; 95% CI, 2.90-3.96) than whites. However, blacks were less likely than whites to be diagnosed with bipolar disorder (OR, 0.60; 95% CI, 0.50-0.72) or mood disorder (OR, 0.50; 95% CI, 0.43-0.58). These same diagnostic patterns persisted after adjustment for selected patient and hospital characteristics. These results provide confirmation of trends observed in earlier studies of single hospitals with smaller sample sizes. Further research is necessary to determine whether the hospital characteristics selected for these analyses are appropriate proxy measures of factors that influence diagnostic judgment in inpatient settings.

Toward understanding ethnic and cultural factors in the interviewing process

The clinical interview is critical in the diagnostic assessment undertaking in clinical settings, and cultural/ethnic influences have been shown to influence the outcome of this process. Specifically, a number of studies have reported that proportionally far more ethnic minorities than Caucasians are likely to be misdiagnosed when assessed for psychiatric disorders. This particularly is the case when open clinical interviews are used. Semistructured interviews, on the other hand, result in an increase in diagnostic accuracy with ethnic minorities. Parameters associated with bias in the clinical interview of ethnic minorities and its impact on assessment, diagnosis, and treatment decisions are examined. Although the current discussion focuses primarily on African Americans, many examples are provided that pertain to other ethnic groups. Strategies for addressing these issues are explored and recommendations for increasing cultural competence are made. (PsycINFO Database Record (c) 2011 APA, all rights reserved).

Interviewer-perceived honesty as a mediator of racial disparities in the diagnosis of schizophrenia

OBJECTIVE

African Americans are disproportionately diagnosed as having schizophrenia, and the factors that contribute to this disparity are poorly understood. This study utilized data from the 1995 MacArthur Violence Risk Assessment Study to examine the impact of racial differences in sociodemographic characteristics, clinical presentation, and perceived honesty on disparities in the diagnosis of schizophrenia among African Americans.

METHODS

Researchers using structured assessments of diagnostic, sociodemographic, and clinical measures interviewed African Americans (N=215) and whites (N=537) receiving inpatient care for a severe mental illness. The impact of interviewers' perceptions of the participants' honesty on racial disparities in the diagnosis of schizophrenia was assessed.

RESULTS

African Americans (45%) were more than three times as likely as whites (19%) to be diagnosed as having schizophrenia. Disparities in sociodemographic and clinical characteristics modestly contributed to disparities in diagnostic rates. In contrast, interviewer-perceived honesty proved to be a significant predictor of racial disparities in schizophrenia diagnoses. After adjustment for perceived honesty, diagnostic disparities between African Americans and whites were substantially reduced. Mediator analyses confirmed that interviewer-perceived honesty was the only consistent mediator of the relationship between race and schizophrenia diagnosis.

CONCLUSIONS

Interviewers' perceptions of honesty among African-American participants are important contributors to disparities in the diagnosis of schizophrenia. Clinicians' perceptions of dishonesty among African-American patients may reflect poor patient-clinician relationships. Methods of facilitating a trusting relationship between patients and clinicians are needed to improve the assessment and treatment of persons from minority groups who are seeking mental health care. (Psychiatric Services 63:875-880, 2012; doi: 10.1176/appi.ps.201100388).

Race and the clinical diagnosis of depression in new primary care patients

OBJECTIVE

The objective was to determine whether the effects of new patient status on primary care depression diagnoses differ by patient race.

METHOD

Primary care visits (n=168,482) from the National Ambulatory Medical Care Survey were analyzed. Logistic regression was used to evaluate main effects of new patient status on depression diagnoses and interactions with race.

RESULTS

Among Whites, approximately 2% of new visits and 3% of return visits resulted in depression diagnoses, whereas among African Americans, these corresponding proportions were 0.5% and 2%, respectively. The lower likelihood of receiving a depression diagnosis during new versus return primary care visits was significantly greater among African Americans than Whites (P=.04).

CONCLUSION

For African American primary care patients, first visits may be a high-risk period for missed diagnoses of depression.

Disparities in diagnosis of bipolar disorder in individuals of African and European descent: a review

BACKGROUND

Over the past 3 decades, a wide range of studies in the United States and the United Kingdom has reported that white individuals are more likely to be diagnosed with bipolar and affective disorders, whereas black individuals appear to be at higher risk for schizophrenia spectrum diagnoses. Despite the pressing need for strategies aimed at eliminating racial and cultural disparities in diagnosis and treatment of bipolar disorder, no systematic review of the existing literature in this area has been done. This study draws together the disparate strands of information in a comprehensive overview of the research base in this area.

METHODS

An electronic literature search of the Medline and PsychINFO databases was conducted in October 2009, supplemented by a review of references in the identified articles, for a total of 51 articles included in this qualitative review.

RESULTS

Black patients have consistently been found to be more likely than white patients to be diagnosed with schizophrenia rather than bipolar disorder. Four factors were identified as potential contributors to racial disparities in diagnostic rates: clinical presentation and expression of symptoms, access to care, help-seeking behaviors, and clinician judgment.

CONCLUSION

Despite efforts to curtail the phenomenon, racial disparities in diagnosis of bipolar disorder persist. Racial and cultural elements may affect how patients manifest behaviors and symptoms and how these are interpreted and attributed by clinicians in the diagnostic process. As an appropriate diagnosis determines treatment options and is central to quality of care, incorrect diagnosis can potentially have a negative impact on treatment effectiveness and accuracy of prognosis.

Ion channels and schizophrenia: a gene set-based analytic approach to GWAS data for biological hypothesis testing

Schizophrenia is a complex genetic disorder. Gene set-based analytic (GSA) methods have been widely applied for exploratory analyses of large, high-throughput datasets, but less commonly employed for biological hypothesis testing. Our primary hypothesis is that variation in ion channel genes contribute to the genetic susceptibility to schizophrenia. We applied Exploratory Visual Analysis (EVA), one GSA application, to analyze European-American (EA) and African-American (AA) schizophrenia genome-wide association study datasets for statistical enrichment of ion channel gene sets, comparing GSA results derived under three SNP-to-gene mapping strategies: (1) GENIC; (2) 500-Kb; (3) 2.5-Mb and three complimentary SNP-to-gene statistical reduction methods: (1) minimum p value (pMIN); (2) a novel method, proportion of SNPs per Gene with p values below a pre-defined α-threshold (PROP); and (3) the truncated product method (TPM). In the EA analyses, ion channel gene set(s) were enriched under all mapping and statistical approaches. In the AA analysis, ion channel gene set(s) were significantly enriched under pMIN for all mapping strategies and under PROP for broader mapping strategies. Less extensive enrichment in the AA sample may reflect true ethnic differences in susceptibility, sampling or case ascertainment differences, or higher dimensionality relative to sample size of the AA data. More consistent findings under broader mapping strategies may reflect enhanced power due to increased SNP inclusion, enhanced capture of effects over extended haplotypes or significant contributions from regulatory regions. While extensive pMIN findings may reflect gene size bias, the extent and significance of PROP and TPM findings suggest that common variation at ion channel genes may capture some of the heritability of schizophrenia.

First-generation immigrants and hospital admission rates for psychosis and affective disorders: an ecological study in Ontario

OBJECTIVE

The immigrant population in Canada, and particularly in Ontario, is increasing. Our ecological study first assessed if there was an association between areas with proportions of first-generation immigrations and admissions rates for psychotic and affective disorders. Second, this study examined if area-level risks would persist after controlling for area socioeconomic factors in census-derived geographical areas-Forward Sortation Areas (FSAs)-in Ontario.

METHODS

Ontario's inpatient admission records from 1996 to 2005 and census data from 2001 were analyzed to derive FSA rates of first admissions for psychotic disorders and affective disorders per 100 000 person-years. Negative binomial regression models were adjusted, first, for FSA age and sex and, second, also for FSA population density and average income.

RESULTS

Using age- and sex-adjusted models, admission rates for psychotic disorders were higher in areas with greater proportions of immigrants. These areas were associated with lower admission rates for affective disorders. When FSA average income and population density were added to the models, the influence of immigrants was attenuated to nonsignificant levels in models predicting psychotic disorders admission rates. However, greater proportions of immigrants remained significantly protective when predicting rates of affective disorders.

DISCUSSION

Our study provides insight about the influence of area-level variables on risk of admission for psychotic and affective disorders in high immigrant areas. There is a dearth of current Canadian research on immigrant admission for psychotic disorders at the individual or area level. Future area- and individual-level studies may better identify groups at risk and possible explanations.

The health disparities industry: is it an ethical conundrum?

Reducing health disparities is the purported mission of a huge network of professionals representing many specialties and organizations offering a variety of products and services. Given its elaborate infrastructure and specialized set of activities, we identity the network as the health disparities industry. In this article, we question the ethics of this industry. Specifically, we ask whether the public mission is trumped by questionable industry leadership, ethics, and quality assurances. Drawing on general principles of ethics and differentiating ethical concerns from ethical problems, we conclude that the collective behaviors within the industry may represent an ethical conundrum. The article concludes with a call for the cross-examination of the industry practices.

Clinicians’ Competence in Assessing Cultural Mistrust Among African American Psychiatric Patients

A two-stage culturally sensitive diagnostic procedure allows for the assessment of cultural factors in paranoid symptom expression among African Americans. The first stage eliminates clinician bias by ensuring that diagnosticians adhere to DSM criteria. The second stage removes cultural bias by having cultural experts (i.e., African American mental health professionals) give best-estimate diagnoses using the same symptom data along with cultural knowledge. The present study uses the culturally sensitive diagnostic interview paradigm and structural equation modeling to examine the effects of demographic background, patients’ self-report of paranoid symptoms, and patients’ self-report of cultural mistrust on clinicians’ ratings of cultural mistrust for a sample of 116 Black psychiatric inpatients. Full and reduced models were tested using structural equation modeling, and the reduced model was the best fit to the data. The results suggest that clinicians can identify cultural mistrust in Black psychiatric patients. Implications for cultural competence training to prevent psychiatric misdiagnosis are discussed.

Exploring the impact of race on mental health service utilization among african americans and whites with severe mental illness

BACKGROUND

Disparities among African Americans and Whites with severe mental illness have been identified in numerous studies. Yet it remains unknown if disparities are associated with race or other vulnerabilities common to this population.

OBJECTIVES

This study used the Behavioral Model for Vulnerable Populations to examine mental health service utilization among 155 African Americans and Whites with severe mental illness for 12 months after discharge from a residential crisis program.

DESIGN

This cross-sectional study was a secondary analysis of data from a randomized trial.

RESULTS

Race did not emerge as a significant predictor of mental health service utilization. Factors associated with frequency of service use were diagnosis, age, drug use, gender, health benefit status, and enrollment in an outpatient mental health program.

CONCLUSION

It is possible that the geographic location of the study, equal access to services, and equal rates of substance use between racial groups explain the lack of racial differences found in this sample.

Mental health service utilization and drinking outcomes in a national population sample: are there racial/ethnic differences?

Racial and ethnic disparities in alcohol use and alcohol-related problems have been well-documented. Less information is available about possible disparities in outcomes related to mental health services utilization. The differential effect of mental health services use by race on drinking outcomes was examined. Wave 2 of a national population sample of employed adults who reported having at least one alcoholic drink in the past year (N = 1,058) encompassed measures of the prevalence of mental health services use in response to stress, and alcohol-related outcomes. Non-white participants who reported using any mental health services, four or more mental health visits in the past year, and eight or more mental health visits in the past year reported lower rates of problematic drinking behaviors, including frequency of drinking to intoxication, heavy episodic drinking, and modified Brief MAST scores, than whites who reported similar use of mental health services.

Eligibility, recruitment, and retention of African Americans with severe mental illness in community research

Data that addresses severely mentally ill (SMI) African Americans (AAs) likelihood to participate in clinical research is limited. This study's purpose was to determine if differences exist between races regarding eligibility, recruitment, and retention in a community-based clinical trial. The sample included 293 participants. Data sources included clinical records and interviews. Logistic regression was used for analysis. AAs were as likely to participate and to complete followup interviews as Whites. In contrast to studies about non-mentally ill AAs, AAs with SMI appeared to be as willing to consent to and to remain in clinical research studies as Whites.

Diagnostic, symptom, and functional assessments of Hispanic outpatients in community mental health practice

With increased US Hispanic diversity come diagnostic challenges associated with culture, language, and expression of mental disorders. In a community-based clinic, we compared diagnostic agreement between Hispanic and non-Hispanic clinicians, and a structured diagnostic instrument, in live and videotaped interviews with Hispanic adults. Percentage agreement and kappas show low diagnostic reliability between clinicians, and between clinicians and instrument. Significant differences appeared in rates of various diagnoses. Non-Hispanic clinicians rated patients' functional capacity and symptom-severity as significantly worse than Hispanic clinicians. Findings match past research with Hispanic patients and raise questions about diagnostic reliability in multi-cultural community mental health practice.

Ethnicity effects on clinical diagnoses compared to best-estimate research diagnoses in patients with psychosis: a retrospective medical chart review

OBJECTIVE

Ethnicity effects on diagnoses are frequently reported and have variably been attributed to diagnostic biases versus ethnic differences in environmental exposures, and other factors.

METHOD

We compared best-estimate gold standard research diagnoses to clinical diagnoses (DSM-III-R and DSM-IV criteria) among 129 white, 57 African American, and 50 Hispanic patients with psychosis admitted to an inpatient research unit from 1990 to 2003.

RESULTS

Clinical and research diagnoses showed greater agreement in Hispanic than in African American patients (white patients were intermediate). Diagnostic agreement for paranoid schizophrenia was likewise the best in Hispanic patients. While paranoid schizophrenia tended to be overdiagnosed in African American patients, it was underdiagnosed in white patients. Patterns of diagnostic agreement for schizoaffective disorder and "other" diagnoses were similar among the 3 ethnic groups.

CONCLUSIONS

Diagnostic unreliability may explain the excess of paranoid schizophrenia reported for African Americans. Further research is needed to elucidate the influence of ethnicity on clinical diagnosis before other theories to explain group differences can be reasonably proposed and reliably tested.

The role of treatment setting and high acuity in the overdiagnosis of schizophrenia in African Americans

Multiple studies have shown that significant disparities exist in the diagnosis of schizophrenia between African Americans (AAs) and Whites with severe mental illness. This phenomenon has been a topic in the literature for nearly three decades, yet it remains unclear what factors contribute most conclusively to the overdiagnosis of schizophrenia in AAs. The purpose of this article was to collectively examine the contributing factors identified in the literature and to discuss the role of acuity and treatment setting in overdiagnosis as well. A variety of client-level (higher rates of use of psychotomimetic substances in AAs) and care process-level (misinterpretation of cultural mistrust as paranoia, under detection of depression, similarities in diagnostic criteria between mood and psychotic disorders, provider bias, miscommunication between patient and provider, changes in diagnostic criteria, differences in diagnostic practice between providers, and a lack of sufficient data obtained) factors emerged as influential in overdiagnosis. However, in this review, it also emerged that AAs tendency to use emergency and acute care services, a systems level factor, could be related as well. It is possible that assessment at a time when symptom acuity is severe might increase the likelihood of a schizophrenia diagnosis in AAs.

Social defeat and the culture of chronicity: or, why schizophrenia does so well over there and so badly here

The history of the way schizophrenia has been conceptualized in American psychiatry has led us to be hesitant to explore the role of social causation in schizophrenia. But there is now good evidence for social impact on the course, outcome, and even origin of schizophrenia, most notably in the better prognosis for schizophrenia in developing countries and in the higher rates of schizophrenia for dark-skinned immigrants to England and the Netherlands. This article proposes that "social defeat" may be one of the social factors that may impact illness experience and uses original ethnographic research to argue that social defeat is a common feature of the social context in which many people diagnosed with schizophrenia in America live today.

Toward a Cognitive Process Model of Ethnic/Racial Biases in Clinical Judgment

The purpose of the present article is to discuss approaches to the development of cognitive process models of misdiagnosis of African Americans, with particular emphasis on structured clinical interviews. Two basic approaches to cognitive process models are discussed. The first is cognitive bias based on prototype models of information processing. The second approach involves using the structured clinical interview to see how and when the decision-making process may be flawed, or where cognitive shifts are made in considering one diagnosis over another. Although routine training in structured clinical interviews may nullify cognitive biases associated with clinician judgment, it does not address cultural biases in the diagnostic system. It is concluded that a comprehensive approach to training in clinical decision making for mental health professionals is needed which include courses in the administration of the Structured Clinical Interview for DSM-IV, sociocultural case formulation, and cross-cultural sensitivity in making psychodiagnostic judgments.

Over-representation of Maori New Zealanders among adolescents in a schizotypy taxon

BACKGROUND

Minority ethnic and migrant groups are often over-represented among those with schizophrenia.

OBJECTIVES

The aim of this study was to determine whether Maori, the aboriginal minority of New Zealand, are over-represented in a schizotypy taxon derived from a general population sample of adolescents.

METHOD

Secondary school students (n = 387) aged 13 to 17 years completed self-report measures of four schizotypy attributes, magical thinking, hallucinatory tendency, self-referential ideation, and perceptual aberration, and indicated ethnic descent and self-identified ethnic belonging.

RESULTS

Taxometric analyses (maximum covariance, maximum eigenvalue, latent modes) yielded consistent evidence of taxonicity of schizotypy. Participants who were of Maori descent were over-represented in the schizotypy group.

CONCLUSIONS

Ethnicity, or the stress and resilience factors for which ethnicity is a proxy measure, has a measurable impact on psychometric risk for schizophrenia.

Differences in patterns of symptom attribution in diagnosing schizophrenia between African American and non-African American clinicians

The authors examined clinician race differences in symptom attribution patterns in diagnosing psychiatric inpatients from a low-income, African American community. Different decision models were applied to patients based on clinician race. African American clinicians diagnosed schizophrenia with higher odds than non-African American clinicians when they believed hallucinations were present and avoided that diagnosis with lower odds when they considered substance abuse issues. Non-African American clinicians usually related the attribution of negative symptoms to the diagnosis of schizophrenia while African American clinicians did not make this linkage. The study highlights the need for more detailed examination of cultural influences on diagnostic judgments.

African-American participants in a bipolar disorder registry: clinical and treatment characteristics

OBJECTIVES

The goal of this paper was to compare clinical characteristics and treatment history of African-American and Caucasian participants in a bipolar disorder registry.

METHODS

The Western Pennsylvania Bipolar Disorder Registry used several recruitment methods to reach individuals self-identified as having bipolar disorder. Individuals who contacted and joined the registry completed an interviewer-administered questionnaire on clinical characteristics and treatment history. A sample of 2,718 registry participants was analyzed in order to compare these characteristics and history by race.

RESULTS

African-Americans in the registry reported a greater number of inpatient hospitalizations (9.8 versus 4.4) than Caucasians, as well as a higher suicide attempt rate (64% versus 49%). African-American participants were more likely to report a family member with schizophrenia. With respect to psychotropic medication, African-Americans were less likely to report taking antimanic medication or benzodiazepines, but more likely to report taking antipsychotics than Caucasians.

CONCLUSIONS

The present findings reinforce previous reports regarding the chronicity and severity of bipolar disorder among African-Americans. They also support previous studies that found high rates of attempted suicide among African-Americans with bipolar disorder. These findings provide further impetus for specific community and mental health services delivery efforts to reduce barriers to early accurate diagnosis and to appropriate ambulatory treatment for bipolar disorder.

Clinical, psychosocial, and treatment differences in minority patients with bipolar disorder

OBJECTIVES

The clinical profile of minorities with bipolar disorder has been largely unexplored. We compared the clinical (e.g. psychiatric and substance use comorbidity), psychosocial, and treatment characteristics between white and minority patients with bipolar disorder (minorities were defined as black or other minority, which included Hispanic, Asian-American, or Native-Americans).

METHODS

We collected demographic, diagnosis, and treatment information using the Structured Clinical Interview for DSM-IV (SCID) from 330 inpatients with a current major affective episode across 11 Veterans Affairs (VA) Medical Centers enrolled in the VA Cooperative Study (Reducing the Efficacy-Effectiveness Gap in Bipolar Disorder).

RESULTS

Twenty-four percent (n=80) were minority; 9% (n=30) were women, 4% (n=20) were >or=65 years old; and the majority (87%, n=286) had bipolar type I. Minorities compared with whites were no more likely to have a current episode of psychosis (30% versus 37%, respectively; p=0.28). However, minorities were more likely than whites to have a cocaine use disorder (adjusted odd's ratio, OR=2.2; 95% CI: 1.4-3.5; p<0.01) or current alcohol abuse disorder (adjusted OR=1.8; 95% CI: 1.1-3.9;p<0.05). Further breakdown by race/ethnicity revealed that cocaine use disorder was most prevalent among blacks (n=14, 29%), compared with all other minorities (n=2, 6%) or whites (n=10, 4%; p<0.001). Other minorities compared with blacks or whites were more likely involuntarily committed during some part of their index hospitalization (adjusted OR=2.47; 95% CI: 1.1-5.7; p=0.04).

CONCLUSIONS

Minorities with bipolar disorder may be a more vulnerable population because of higher rates of substance use disorder and higher rates of involuntary psychiatric commitment. Moreover, the specific profile of vulnerability may differ across minority groups.

The heresy of African-centered psychology

This paper contends that African-centered models of psychopathology represent a heretical challenge to orthodox North American Mental Health. Heresy is the defiant rejection of ideology from a smaller community within the orthodoxy. African-centered models of psychopathology use much of the same language and ideas about the diagnostic process as Western psychiatry and clinical psychology but explicitly reject the ideological foundations of illness definition. The nature of the heretical critique is discussed, and implications for the future of this school of thought are offered.

Clinician race, situational attributions, and diagnoses of mood versus schizophrenia disorders

This research examined clinicians' consideration of situational factors in diagnostic decisions of mood vs. schizophrenia disorders among psychiatric inpatients from a low-income, African American community. Clinicians completed questionnaires describing their diagnostic decisions. Responses reflecting the usage of situational information were investigated. African American clinicians used situational information more than non-African American clinicians. However, this increased attention to situational information was not uniquely associated with a particular diagnostic decision for African American clinicians. In contrast, consideration of situational attributions by non-African American clinicians did increase the probability of a mood diagnosis. Logistic regression analyses suggested differential application of a diagnostic standard among African American and non-African American clinicians. Implications for enhancing the cultural sensitivity of diagnosis practices are discussed.