Examining Ethnoracial Disparities in the Prevalence of Schizophrenia Spectrum Disorders

SPECIAL REPORT: SCHIZOPHRENIA

CLINICAL CONVERSATIONS

A 2025 study aimed to identify ethnoracial disparities in the prevalence of schizophrenia spectrum disorders and positive psychotic symptoms in the US, as well as the role of social neighborhood inequities on said disorders. Investigators found there was a higher prevalence among minority groups, particularly Black individuals, and this was connected to social inequities and community-level vulnerabilities and associated with structural racism.¹ To better understand these findings, Psychiatric Times sat down with one of the study authors, Mark Olfson, MD, MPH.

Psychiatric Times: Last year, you were part of a study that examined the ethnoracial disparities in the prevalence of schizophrenia spectrum disorders.¹ Can you share more information about the conclusions of that study? What finding surprised you most?

Mark Olfson, MD, MPH: We analyzed a nationally representative household sample of clinician-administered structured diagnostic interviews. We found that non-Hispanic Black and multiracial adults had a higher prevalence of schizophrenia spectrum disorders and psychotic symptoms compared with non-Hispanic White individuals. When we accounted for neighborhood social vulnerability, which captures structural social determinants such as socioeconomic disadvantage and housing instability, the Black-White disparities in prevalence of schizophrenia spectrum disorders and psychotic symptoms were substantially reduced and no longer statistically significant. These findings suggest that structural neighborhood inequities may explain a meaningful portion of these disparities.

The mechanisms through which these social determinants exert their effects remain unclear. Although several pathways are possible, one hypothesis is that higher rates of perinatal complications in socioeconomically disadvantaged neighborhoods, potentially related to limited access to high-quality prenatal care, maternal stress, and other environmental exposures, may contribute to the association between structural social determinants and risk of psychosis.

PT: Black youth with first-episode psychosis experience critical disparities in care. What tips or insights can you offer your peers to help improve care for this vulnerable population?

Olfson: For Black youth with first-episode psychosis, it is important to prioritize rapid engagement in coordinated specialty care and minimize delays in treatment, as Black patients often experience longer durations of untreated psychosis. Building trust through culturally responsive care is also critical. This includes acknowledging the historical and contemporary reasons for mistrust of the mental health system, involving family and community supports when appropriate, and being attentive to bias and assumptions that may contribute to misdiagnosis.

Psychiatrists and mental health clinicians should also connect patients with social services that address key social determinants, such as housing instability, transportation barriers, insurance gaps, and food insecurity. These factors can affect treatment engagement and outcomes. Clinicians should further remain mindful of potential diagnostic and treatment biases, including the tendency for Black patients with affective or trauma-related symptoms to be more readily diagnosed with schizophrenia spectrum disorders. Finally, building partnerships with community organizations, schools, and primary care clinicians can help accelerate early identification and improve continuity of care.

PT: Social determinants of health are returning to the DSM, as per the new proposed framework. Do you believe this will make a difference in patient outcomes?

Olfson: Greater emphasis on social determinants of health within the DSM framework has the potential to make a meaningful difference for patients. Explicitly incorporating social determinants of health into the diagnostic formulation might encourage psychiatrists to more systematically evaluate factors such as housing instability, financial strain, and neighborhood conditions that can influence the onset and course of treatment.

By making these factors more visible in the clinical formulation, the DSM could help psychiatrists and other mental health clinicians tailor treatment plans, connect patients with appropriate supports, and advocate for resources to overcome barriers to care. While it would be unreasonable to expect that documentation alone will eliminate long-standing inequities, integrating social context into routine psychiatric assessment is an important step toward patient-centered and responsive care and, ultimately, improved outcomes.

PT: What research needs to be done to improve real-world outcomes for Black Americans with schizophrenia?

Olfson: As a White psychiatrist, I approach this question with humility and an awareness of the limits of my lived experience. With that in mind, research aimed at improving outcomes for Black Americans with schizophrenia should focus on understanding and addressing the structural and social factors that influence risk, diagnosis, access to care, and recovery.

Important priorities include examining how structural determinants, such as neighborhood disadvantage, systemic racism, and economic inequality, affect the onset of psychosis and long-term outcomes. Research might further investigate barriers to timely and continuous care, including disparities in insurance coverage, geographic access to specialty services, and availability of early-intervention programs. Studies examining access to coordinated specialty care may be particularly important, given the strong connection between early treatment and long-term prognosis.

There is also a need to better understand diagnostic processes and potential sources of bias that contribute to well-documented racial disparities in schizophrenia diagnoses. Clinician decision-making, institutional practices, and structural influences on diagnostic patterns are all underdeveloped research areas that could promote improved diagnostic accuracy and help ensure patients receive appropriate care.

Further work might evaluate culturally responsive and community-engaged models of care that strengthen trust, integrate family and community supports, and address social needs alongside psychiatric treatment. Implementation research is important to determine how effective interventions can be delivered equitably in real-world settings. Finally, research is needed to evaluate how health care systems and public policies, including those related to housing, disability benefits, crisis response, and the criminal justice system, influence outcomes for Black individuals with schizophrenia and other serious mental illnesses.

PT: What do we know about the physician-patient alliance and its relationship to medication adherence and general outcomes in schizophrenia?

Olfson: A strong physician-patient alliance has been consistently associated with better outcomes in schizophrenia, including improved adherence to antipsychotic medications. Patients who feel heard, respected, and involved in their treatment decisions are more likely to take medications as prescribed, remain engaged in care, and continue follow-up. Conversely, weak alliances, especially when treatment is inadequately explained or perceived as coercive, can undermine adherence and increase the risk of relapse. For psychiatrists, investing time in shared decision-making, transparent discussions about benefits and adverse effects, and collaborative goal setting can strengthen the therapeutic alliance and support recovery.

PT: How does race impact metabolism of antipsychotic medications, and what should clinicians consider when prescribing and monitoring?

Olfson: There are no consistent pharmacokinetic differences between Black and White patients that justify different antipsychotic dosing based on race. Most antipsychotics are metabolized through hepatic enzymes such as CYP2D6 and CYP3A4. While genetic polymorphisms in these pathways can influence drug levels, these variants occur across all populations and vary widely among individuals, frequently more within than between racial groups. As a result, race is not a proxy for pharmacokinetics. A more clinically useful approach involves individualized prescribing and close clinical monitoring of effectiveness and adverse effects.

Dr Olfson is the Elizabeth K. Dollard Professor of Psychiatry, Medicine, and Law at Columbia University Medical Center (CUMC), a professor of epidemiology at CUMC, and a research psychiatrist at the New York State Psychiatric Institute.

Reference

1. Anglin DM, Olfson M, van der Ven E, et al. Neighborhood social vulnerability and racial disparities in schizophrenia spectrum disorder prevalence. Am J Psychiatry. 2025;182(9):850-860.