Ethnicity and Diagnosis in Patients With Affective Disorders
J Clin Psychiatry 2003;64:747-754
© Copyright 2014 Physicians Postgraduate Press, Inc.
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Background: Clinically, African American
psychiatric patients are disproportionately diagnosed with
schizophrenia compared with white patients. Why this occurs is
unknown. Extending prior work, the authors hypothesized that
first-rank symptoms distract clinicians so that they fail to
identify affective disorders in African Americans.
Method: 195 African American and white patients
with at least 1 psychotic symptom (delusions, hallucinations, or
prominent thought disorder) at admission were recruited from
January 1, 1998, through May 31, 2001. Each patient received 3
independent DSM-IV diagnoses: a clinical diagnosis, a
structured-interview diagnosis, and an expert-consensus
diagnosis. The expert-consensus diagnoses were derived from the
structured interviews, which were audiotaped and transcribed, and
medical records. After reviewing edited transcripts and medical
records from which ethnic cues had been eliminated, 2
psychiatrists assigned expert-consensus diagnoses and first-rank
symptom ratings. For the 79 patients who received an
expert-consensus diagnosis of an affective disorder, clinical
variables, diagnoses, and first-rank symptoms were compared
between African American (N = 39) and white (N = 40) patients.
Results: Seventy-nine (41%) of 195 patients were
diagnosed with an affective disorder by expert consensus. African
American men with an expert-consensus affective disorder were
significantly (p < .03) more likely than other patients to be
diagnosed with a schizophrenia spectrum disorder by clinical
assessment and structured interview. Although first-rank symptoms
were more commonly identified in African American men, this
finding did not explain the difference in diagnoses. Post hoc
analyses suggested that African American men diagnosed with a
schizophrenia spectrum disorder were more likely than other
patients to have been identified during structured interview as
having psychotic symptoms in the absence of affective symptoms.
Conclusion: The apparent misdiagnosis of
schizophrenia in African-Americans with mood disorders cannot be
ascribed to differences in first-rank symptoms. However, it may
be due to a perception that psychotic symptoms are more chronic
or persistent than affective symptoms in these patients.