Mental health misdiagnosis twice more likely for socially disadvantaged groups
The shooting of an unarmed teenager in Ferguson, MO, has ignited a global discussion about implicit racial bias. One group of people you might think would be immune from this hidden bias is clinical therapists, people trained to understand the human mind. But a new field study finds that the social identities of patients and their therapists affect the accuracy of the diagnosis: Therapists were twice as likely to misdiagnose mental illness when their patients were members of a disadvantaged, compared to an advantaged, group.
In her own practice, Ora Nakash, a clinical psychologist at the Interdisciplinary Center in Herzliya, Israel, began wondering how the social identities of her clients were affecting her decision-making process. “For example, a White therapist can interpret affect disregulation symptoms of a client who is also White as rooted in financial pressures and diagnose him/her as having transient adjustment disorder,” she explains. “Conversely, if the client is African American, the same symptoms might be seen as proof of the client’s persistent borderline personality disorder.”
In a previous study, Nakash found that even with similar information collected during the mental health intake, clinicians weighed the information differently to assign a diagnosis depending on patients’ ethnicity or race. “Here, we wanted to check if the therapist’s social identity might impact the diagnostic decision-making process as well,” she says.
So Nakash and colleague Tamar Saguy took to the field, investigating regular practice in community mental health clinics in three large cities in Israel that serve mostly low- to middle-class populations. The study focused on differences between encounters involving Mizrahi (Jews of Asian/African descent) and Ashkenazi (Jews of European/American descent) patients.
“These ethnic groups are interesting both in the context of the Israeli society, as they make up the majority of the Jewish population in Israel, but also in the broader context of mental health disparities,” Nakash explains. “We know that minority groups, including migrants and ethnic minorities in many Western societies, tend to receive lower quality mental health care and may suffer from greater risks for mental illness.” Both the Mizrahi and Ashkenazi migrated early in the history of Israel, making it easier for the researchers to investigate the effects of belonging to a disadvantaged ethnic group while controlling for the effects of migration.
Why are Mental Health Issues Routinely Misdiagnosed?
It’s hardly a secret that in the mental health field, everyone gets their take; There is no definitive medical test for any mental illness, and most mental health professionals don’t have the time or resources to dig as deep as one hopes.
Do Mental Health Professionals Favor Certain Diagnoses?
In the 1970-80s eating disorders were en vogue, diagnosed at never before seen rates (partly due to increased awareness amongst medical professionals). The past decade has seen a dramatic rise in the diagnosis of Borderline Personality Disorder (and/or self-injury, which isn’t actually a diagnosis but let’s not be picky, shall we?).
Bias is part of the mental health system, whether we like it or not. Everyone, mental health professionals included, is prone to it: finding what they’re looking for. Infallibility doesn’t come with a medical license, a piece of paper on the wall.
Psychologists aren’t required to be objective, nor would I want them to be, but imagine:
You have a panic attack, end up in an emergency clinic because it feels like maybe you’re having a heart attack. They refer you to a psychiatrist.
Wouldn’t you feel more comfortable being given a label like Generalized Anxiety Disorder, and medication/s for said condition -not to mention the hefty pound of stigma that goes with it- if there were a better basis for it? If seeking a psychiatrist for a second opinion wasn’t quite so thoroughly frowned upon, or just plain hard to get? If asking questions, and acting as a self-advocate, wasn’t more likely to result in being treated as a problem rather than a patient?
People with mental health issues often have trouble communicating (symptoms)
Most psychotherapists/psychologists are not doctors, and most GPs aren’t qualified to diagnose a mental illness; They rely on psychiatrists just as much as we do.
There’s always the risk my experience won’t be expressed very well. Because it’s “just my own reflections” on what’s happening in my head, and whatever the professional in question happens to see on the day, the results are a best guess.
Which is OK but isn’t it about time they admit it?
The researchers followed patients during the intake sessions with their therapists. Afterward, they asked the patients to complete a separate structured diagnostic interview (called the MINI) with an independent interviewer. Therapists also completed study measures immediately following their sessions. Comparing the therapists’ evaluation with the evaluation obtained from the independent interview provided the researchers a measure of diagnostic accuracy.
Nakash and Saguy were surprised at the magnitude of the differences in the accuracy of diagnosis they found. “Even in a clinical setting, which offers conditions to overcome bias in decision-making - motivation to help, and time and space to collect ample information to overcome stereotypical thinking - we see that misdiagnosis is almost twofold when a socially advantaged therapist meets a socially disadvantaged client compared to seeing a socially advantaged client.” They also found that the quality of the rapport was worse in these encounters, as published today in the journal Social Psychological and Personality Science.
“This study is the first to empirically examine diagnostic accuracy in the context of mental health intakes when considering the identity of the client and therapist,” Nakash says. “If members of disadvantaged groups are more frequently misdiagnosed relative to advantaged group members as indicated by our findings, it is no surprise that the quality of the mental health services they receive, and their mental health outcomes, are worse.”
Bipolar disorder is a disabling psychiatric illness that is often misdiagnosed, especially on initial presentation. Misdiagnosis results in ineffective treatment, which further worsens the outcome. Major contributors toward misdiagnosis include lapses in history-taking, presence of psychiatric and medical comorbidities, and limitations in diagnostic criteria. Careful screening for symptoms of hypomania/mania and clinical features suggestive of bipolarity as well as use of collateral history and screening instruments, such as mood questionnaires, might help in limiting the rate of misdiagnosis.
Bipolar disorder is often misdiagnosed. Two surveys, one taken in 1994 and one taken in 2000, reveal little change in the rate of misdiagnosis.
As per the survey taken by the National Depressive and Manic-Depressive Association (DMDA), 69 percent of patients with bipolar disorder are misdiagnosed initially and more than one-third remained misdiagnosed for 10 years or more. Similarly, a survey done in Europe on 1000 people with bipolar disorder found a mean time of 5.7 years from the initial misdiagnosis to the correct diagnosis, while another study reported that on average patients remain misdiagnosed for 7.5 years.
Diagnosis of patients with bipolar illness can be challenging as most of these patients seek treatment only for depressive symptoms, and more often than not, the first episode of mood disturbance is depression rather than mania. Two studies in 1999 and 2000 concluded that almost 40 percent of bipolar disorder patients are initially diagnosed with unipolar depression. By DSM-IV criteria, patients need to have an episode of hypomania or mania and an episode of depression in order to be given the diagnosis of bipolar disorder I. The diagnosis of bipolar II disorder can be even more challenging as the criteria in DSM-IV can be overly restrictive, requiring a full symptomatic picture of mania with a duration of four days, while many experts believe that the average duration of the hypomanic state is 1 to 3 days. Furthermore, in bipolar II, it can be difficult to elicit a past history of hypomanic episodes from the patients. An episode of hypomania has a milder presentation than mania and can happen without impairment in functioning at work or in a patient’s social life, which may be why hypomanic episodes are unreported by the patients. In other words, the increased energy and heightened activity often experienced during hypomanic episodes may not be considered negative events by the patients who experience them.
The findings, they say, have important implications to clinical practice and training. They hope the study will be a call to action for the clinical community. “Our study has implications both to the need to rethink clinical training as well as increase the ethnic diversity of mental health providers.,” Nakesh says. “As consumers of mental health services, I believe clients should ask about their therapist’s experience and training working with diverse client population.” She adds that cultural competence training should be part and parcel of educational and training programs for all mental health providers.
As to why this dynamic occurs in the clinical setting, the researchers are still investigating potential reasons. It could be due to favoritism for people similar to the therapists or could be a result of cross-cultural difficulties. In future work, the researchers hope to study how different mechanisms, such as ability to take the other person’s perspective, may explain, or even help curb, some of the diagnostic bias.
“The ultimate goal of our work is to develop intervention programs for therapists training to improve diagnostic accuracy in the work with diverse client population,” Nakash says.
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The paper, “Social Identities of Clients and Therapists During the Mental Health Intake Predict Diagnostic Accuracy,” by Ora Nakash and Tamar Saguy, was published in Social Psychological and Personality Science online on March 16, 2015.
The journal Social Psychological and Personality Science is a collaboration from the Association for Research in Personality, the European Association of Social Psychology, the Society of Experimental Social Psychology, and the Society for Personality and Social Psychology, and is co-sponsored by the Asian Association of Social Psychology and Society of Australasian Social Psychologists.
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Lisa M.P. Munoz
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571-354-0754
SAGE Publications
Journal
Social Psychological and Personality Science