John J. Miller, MD:Sandy, what are some of the health inequities or social determinants of health that might limit the optimal treatment of schizophrenia?

Sandy Dimiterchik: This month [July] is Minority Mental Health [Awareness] Month. It’s a [good] time to look at the barriers to care that people who are minoritized face. There’s a lack of awareness, there’s a lack of access to quality care. I’ve experienced different systems, so to speak. I had a kind psychiatrist who only charged me $25, and he got me all my medications through samples for a couple of years. When I found myself at a homeless shelter or assisted living facility, there was a doctor who did a similar thing for the residents. They were so excited when they met me because I was taking atypical antipsychotic drugs, and they were still on the older versions. They went to the doctor and said, “Hey, Sandy’s taking this. What about us?” I’ve also experienced working through the county. That can be difficult because sometimes they do first come, first served, or it might take a while to get your appointment. I’ve also had private insurance, which of course private insurance was the best quality for me.

John J. Miller, MD: Thank you for sharing that.

Caroline P. Carney, MD, MSc, FAPA, FAPM, CPHQ: Dr Miller, could I jump in on that?

John J. Miller, MD: Please, Dr Carney.

Caroline P. Carney, MD, MSc, FAPA, FAPM, CPHQ: I think one of the things we see building, Sandy, on what you’re saying in terms of social determinants, often is related to the negative symptoms and the cognitive symptoms an individual has in terms of their ability to be able to ultimately navigate life, depending on the severity of schizophrenia. [This includes the ability] to pay bills, to keep the heat on, to be able to have enough executive planning to go to the grocery store, bring home food, make meals, to do the tasks that the disease itself influences the ability to do. And what ends up happening is a compounded effect. There is another issue in terms of the positive symptoms that may be frightening to family members or social supports. Individuals tend to lose that critical part of living in terms of having that social support and community. And that as we know is a huge predictor of how well a person does over time.

John J. Miller, MD: Thank you for that.

Nev Jones, PhD: Just a few things I would add there as well. One, in terms of the big picture, what we know from the psychiatric epidemiology literature is that many major determinants of health, including poverty, childhood adversity, and neighborhood adversity, are among the strongest predictors of developing psychosis. Just the onset of psychosis itself is heavily shaped by underlying social and structural determinants. Then those same determinants proceed to influence every aspect of access to treatment and services, the quality of services once people are able to access them in some way, as well as long-term outcomes. We see ethno-racial disparities at every single one of those junctures.

In the United States, African Americans are 3 to 4 times as likely to be diagnosed with schizophrenia and experience poor services, poor access, and poor outcomes along the pipeline. I also think it’s really important to emphasize that some of that has to do with experiences of services. We know that during initial pathways to care, members of minoritized ethno-racial groups are much more likely to experience coercion, seclusion, and restraint in inpatient environments, which in turn impacts treatment engagement for very good reasons. People who have had bad experiences with the system don’t necessarily want to continue. I think one of the biggest challenges probably of the times we’re in, in 2023, in light of Black Lives Matter, is seriously engaging with these disparities as they play out across every aspect of what those of us working in psychosis services or community mental health as well as on the private side are facing here.

Transcript edited for clarity.