CGPR: Can you tell us about the work that you do?

Dr. Black: I am the deputy editor for health equity for the American Journal of Geriatric Psychiatry, the inaugural vice chair for education at the Institute of Living at Hartford Hospital, and adjunct assistant professor at Yale School of Medicine. I have dedicated the last five years of my clinical practice to working in a state-funded facility where my patients face the multiple challenges of belonging to racial and ethnic minoritized groups and struggling with poverty and severe mental illness. I see some of the most vulnerable patients of New Haven. 

CGPR: You used the term “racial and ethnic minoritized groups.” Can you talk about this term? 

Dr. Black: Yes. Word choice matters. The term “minorities” implies that Black and Brown people are fewer in number or lesser in quality than the White “majority” (Black C et al, Lancet Reg Health Am 2023;19(4):100464). It also does not highlight the structural racism that is found in medicine, which is why I prefer to use the term “minoritized.” Minoritized refers to groups that have been socially, economically, and politically marginalized, regardless of their actual numbers within the population.

CGPR: “Structural racism” in medicine is a commonly used but frequently misunderstood term. Can you define it and discuss some key examples? How is it defined differently from other forms of racism? 

Dr. Black: Many forms of racism create barriers to well-being for racially minoritized people. As a Black physician descended from those who shaped Black American history, I have encountered “interpersonal racism,” where one person treats another poorly based on their appearance. This includes scenarios where a Black clinician is perceived as less competent because of their background. “Structural racism” in medicine involves policies and practices—including clinical practices—that collectively disadvantage Black people (Braveman P et al, Health Affairs 2022;41(2):171–178). For instance, the Flexner Report of 1910 led to the closure of most medical schools admitting Black students and created admissions criteria favoring those with educational and social privilege. This created a multigenerational deprivation of over 35,000 Black American physicians (Campbell K, JAMA Network Open 2020;3(8):e20152020). Today, the words “minorities” and “underrepresented” describe the fewer numbers of Black physicians, but “minoritized” and “historically marginalized” more fully capture the intentional results of structural racism. “Institutional racism” refers to the systematic policies and practices within institutions, such as medical schools and professional organizations, that result in unequal access to resources and opportunities based on race, perpetuating disparities in outcomes.

CGPR: You’ve argued that people of racial and ethnic minority groups are often overdiagnosed with psychotic disorders, and they may carry an incorrect diagnosis into old age. Can you tell us more about this?

Dr. Black: Research indicates that clinicians diagnose Black patients with schizophrenia spectrum disorders at a rate three to four times higher than White patients (Faber SC et al, Front Psychiatry 2023;14:1098292). Similarly, clinicians diagnose Hispanic patients three times more often with psychotic disorders compared to White populations (Schwartz RC and Blankenship DM, World J Psychiatry 2014;4(4):133–140). These disparities may stem from diagnostic criteria normed by White researchers without adequate representation of minoritized populations.

CGPR: Knowing that our diagnoses are skewed, how do we engage that statistic in real-time clinical practice?

Dr. Black: I second-guess everything with healthy suspicion in any older adult diagnosed with a primary psychotic disorder. I look for contextual irregularities: “Did you say your psychosis started at age 40 after someone just died?” I assess for substance use and trauma, as well as whether symptoms started at the typical age of onset. Many of our misdiagnosed patients will be diagnosed with schizophrenia far after the normative bell curve. 

CGPR: Are you more inclined to recommend trialing discontinuation or tapering of antipsychotics in older adults of racial and ethnic minoritized groups?

Dr. Black: Yes. In addition to diagnostic reverification, I wonder whether they still need 20 mg of olanzapine, or whether we can get by with 10 mg in older age. This is a huge step toward social justice as well. If I suspect a patient might have an incorrect diagnosis, I might say, “I have a whiff that something else might be going on—possibly trauma, substance use, or depression. I can’t guarantee this will work, but I can guarantee it’s worth a shot. Let’s have a journey together and see how it goes. If it doesn’t go well, I’m here for you, and we can go back.” I have not had an unsuccessful conversation with that approach.

CGPR: How do you suggest clinicians approach the topic of racism with patients when there is suspicion of a misdiagnosis? 

Dr. Black: I start with the literature. If I suspect a patient is misdiagnosed as psychotic, I will give them the data: “Medicine is working on being more equitable, but there is still a lot of wrongdoing. Did you know that Black people are four times more likely to be misdiagnosed with schizophrenia? When I listen to your substance use and trauma history, I suspect this might be a case where we can reconsider your diagnosis” (Schwartz RC and Blankenship DM, World J Psychiatry 2014;4(4):133–140). You can root your conversations in history and evidence, and approach these topics with humility. People from racial and ethnic minoritized groups are aware that they face disparities and that their loved ones are often excluded from important conversations and decision making. When you acknowledge this, you open the door to have a conversation. If we do a thorough diagnostic reevaluation and find the patient still appears to have a primary psychotic disorder, then we have offered them the opportunity to feel more confident about their diagnosis.

CGPR: How can we work on our own unconscious biases and stereotypes that contribute to misdiagnosis?

Dr. Black: Be receptive for times when patients shut down or challenge you. Listen for “I don’t agree” or “That doesn’t sound right.” Slow down when people are agitated. There is a long history of racism that affects the behavior of many of our patients. Instead of thinking about a patient as rude, suspicious, nontrusting, or noncompliant with medications, don’t push away—lean in (Black C, Am J Geriatr Psychiatry 2023;31(8):568–569)! Ask open questions and get to know them as an individual. One of the hardest things for clinicians to understand is that our medical knowledge can be wrong in racial and ethnic minoritized groups. Disparities may appear to be in a silo from real-time clinical practice and objective knowledge. The best thing clinicians can do to promote racial justice is to know that medicine, our colleagues, and we ourselves are often wrong. If we can keep that knowledge in mind, we can have a healthy approach to reconsider and dig into the patient’s narrative. 

CGPR: Psychiatric symptoms within racial and ethnic minoritized groups are not always well captured by clinicians. How can we tease out symptoms of mental illness when less familiar with a patient’s culture, or when a clinician has not endured systemic discrimination?

Dr. Black: First, know your own biases and welcome them. Remember that the risk factor is racial trauma, not race. The histories and experiences of our patients may be vastly different from our own. All of us have intersecting identities, including race, gender, history, and accumulated trauma. Next, use Occam’s razor to find the simplest diagnosis that can hold the most symptoms, keeping in mind that our diagnostic criteria were normed on predominantly White populations. We have psychotic features in bipolar disorder, depression, or following a traumatic event. If hallucinations are linked to a traumatic event, I would caution against adding a primary diagnosis of schizophrenia before trying PTSD or major depression with psychotic features. Depression can have psychotic features and correlates even better with PTSD. If we need an antipsychotic for a psychotic symptom within a primary mood diagnosis, it then leaves the door open for removing the antipsychotic in the future. Also, I suggest checking with the patient’s loved ones to see if their beliefs or experiences fall within or beyond individual and cultural norms.

CGPR: What advice do you have for administering screening scales in patients from diverse backgrounds? 

Dr. Black: It is very difficult when we try to use screening tools that were normed on one group for everyone and make caveats for other groups. While we are waiting for a rebuilt set of screening tools, be mindful of the literature and individual questions that fall apart for someone enduring discrimination. For example, the schizotypal personality questionnaire was normed on predominantly White populations to detect traits associated with psychosis. Certain questions fall apart for some patients, such as “Do you often feel that other people have it in for you?” That may seem a little bizarre for some patients, but if a Black person turns on the TV after George Floyd, it may seem contextually appropriate. Research indicates that such questions pathologize mistrust in Black patients toward psychosis misdiagnosis (Wolny J et al, Schizophr Res 2023;253:30–39). So, use the diagnostic tools we have, but also don’t be afraid to go off the beaten course when you truly detect that something evidence-based per disparities literature might be skewing the relevance and validity in your patient. 

CGPR: Any tips for cognitive screening in racial and ethnic minoritized groups?

Dr. Black: I would disassociate any correlation between lower educational attainment, cognitive evaluation, and any particular group or culture. Approach each person as an individual.

CGPR: What’s the current understanding of why Black Americans are more likely to develop Alzheimer’s disease?

Dr. Black: Although there may be epigenetic changes, we currently lack reliable genetic markers to explain why individuals from certain backgrounds are more likely to develop Alzheimer’s disease (Logue MW et al, J Clin Med 2023;12(16):5189). However, beginning in infancy, Black Americans often face nutritional deficits due to systemic racism, which limits access to nutritious food and quality health care (Beech BM et al, Front Public Health 2021;9:699049). These early-life disadvantages can increase the risk of various health issues later in life, including cognitive impairment. Additionally, racism contributes to educational inequities and misdiagnosis. Over time, the cumulative effect of these systemic barriers significantly raises the risk of Alzheimer’s disease (Weuve J et al, Epidemiology 2018;29(1):151–159). 

CGPR: Thank you for your time, Dr. Black.