As we all know, Emancipation was only one battle won in the centuries-long struggle for Black Civil Rights – a struggle that is far from over. Racism continues to rear its head in every aspect of American life. Income and housing inequality, police brutality, voter suppression, hate speech, and political bigotry are just a few of the forms that racism still takes.
One racial justice issue that doesn’t get discussed nearly as much as it should is healthcare equity. According to the CDC, African American adults are less likely to see a doctor due to high costs, lack of accessible care, or other barriers. Stigma around mental health in the Black community also contributes to a reluctance to recognize the need for the help of a physician or therapist. Institutional racism means the health concerns of black patients are often taken less seriously than Caucasian-American patients, and serious health issues are often diagnosed later. As noted in the following AAMC article, inadequate treatment of pain because of a patient’s race or ethnicity is happening (in 2020) and is simply unacceptable. The CDC reports that African Americans ages 18-49 are twice as likely to die from heart disease than Caucasian-Americans, and African Americans ages 35-64 are 50% more likely to have high blood pressure than Caucasian-Americans. They are also more likely to suffer from conditions such as diabetes and strokes at an earlier age, as experiences of racism in healthcare often deter people of color from getting the preventative screenings needed to catch the warning signs of these issues. Subsequently, we have seen that black individuals have suffered disproportionately due to COVID-19.
These health inequalities are also pronounced in the black LGBTQ community. Black gay and bisexual men are more affected by HIV more than any other group in the United States; in 2018, they accounted for 26% of total new HIV diagnoses and 37% of new diagnoses among all gay and bisexual men, according to the CDC. Queer women, and in particular Black queer women, are less likely to have regular preventative care such as mammograms and cervical cancer screenings. Black transgender women experience profound health and wellness inequality. An estimated 44% of black transgender women are living with HIV. Transgender women of color are also disproportionately targeted in violent hate crimes and make up the majority of transgender murder victims (Fenwayhealth.org).
As a leading behavioral health company, and as we’ve recognized in the past few weeks, we have an obligation and opportunity to better educate ourselves and others in the field on specific needs in Black communities. Countless studies have shown that implicit bias affects the quality of patient care. We provide services to a diverse population of patients, so understanding implicit bias is especially important in providing individualized quality care. Unconscious thought processes and decision-making can affect the provider-patient interaction, therapeutic options, diagnoses, and other areas of health care. A 2017 systematic review revealed that health care professionals exhibit about the same levels of implicit bias as the general population does, and evidence indicates that biases are likely to influence diagnosis and treatment decisions in some circumstances. Even professional clinicians with a lot of experience interacting with diverse groups have implicit biases. A 2015 study by Kopera and colleagues showed that mental health professionals had better approach to emotions, expressing more compassion, sadness, interest, and acceptance than non-professionals and medical students towards patients with mental illness, but both groups held negative implicit bias attitudes towards the mentally ill.
An example of how ethnicity influences specific psychiatric diagnosis is that African American patients have been found to be diagnosed with schizophrenia spectrum disorders more frequently and depression less frequently during routine clinical assessments compared with similar Caucasian patients. Furthermore, this apparent misdiagnosis of schizophrenia may lead to inadequate recognition and treatment of mood disorders. Which in turn results in the lower use of mental health treatment for mood disorder among African Americans.
With regard to children and adolescents, research shows that even after controlling for important socio-demographic variables and functional status, race and ethnicity still influenced the diagnosis and clinical characteristics of children in treatment (Nguyen et al, 2007). When the mental health needs of minority children are poorly understood, these children and adolescents are likely to be inadequately served by systems of care (Gibbs & Huang 2003). There is little research on the psychiatric diagnoses of racially and culturally diverse youth as compared to Caucasian youth despite the growth in population of racially and ethnically diverse children! There is a limited understanding of influence of ethnicity on diagnosis and we know the differences in assessment and diagnosis in minority children have important implications for treatment and outcomes. Inaccurate assessment and diagnosis may lead to inappropriate treatments and subsequent disparities in care for ethnically and racially diverse children and their families.
For example, African American youth are more likely than Caucasian youth to be given a diagnosis of ADHD and less likely to have been given the diagnosis of mood disorders (Yeh et al., 2002). In a retrospective chart review of hospitalized adolescents, African American youth were more commonly diagnosed with conduct disorder than Caucasian youth (Delbello, Lopez-Larson, Soutullo & Stratowski, 2001).
In another study, although African American and Native Hawaiian children were more likely to have been diagnosed with disruptive behavioral disorders, there was no corresponding elevation in scores on the caretaker derived CBCL (Child Behavioral Checklist) externalizing subscale. This inconsistency may be explained by culturally based differences in clinician and caretaker perspectives or may also indicate the possibility of clinician bias in assigning diagnoses.
Most research has been done in children showing a misdiagnosis of children with disruptive behaviors who have mood disorders. So, what contributes to the misdiagnosis?
Clinician factors that influence diagnosis include:
- Ratings of child problem behavior are a function of the observer and child ethnicity
- Clinician perception of the child based on his or her own cultural frame of reference
- Cultural variations in attitudes toward interpretations of children’s behaviors
- Culturally based differences in clinician and caretaker perspectives
- Clinician bias in assigning diagnosis
The aforementioned points are evidence for the necessity for cultural competency training for mental health providers. As clinicians, we know that misdiagnosis leads to unnecessary overprescribing of antipsychotic medication, resulting in unnecessary increased risk for development of metabolic syndrome in children and adults. And these are the patients who then have increased vulnerability for COVID-related deaths, for example!
In 1863, slavery was abolished in the United States and in 1954, 91 years later, segregation was ruled unconstitutional. Today in 2020, there is still so much work to be done. True racial justice cannot exist while these barriers to health and wellness still exist. While recent injustices are currently plaguing the minds of many of us, they are only a fraction of the various racial injustices Black individuals may deal with on a daily basis that are barriers to obtaining health and wellness. One important initiative we can do as mental health providers is to begin with self-reflection and work towards becoming more aware of our own implicit biases. What are some prejudices that you might hold that you are not aware of? We all have a role to play in making this better, and with more implicit bias training and more culturally competent assessment process at ERC/Insight we are hopeful that it can happen!
Toya Roberson-Moore, MD
is a staff Child and Adolescent Psychiatrist for Insight. Board certified in General Psychiatry and Neurology, and Child and Adolescent Psychiatry, she believes in a holistic and integrative approach to the promotion of wellness in adolescents and families while addressing treatment of a variety of mental health concerns. Her clinical interests include treatment of eating disorders and anxiety disorders in the pediatric population. She is also committed to educating future clinicians as evidenced by her role in the co-creation of an internet based pediatric anxiety learning module, a guide for medical students in the diagnosis and treatment of Anxiety Disorders.
She received her bachelor’s degree from the University of Michigan and Doctor of Medicine from Wayne State University. She completed both her Adult Psychiatry Residency and Child and Adolescent Psychiatry Fellowship at the University of Illinois at Chicago.
Dr. Roberson-Moore distinguished herself as Chief Resident during her second year of Fellowship. She has a broad clinical base, with training in Cognitive Behavioral Therapy, Psychodynamic Therapy, Dialectical Behavioral Therapy, Family Therapy, Play Therapy and Parent Management Training. Dr. Roberson-Moore also has extensive training in working with traumatized children and adolescents. She is also deeply involved with her communities as a dancer, volunteer, and mentor.
Dr. Roberson-Moore holds an academic appointment as Clinical Assistant Professor in the Department of Psychiatry at the University of Illinois at Chicago School of Medicine. Dr. Roberson-Moore is a diplomat of the American Board of Psychiatry and Neurology. Dr. Roberson-Moore holds memberships in the American Academy of Child and Adolescent Psychiatry (AACAP), Illinois Psychiatric Society, and Illinois Council of Child and Adolescent Psychiatry.