Racial Profiling in Psychiatry: Does It Help Patients?
Racial Profiling in Psychiatry: Does It Help Patients?
A 42-year-old man presents to your clinic asking for help with depression. His complaints are familiar: sadness, some anxiety, loss of appetite, low energy, difficulty in concentrating at work, and inability to sleep despite feeling exhausted. He does not want therapy but would be willing to try a medication. As you reach for your prescription pad, you try to decide which SSRI and what dosage to start with. Should his race or ethnicity affect your decision? Is race a relevant variable for psychopharmacology?
These questions have attracted great interest. In a 2002 cover story in the New York Times Magazine, psychiatrist Sally Satel proudly asserted "I Am a Racial Profiling Doctor."1 When she treated African American patients in her Washington, DC, clinic, she started them on lower doses of fluoxetine because, she claimed, "40% of them are slow metabolizers of antidepressants." Citing other examples in medicine, she defended this politically incorrect decision: "When it comes to practicing medicine, stereotyping often works." Racial profiling in medicine received a major boost in June 2005 when the FDA granted BiDil, a fixed-dose combination of isosorbide dinitrate and hydralazine, a specific indication for treating heart failure in patients who identify themselves as black.2
Should psychiatrists follow these leads and use a patient's race or ethnicity to guide treatment decisions? In this article, I will describe the evidence that supports racial profiling in psychiatry and will explore some of the relevant concerns. This is not a systematic review: many good ones have already been published.3-5 Instead, I hope to outline the basic issues and explain why I am not a racial-profiling psychiatrist.
Is race real enough?
Any discussion of racial profiling must start with some basic questions. What exactly is race? What about ethnicity? Are they valid and relevant categories for medical decision making? After all, if we are going to profile, we want to make sure that we are using appropriate variables.
However race is defined, the basic concept in medicine is that different groups of people differ in ways that are biologically significant. This idea is an ancient one. Hippocratic writers taught that bodies adapted themselves to local environments and, as a result, environmental differences became embodied as biologic differences between people from different areas. Wise physicians would have considered these differences in their diagnoses and treatments. As taxonomists began systematic study of biologic diversity in the 18th century, they subjected humans to their classifying efforts.
German naturalist Johann Blumenbach proposed a 5-race classification: Ethiopian, Mongolian, Caucasian, American, and Malay. Later writers, especially in the early 20th century, defended more nuanced divisions, distinguishing English from Irish and Scot, Sicilian from Italian, and so forth. In all these taxonomies, a race was a group of persons that shared both ancestry and superficial distinguishing characteristics (eg, skin color, hair texture, facial structure). Racial distinctions had unchallenged relevance for both social policy and medical practice.
Eagerness to discriminate by race diminished in the mid-20th century in the aftermath of American and Nazi eugenic programs. A consensus emerged, typified by the United Nations Educational, Scientific and Cultural Organization statements on race in 1950 and 1951, arguing that race was artificial and dangerous and should be banned from science and social policy. This idea found support in the work of population geneticists who showed in the 1970s that the amount of variation within groups far exceeded the variation
that distinguished between different groups.6,7
Antiracial sentiment reached its zenith in June 2000 at the announcement of the completion of the Human Genome Project. Sharing the stage, Bill Clinton, Craig Venter, and Francis Collins celebrated the finding of human sameness: with all humans sharing 99.9% of their genetic code, race had no basis in genetics.
Race, so entrenched and evocative, could not be dispensed with so easily, however. Throughout the 20th century, researchers had continued to map racial distributions of blood types, drug-
metabolizing enzymes, and other genetic and biochemical markers. As soon as the 99.9% overlap was announced, geneticists turned it upside down. Even just a 0.1% variation meant that individuals differ at 3 million base pairs. Within this limited variation lies the secret of all human variability that is of genetic origin, whether for skin color, disease susceptibility, or drug response. Studies of the distribution of genetic variation have supported the validity of racial categories. One analysis of 1056 persons from 52 populations found that it could correctly identify the race and geographic origin of individuals based solely on their genetic markers.8
One of the largest studies of human variation, the International Haplotype Map (HapMap) Project has been interpreted similarly. The HapMap is being created to simplify the search for genetic causes of human disease. By defining which regions of the genome vary, the HapMap will allow researchers to focus their searches on the 0.1% in which variations exist.9,10
The first draft of the HapMap was published in 2005.11 It was based on a carefully selected sample: 90 people from Provo, Utah; 90 from Ibadan, Nigeria; and 90 from Asia (45 each from Tokyo and Beijing). Although the authors did not set out to test the genetic reality of race, they did note that a handful of alleles distinguished these
3 groups. Subsequent clinical studies have used the HapMap to confirm that the self-reported race of research subjects matched their genetic profiles.12 Other work has also demonstrated a close correlation between self-reported race and genetic ancestry. A recent letter in the New England Journal of Medicine reported that persons who self-identified as white generally had greater than 90% European genetic ancestry, while people who self-reported as black had a substantial proportion of African genetic ancestry.13
The implication of this work is that race, as popularly understood, is real and correlates with genetics and ancestry. This seeming clarity came at a useful time. Concerned that minority groups had been underrepresented in clinical research, Congress passed the NIH Revitalization Act of 1993 that mandated the inclusion of diverse populations in clinical research. How has this been implemented? Blumenbach would be proud. The FDA, following the lead of other federal agencies, recognizes 5 races—American Indian or Alaska Native, Asian, black or African American, Native Hawaiian or Other Pacific Islander, and white—and 2 ethnicities—Hispanic or non-Hispanic. Such categorizations, especially ethnicity, leave much to be desired, but they enjoy bureaucratic familiarity and genetic justifications.