In the United States, race and ethnicity have a significant impact on psychiatric diagnosis and treatment.³^–⁵ Moreover, the need to reduce disparities in the mental health care of racial and ethnic minorities was recently underscored by the United States Surgeon General.⁶ African Americans are frequently misdiagnosed as having schizophrenia when instead they have bipolar disorder or a psychotic depression. Depression is frequently under-recognized and under-treated among Asian Americans as they tend to under-report their affective symptoms.⁷ Moreover, treatment approaches and responses often differ depending on the diagnosis. The reasons for misdiagnosis are complicated. They include the fact that individuals from some ethnic or cultural backgrounds may not seek treatment until later in the course of their illness than do Caucasian individuals; this results in the perception of a more severe illness.⁵ The late presentation may, in part, be related to mistrust of the health care system, lack of familiarity of what mental health services are about, and fear of stigma associated with mental illnesses. Physician biases also play a major role in misdiagnosis. Psychiatric diagnoses are often established by eliciting symptoms from patients that are then interpreted by the psychiatric expert. Many disorders have overlapping symptoms and can be used to support one diagnosis or to disregard another. In the case of African Americans, affective symptoms are frequently ignored and psychotic symptoms are emphasized. This pattern has also been seen in other ethnic populations, including Hispanics, some Asian populations, and the Amish (in the United States). African American patients are also more likely to receive higher doses of antipsychotics, to receive depot preparations, to have higher rates of involuntary psychiatric hospitalizations, and to have significantly higher rates of seclusion and restraints while in psychiatric hospitals.^3,^5,⁸ The tendency is to oversedate such patients to reduce their “risk of violence” despite, in some cases, little evidence that the patient has ever been violent. These biases in psychiatric treatment continue and must be addressed.

Differences in Presentation of Illness

Cultural differences in the presentation of psychiatric illnesses abound. For instance, a Cambodian woman may complain of dizziness, fatigue, and back pain, while she ignores other neurovegetative symptoms and is unable to describe feelings of dysphoria. American mental health care providers are generally unfamiliar with various Indo-Chinese culture-bound syndromes and with the meaning attributed to those symptoms by various cultures.^9,¹⁰ For example, common American expressions such as “feeling blue” cannot be readily translated into Indo-Chinese languages. A Cambodian clinician will ask Cambodian patients if they “feel blue” by using Cambodian terms that literally translate into “‘heavy, overcast, gloomy.” The Laotian way of describing “feeling tense” is feeling like a “balloon blown up until it is about to burst.” Westermeyer,¹¹ in a case-controlled study in Laos, documented the general inability of Western psychiatrists to recognize the Laotian symptoms of depression. Similarly, many depressed Chinese Americans who seek help in primary care clinics complain mostly of physical symptoms, and minimize their depressed mood.

Depression may be missed by psychiatrists and by primary care physicians who search for biological and structural reasons for complaints (such as back pain, headaches, and dizziness). Oftentimes afflicted patients are treated with meclizine for dizziness and analgesics for pain, where an antidepressant would have been most appropriate.

From a cross-cultural perspective, evaluating the meanings of bizarre delusions, hallucinations, and psychotic-like symptoms remains a clinical challenge. A nonpsychotic patient may admit to hearing voices of her ancestors (a feature that is culturally appropriate in certain cultural groups). In many traditional, non-Western societies, spirits of the deceased are regarded as capable of interacting with and possessing those still alive. It is difficult to determine whether symptoms are bizarre enough to yield a diagnosis of schizophrenia without an adequate understanding of a patient’s sociocultural and religious background. On the other hand, caution must be taken not to assume that bizarre symptoms are culturally appropriate when in fact they are a manifestation of psychosis. The use of bicultural and bilingual interpreters, along with the search for information from other sources (such as family, community leaders, or religious officials), may help to determine whether an individual’s experience is culturally appropriate or acceptable.

Additionally, while a great deal of attention has been paid to the study of panic disorder in Caucasians, little empirical research within the United States has looked at the phenomenology of panic disorder among minority groups. Compared to Caucasians, African Americans with panic disorder report more intense fears of dying or going crazy, higher levels of numbing and tingling in their extremities, and higher rates of co-morbid posttraumatic stress disorder (PTSD) and depression.¹² African Americans also use somewhat different coping strategies (e.g., religious practice and counting one’s blessings) and endorse less self-blame. The incidence of isolated sleep paralysis is also higher in African Americans.¹²