Most studies evaluating the impact of ethnicity on psychiatric diagnosis typically have involved adults. However, children and adolescents usually present to the hospital relatively early in the course of their illness; consequently, misdiagnoses of affective illness as a psychotic disorder can lead to long commitments of inappropriate treatments and inaccurate prognoses. A misdiagnosis of schizophrenia in an African American adolescent could also result in failure to initiate appropriate treatment for an affective illness at a critical life stage.
Consistent with studies of adults, several investigations have reported that ethnic differences in diagnostic patterns also occur in children and adolescents. Fabrega and colleagues (1993) used a semi-structured interview to assess adolescent outpatients at intake appointments at a public university-based facility and found that conduct disorder was more frequently diagnosed in African American youth, whereas eating disorders were more often diagnosed in white youth. Kilgus and colleagues (1995) retrospectively examined ethnic differences in discharge diagnoses of 352 psychiatric inpatients (ages 12 years to 18 years) accepted for treatment at a South Carolina state hospital in 1988. They reported that African American adolescents had fewer mood/anxiety and substance-abuse diagnoses but significantly more psychotic/organic diagnoses than whites. The different patient populations, methods of acquiring diagnostic data and small sample sizes, however, may account for these contrasting results.
In a more recent study, our research group examined ethnic differences in rates of discharge diagnoses of 1,001 adolescents who were hospitalized in an acute inpatient unit (DelBello et al., 2001). Consistent with the adult literature, we found ethnic differences in clinical assignment of diagnoses of hospitalized adolescents. Specifically, there were more African Americans than whites diagnosed with schizophrenia and psychotic disorders not otherwise specified, while more whites than African Americans were diagnosed with major depression. Within the group of adolescents diagnosed with a major affective or psychotic disorder, African American males were the most likely group to receive a psychotic-disorder diagnosis. Additionally, whites were more often diagnosed with alcohol(Drug information on alcohol)-use disorders, while African Americans were more likely to receive a diagnosis of conduct disorder.
As previously discussed, there are several possible explanations for the ethnic differences found in adolescents. Ethnic differences in rates of psychiatric disorders may actually exist in adolescents. However, Cuffe and colleagues (1995), in an epidemiological study using a semi-structured diagnostic interview, found no difference in the rate of affective disorders between the two populations. Mis-diagnosis, either from ethnic differences in clinical presentation or clinician biases, might contribute to the ethnic differences in clinical assignment of psychiatric diagnosis found in adolescents. Alternatively, referral biases may account for the differences.Prescribing Pattern Differences
Studies examining ethnic differences in psychotropic medication prescribing patterns have demonstrated that African American children and adolescents are less likely to receive psychotropic medications than similarly diagnosed white children and adolescents. The largest difference is found for prescriptions of stimulant and antidepressant medications (Goodwin et al., 2001; Zito et al., 1998). Melfi and colleagues (2000) reported that in a Medicaid population, African American adults were less likely than whites to receive medication when they were initially diagnosed with depression. Furthermore, in this study African Americans were more likely to receive prescriptions for tricyclic antidepressants as compared to whites, who were more likely to receive selective serotonin reuptake inhibitors.
Some of the factors that may affect prescribing patterns are cultural differences in symptom expression, which might result in lower rates of illness detection for African Americans, cultural bias in diagnosis or lower rates of mental health service use among African Americans (Goodwin et al., 2001). In contrast, in a sample of hospitalized adolescents with bipolar disorder, African Americans were more likely than whites to receive antipsychotic medications, even though they had similar rates of psychosis (DelBello et al., 2000). Although confounding factors such as socioeconomic status might have contributed to these results, these data suggest the need for further investigation.
While such studies are also important for adults, children and adolescents are at a particularly vulnerable developmental period. For example, if similar rates of attention-deficit/hyperactivity disorder among whites and African Americans are found, yet stimulant medications are being under-prescribed for African Americans, this may result in increased rates of academic difficulties and school failure among African American children.Future Directions
Epidemiological studies, particularly those involving child and adolescent patients, are essential to assess whether there are actual ethnic differences in the rates of psychotic and mood disorders. However, if results of these investigations are similar to previous investigations, future efforts should be directed at teasing apart which of the potential explanations contributes to the ethnic disparity in clinical assignment of psychiatric diagnosis, as well as pharmacological treatment.