Dr Leesha Ellis-Cox Confronts Racial Bias, Diagnosis Disparities in Mental Health Care

Within the estimated 2.3 million Americans living with bipolar disorder, disparities persist in diagnosis rates, particularly among Black Americans.¹ In a written interview with The American Journal of Managed Care^® (AJMC^®), psychiatrist Leesha Ellis-Cox, MD, MPH, discusses how the lack of representation among Black health care providers, who comprise only 5.7% of US physicians,² plays a role in these disparities. Additionally, she addresses how social stigma, deep-rooted mistrust of the US health care system, and limited access to care further exacerbate the issue.

Leesha Ellis-Cox, MD, MPH

AJMC: What are some of the key reasons why African Americans are less likely to receive a correct diagnosis for bipolar disorder compared with other ethnic groups?

Ellis-Cox: According to a 2023 study published in Frontiers in Psychiatry, African Americans are 3 to 4 times more likely to be diagnosed with schizophrenia-spectrum disorders compared with White Americans.³ The implications of misdiagnosis can be far-reaching, from prescribing inappropriate medications to costly hospitalizations to the inability to obtain employment because diagnoses become labels that follow individuals to unnecessary involvement with the criminal justice system. Racial bias lies at the heart of misdiagnosis for Black people. Psychosis is overemphasized in African Americans while mood symptoms are minimized.

Psychosis refers to a disconnection from reality, characterized by hallucinations, paranoid and persecutory delusions, disorganized speech, and bizarre behaviors. Psychosis is a symptom experienced in various psychiatric disorders, such as major depressive disorder, bipolar disorder, and schizophrenia. However, mental health providers may incorrectly assume that the presence of psychotic symptoms in Black individuals is secondary to a psychotic illness like schizophrenia and not screen for the presence of a mood disorder that may better explain their clinical presentation. Anxiety and paranoia can also be misconstrued in African Americans, which can lead to misdiagnosis.

A 2020 poll conducted by the Kaiser Family Foundation found that 7 in 10 African Americans have experienced discrimination or mistreatment based on their race and almost half believed that their lives were in danger.⁴ Given these numbers, what might be deemed by some providers as an irrational fear of law enforcement would actually be a realistic and even an expected response by African American men and women living in the US. Without the use of a culturally informed approach in the evaluation and treatment of mental health in Black people, that individual is prescribed an antipsychotic medication rather than referred to therapy to address their trauma history and anxiety symptoms.

Lastly, because of stereotypes and racist tropes that persist, such as that of the angry Black woman and the violent, angry “Black Buck,” strong emotions like anger and rage may not elicit an empathic or curious response in White mental health providers. Instead, providers may see these responses as dangerous conditions that must be quickly subdued, not pain that should be explored.

AJMC: How does the underrepresentation of Black or African American providers in the health care system contribute to the challenges faced by Black Americans with bipolar disorder?

Ellis-Cox: While 14% of the population in the US is African American, according to the US Census, only 2% of psychiatrists identify as such.⁵ Statistics are similar in other fields where Black mental health professionals are underrepresented including psychology, therapists, and licensed counselors. The lack of representation among mental health providers has significant consequences.

Stigma is pervasive and leads many people of color to forego mental health treatment altogether. When they do seek treatment, it is exceedingly difficult to find a person of color to provide mental health services. Patients may not feel comfortable being honest about their symptoms or feel dismissed and invalidated when they elect to discuss their emotions. This can contribute to misdiagnosis, breakdown of the therapeutic alliance, and termination of treatment.

Without appropriate treatment, African Americans may experience worsening symptoms that end in job loss, substance use, self-harm, family turmoil, or death by suicide. A paucity of Black mental health providers also means that clinical research exploring barriers to care and the utility of evidenced-based pharmacologic and psychosocial treatments for mood disorders like bipolar disorder does not include Black study participants, limiting the applicability of the results.

AJMC: How does the mistrust of the US health care system among Black Americans affect their access to appropriate diagnosis and treatment for bipolar disorder?

Ellis-Cox: It has been said that racism is as American as apple pie, baked into the foundation of this country and its institutions. Much like housing, the criminal justice system, education, and the banking industry, the US health care system has its own sordid past when it comes to racism and discrimination.

During slavery, Dr Samuel Cartwright, a physician practicing in Mississippi and Louisiana, coined the terms “drapetomania” and “dysaesthesia aethiopica” to justify the cruel and inhumane treatment of African slaves forcibly brought onto American soil. He described drapetomania as a condition wherein enslaved people who desired freedom were deemed mentally ill and the cure was whippings. Dysaesthesia aethiopica was the name for the mental illness that caused enslaved people to be lazy, and harsh punishment was the cure for this disease, too.

Then, there was the 40-year Tuskegee syphilis experiment where the US government intentionally deceived almost 400 Black men and withheld medical treatment to examine the course of untreated syphilis. Over 100 men died as a result of this horrific study. There are countless other examples of medical maltreatment in the name of science, like conducting surgical procedures on enslaved women without consent or the use of anesthesia because many believed (and still do) that African Americans have a higher pain tolerance and thicker skin, or the tragic story of Henrietta Lacks. These experiences have led to mistrust and even fear of the medical community.

One might ask why a Black individual would willingly choose to seek out mental health services—especially from a non-Black provider—if he or she can’t trust the physician will honor the ethical principles of beneficence, nonmaleficence, and justice given America’s haunting past and the current socio-political climate.

AJMC: How can mental health providers better understand and address the unique social stigma surrounding mental illness within the African American community?

Ellis-Cox: Although race has been used as a scientific marker to explain biological differences, race is a poor proxy to explain genetic diversity. Race, quite simply, is a social construct with no biological meaning, but it has profound implications on the health and well-being of American people especially people of color. Race has been weaponized, wreaking harm and havoc, causing division, and contributing to poor health care outcomes and health care disparities. Countless studies demonstrate this, across multiple specialties.

To see meaningful change, mental health providers cannot deny the existence of racism nor fail to acknowledge the impact of racism on the mental health of and delivery of services to African American people. Implicit and explicit biases are real phenomena. In this line of work, a health care provider must maintain an open mind and consider that what they think they know, what they have been taught, and what they have internalized could be wrong. Adopting a position of curiosity rather than judgment is a powerful and thoughtful way to begin the delicate work of confronting and correcting internalized racial bias and lead to the dismantling of stigma around mental illness for African Americans.

When health care providers take on this task, on their own and through institutional and agency-wide training in cultural humility, they can better ensure that the unique and diverse emotional needs of patients who may not look like them are understood and addressed with professionalism, compassion, and cultural sensitivity. That’s when true healing and connection begin for both the provider and the individual seeking treatment.

AJMC: Do you have any closing thoughts?

Ellis-Cox: The late Reverend Dr Martin Luther King Jr said, “Of all forms of inequality, injustice in health care is the most shocking and inhumane.” This is an important topic, and we need to get this right for the health of our patients, communities of color, and our entire country. Elevating the health of the most impoverished, disenfranchised, and ignored elevates the health and well-being of everyone. I believe we can make a difference and profoundly change the mental health landscape if we commit to doing the good and hard work of examining and correcting our biases on an individual and organizational level through being thoughtful, curious, and always willing to learn.

References

1. Bipolar disorder and Black Americans. Mental Health America. Accessed February 2, 2024. https://www.mhanational.org/bipolar-disorder-and-black-americans

2. Boyle P. What’s your specialty? New data show the choices of America’s doctors by gender, race, and age. AAMCNews. January 12, 2023. Accessed February 2, 2024. https://www.aamc.org/news/what-s-your-specialty-new-data-show-choices-america-s-doctors-gender-race-and-age

3. Faber SC, Khanna Roy A, Michaels TI, Williams MT. The weaponization of medicine: early psychosis in the Black community and the need for racially informed mental healthcare. Front Psychiatry. 2023;14:1098292. doi:10.3389/fpsyt.2023.1098292

4. Poll: 7 in 10 Black Americans say they have experienced incidents of discrimination or police mistreatment in their lifetime, including nearly Half who felt their lives were in danger. News release. KFF. June 18, 2020. Accessed February 2, 2024. https://www.kff.org/racial-equity-and-health-policy/press-release/poll-7-in-10-black-americans-say-they-have-experienced-incidents-of-discrimination-or-police-mistreatment-in-lifetime-including-nearly-half-who-felt-lives-were-in-danger/

5. Black mental health. Black Mental Health Workforce. Accessed February 2, 2024. https://abpsi.org/blackmhworkforce/#:~:text=Nationally%2C%204%25%20of%20psychologists%20(,are%20reported%20to%20be%20Black