freakoutcrazy

Blog des AK Psychiatriekritik der NFJ Berlin

Monat: Juni, 2012

Atypical antipsychotics are associated with incident diabetes in older adults without schizophrenia or bipolar disorder

by ebmh

Question

Is atypical antipsychotic use associated with incident diabetes or hyperlipidaemia in older people without schizophrenia or bipolar disorder?

People

Medicare advantage or commercial managed healthcare plan enrolees aged 65 and above with no history of schizophrenia, bipolar disorder, diabetes (for the hyperlipidaemia study) or hyperlipidaemia (for the diabetes study) in the previous year. In the diabetes study, cases were 13 075 people who initiated diabetes treatment between 2004 and 2008 (identification period), and controls were 65 375 people who had not received diabetes treatment during this time. In the hyperlipidaemia study, cases were 63 829 people newly started on hyperlipidaemia medication, and controls were 63 829 people who had not received hyperlipidaemia medication. Controls were matched to cases based on age, sex, health plan type and index date. The index date for cases was the date of first diabetes or hyperlipidaemia medication prescription fill. For controls, the index date was a randomly selected date in the identification period.

Setting

USA; from 2003 to 2008.

Risk factors

Atypical antipsychotic exposure in the year prior to diabetes or hyperlipidaemia treatment initiation (preindex period), identified using pharmacy claims data. Medications considered as atypical antipsychotics were aripiprazole, clozapine, olanzapine, paliperidone, quetiapine, risperidone and ziprasidone. Participants taking atypical antipsychotics were stratified according to the drug prescribed, dose and the number of days of exposure during the year before the index date. Analyses were adjusted for the overall burden of comorbidities (assessed using the Charlson Comorbidity Index) during the preindex period, and specific comorbidities including diabetes (in the hyperlipidaemia study), hyperlipidaemia (in the diabetes study), hypertension, obesity, dementia, depression, anxiety and adjustment disorders. The hyperlipidaemia study additionally adjusted for stroke, coronary heart disease or ischaemic heart disease as indicators for cardiovascular disease.

Outcomes

Incident onset of treatment-dependent diabetes or hyperlipidaemia.

Methods

Design

Two case control studies.

Follow-up period

One year.

Main results

During the preindex period, 1.3% of diabetes cases had been exposed to an atypical antipsychotic compared with 0.8% of controls (OR 1.32, 95% CI 1.10 to 1.59). A greater overall burden of comorbidity, diagnosis or treatment of hyperlipidaemia or hypertension, and diagnosis of obesity or dementia were all associated with increased odds of initiating diabetes treatment, while an anxiety diagnosis was associated with decreased odds of initiating diabetes treatment. In the hyperlipidaemia study, 0.8% of cases had been exposed to an atypical antipsychotic during the preindex period compared with 1.0% of controls (OR 0.76, 95% CI 0.67 to 0.87). Greater burden of comorbidity, diagnosis or treatment of diabetes, depression, obesity or cardiovascular disease during the preindex period was associated with increased odds of initiating hyperlipidaemia treatment. A diagnosis of dementia or adjustment disorders was associated with decreased odds of initiating hyperlipidaemia treatment.

Conclusions

In older adults, treatment with atypical antipsychotics for conditions other than schizophrenia and bipolar disorder is associated with increased odds of incident medication use for diabetes, and reduced odds of incident medication use for hyperlipidaemia.

Notes

Onset of diabetes or hyperlipidaemia may have preceded initiation of drug treatment, as lifestyle modification may have been tried before initiation of drug treatment.

Abstracted from

Erickson SC, Le L, Zakharyan A, et al. New-onset treatment-dependent diabetes mellitus and hyperlipidemia associated with atypical antipsychotic use in older adults without schizophrenia or bipolar disorder. J Am Geriatr Soc 2012;60:474–9.

Footnotes

  • Sources of funding Not reported.

This paper is freely available online under the BMJ Journals unlocked scheme, see http://ebmh.bmj.com/info/unlocked.dtl

Advertisements

Maternal antidepressant use and adverse outcomes: a cohort study of 228,876 pregnancies

by ajog

Objective

The purpose of this study was to describe antidepressant medication use patterns during pregnancy and pregnancy outcomes.

Study Design

We evaluated a cohort of 228,876 singleton pregnancies that were covered by Tennessee Medicaid, 1995-2007.

results

Of 23,280 pregnant women with antidepressant prescriptions before pregnancy, 75% of them filled none in the second or third trimesters of pregnancy, and 10.7% of them used antidepressants throughout pregnancy. Filling 1, 2, and ≥3 antidepressant prescriptions during the second trimester was associated with shortened gestational age by 1.7 (95% confidence interval [CI], 1.2–2.3), 3.7 (95% CI, 2.8–4.6), and 4.9 (95% CI, 3.9–5.8) days, when controlled for measured confounders. Third-trimester selective serotonin reuptake inhibitor use was associated with infant convulsions; adjusted odds ratios were 1.4 (95% CI, 0.7–2.8); 2.8 (95% CI, 1.9–5.5); and 4.9 (95% CI, 2.6–9.5) for filling 1, 2, and ≥3 prescriptions, respectively.

Conclusion

Most women discontinue antidepressant medications before or during the first trimester of pregnancy. Second-trimester antidepressant use is associated with preterm birth, and third-trimester selective serotonin reuptake inhibitor use is associated with infant convulsions.

Some Antidepressants Increased Risk of Death in ICU

by Clinical Endocrinology News

Patients on selective serotonin reuptake inhibitors or serotonin norepinephrine reuptake inhibitors when they were admitted to an intensive care unit were 73% more likely to die in the hospital, compared with ICU patients who were not on these antidepressants, a retrospective study found.

Dr. Katherine M. Berg and her associates analyzed electronic records from admissions to four ICUs in 2001-2008 to compare outcomes for 1,876 patients who were on a selective serotonin reuptake inhibitor (SSRI) or serotonin norepinephrine reuptake inhibitor (SNRI) and 8,692 control patients who were not taking an SSRI or SNRI before admission.

The mortality risk remained elevated at 1,000 days after ICU admission, she reported in a late-breaking poster presentation and discussion session at an international conference of the American Thoracic Society.

Certain subgroups were at even greater risk of dying in the hospital if they were on an SSRI or SNRI when admitted to the ICU. Patients who had acute coronary syndrome or had undergone cardiac surgery were more than twice as likely to die if they were on an SSRI/SNRI when entering the ICU, compared with controls, said Dr. Berg, a pulmonary/critical care fellow at Massachusetts General Hospital and Harvard University, Boston.

The increased mortality risk appeared to be associated mainly with medications that have higher degrees of serotonin reuptake inhibition. „Citalopram, which is a lower-potency drug, by itself did not incur a higher mortality risk, but sertraline, which is one of the more potent drugs, did. Even comparing the two drugs to each other, if you were on sertraline, your mortality risk was higher“ than if you were on citalopram, Dr. Berg said in an interview.

Fluoxetine, paroxetine, and sertraline were associated with significantly higher mortality, but no significant mortality differences were seen between patients on citalopram or escitalopram and control patients.

Of the 8,692 control patients, 7% died in the hospital, compared with in-hospital death rates of 10% in 286 patients on fluoxetine, 13% in 320 patients on paroxetine, and 15% in 426 patients on sertraline at the time of ICU admission. The remaining 844 patients were on other antidepressants.

The study adjusted for the effects of each patient’s age, Simplified Acute Physiology Score, and combined Elixhauser comorbidity score on in-hospital mortality risk.

Slight but statistically significant differences in the characteristics of the two groups included a greater proportion of women in the SSRI/SNRI group, compared with controls (57% vs. 40%), and a higher prevalence of diabetes (21% vs. 17%) or chronic obstructive pulmonary disease (11% vs. 7%) in patients on an SSRI/SNRI, compared with controls. Patients in the SSRI/SNRI group were more likely to have an infection than were controls (11% vs. 8%), but less likely to have acute coronary syndrome (8% vs. 10%) or cardiovascular disease (67% vs. 70%).

Further studies are needed to ascertain if this is a causal relationship or just an association between SSRI/SNRI use and mortality in ICU patients, she said. The findings are limited by the retrospective nature of the study, which also was unable to control for the effects of potentially important confounders such as smoking status or the presence of depression.

The data came from the Multiparameter Intelligent Monitoring in Intensive Care II database, a public collection of data with patient identifiers removed.

Antidepressants were the most commonly prescribed medication class in the United States in 2011, and SSRIs were the most common type of antidepressant, she said. SSRI use has been associated with increased risk of bleeding, falls, bradycardia, and stroke in previous studies, which also suggest a possible protective effect of SSRIs in patients with coronary artery disease.

Dr. Berg reported having no financial disclosures.

Chemical Imbalances and Other Black Unicorns

by MadinAmerica

“What do you think caused your problems?,” I asked.

“I have a chemical imbalance, a chemical imbalance, an imbalance in the brain that makes me ill.”

Sarah* had a diagnosis of bipolar disorder. Since her adolescence she had become acquainted with dark, shifting moods that meant she was sometimes uncontrollable and frenzied, and other times found it so effortful to live that she would retire to her bed for weeks, not eating, not bathing, not sleeping. Her every waking moment was spent contriving her own end, but to do that was too effortful itself.

Sarah joins an ever-growing troupe of patients who tell me that they have a chemical imbalance in their brain. Some have been told this by psychiatrists, others by their relatives, others still from mental health charities. None have heard this term from me. The notion that mental illnesses are caused by chemical imbalances is neither true, nor helpful. Worse still, the idea of mental illnesses as chemical imbalances is making us ill.

 

Medical or a Marketing Term

The term ‘chemical imbalance’ is not a medical or scientific term. Indeed a quick scientific literature search will show that the term is conspicuous by its absence. Despite this, patients and their families are often told by their physicians that their problems are caused by a chemical imbalance in the brain. Most pharmaceutical advertising for psychiatric drugs also tells consumers that mental illnesses are caused by chemical imbalances. The wide array of information for patients and their families on mental illness also frequently couches mental disorders as due to chemical imbalance. At once so simple and yet technical, it is easy to see why so many people find the idea their problems are due to chemical imbalances so compelling. It provides a simple explanation during a time when individuals crave certainty, and is packaged in the respectable veneer of pseudo-medical jargon. Make no mistake, however. There is only one reason why we have ‘learned’ that mental disorders are caused by chemical imbalances. To sell more drugs. There is one main reason too, why doctors tell their patients their problems are due to chemical imbalances. To convince people to take these drugs.

It was supposed to be a beautiful narrative. A previously well person becomes depressed, feels too listless and tired to live. A chemical imbalance is identified as the perpetrator. The ‘chemical imbalance’ is corrected with an antidepressant, and the patient is restored to her previous self. It is a story of restitution. It is a story where medicine is the hero and bad biochemistry the villain. It is a story with no basis in reality. Instead, we have convinced individuals that they are in some way defective and in need of lifelong treatment.

Making Us Sick

When a physician prescribes an antidepressant, he cannot but help but also prescribe an idea. He may not wish to prescribe the idea, indeed, he often is not aware he is prescribing the idea, but the physician nevertheless is prescribing the idea. The idea is that the problem is a chemical one, with a chemical solution. If it is a chemical problem, then it is largely outside of one’s control. The source of distress is no longer rooted in the fabric of society, interpersonal discord, a life story punctuated by loss, trauma and abuse, but it is located within the individual. It is located within the brain. Suddenly, the problem is no longer unemployment, widening inequality, social disadvantage, or alienation: the problem is you.

Once individuals become inculcated in dealing with their problems with psychiatric medication, they often increasingly see their emotions and life problems as outside their control. Further, they have little problem with medicating away emotions within the usual scope of mental life. It is not unusual for such patients who are a little upset, a little anxious, or angry, and mostly understandably so, to dull away these feelings with a dose of antipsychotic or benzodiazepine. In doing so, they undermine their coping skills and ability to tolerate the rich array of emotions threaded into the tapestry of life.

The most troubling aspect of the message is, instead of one of resilience and recovery, it is one of vulnerability and reliance. Although part of the reason why antidepressants ‘work’ is the idea provides a lifeline to an individual as a message of hope, this is transient. Eventually, patients come to wonder, ‘If I have a chemical balance, won’t it come back if I stop taking this pill?’ or ‘If antidepressants are like insulin for diabetes, don’t I need to take this forever?’ Whilst antidepressant prescriptions have on the whole been rising, the number of new prescriptions for antidepressants has not been increasing year on year. This fits with epidemiological data that show that the number of new cases of depression has actually been decreasing, but the total number of people depressed has been increasing2. What this suggests is not that more people are becoming depressed, but that fewer people are getting better. It is not so much we are all becoming depressed, but when we do, we’re staying that way. In convincing people that they have a chemical imbalance, we have disempowered them to look at how they can change their life for better, and instead made them reliant on medication. As a result instead of making people better we have kept people sick.

 

The New Phrenology and the Eclipse of the Social World

Today, the majority of research into the causes of mental distress focuses on neuroimaging and genetics. There are other niche interest including immunology, endocrinology, and proteomics, but on the whole, most research is biologically-oriented and focuses on brain scanning and genes. This has come at the expense of research into the social world in which people become depressed, go manic, or have psychotic experiences.

Now we should not ignore avenues of research that have the potential to transform our understanding and help individuals. My contention is that, with the possible exception of dementia, not a single patient has actually benefited from any neuroimaging research. Despite billions of research dollars, many at the public expense, not a single treatment or innovation has come out of this funding. In contrast, the finding that the relapse rate for schizophrenia was higher in families with high expressed emotion led to the development of family therapies, the finding that depression followed particular life events led to the development of interpersonal therapy, and the finding that women lacking a close confiding relationship were more likely to develop depression led to the development of befriending programs for depressed women. Yet, it has become exceedingly hard to get research funding to explore further the social and environmental determinants of health. If I wanted to do a study neuroimaging manic hedgehogs, I would not find much difficulty getting funding. On the other hand, If I wanted to explore the role of social support in outcomes for those who have psychotic experiences, it would be an uphill battle.

It comes as no surprise that when there is a Republican administration, research exploring the social determinants of mental health dwindles, and there is more funding for biological research. The obfuscation of the wider social determinants of mental distress is deliberate. Unfortunately, we have become so obsessed with finding the elusive cause of mental illness using new technologies, we have become complicit in forgetting about the determinants of our mental health in the social world.

Like a black unicorn, we have cultivated a dangerous mythology in the promotion of the notion that mental illnesses are due to chemical imbalances. Whilst there is of course a biological basis to our emotions, thoughts and behaviors, this level of explanation is unhelpful because it ignores what our feelings and experiences of living mean, and ignores the context in which we experience joy, love, anger, sadness and fear. By convincing individuals that their problems are due to chemical imbalances, we have succeeded not only in creating a generation who has recoded their moods and feelings into neurochemicals, we have undermined their ability to manage these problems themselves. Most troubling of all, the notion of chemical imbalances has transformed mental illnesses from temporary aberrations of mental states understandable within a particular context, to permanent disorders of the self embedded in the brain.

*Sarah represents a composite of different patients and not one individual.

A Post-Racial Public Mental Health System: If Not Now, When?

by MadinAmerica

 In answer to the question posed in the title to this article, probably not for a long, long time. Or perhaps more accurately, when the entire country does.

We often seem to forget that the public mental health system reflects the larger social system of which it forms part. To judge from the pronouncements that emanate from local and Federal governmental agencies, many of us, whether providers or peer/survivors, continue to define our reality and our own identities within a parochial system that seeks to avoid harsh realities. Specifically, it ignores poverty, as I’ve written in earlier articles, and makes use of euphemism to protect the sensibilities of those in the system who have power. The best example of the latter is the willingness of government agencies in New York State and elsewhere to promote discussions of “multi-culturalism”, yet no word about racism.

Now it’s hard to quarrel with multi-culturalism: no victims and no victimizers, validation of cultural self-identity and pluralism, promotion of public amity. On the other hand, when you talk about racism, there’s bound to be discord and a lot of apprehension. I was introduced to multi-cultural training in the early 1990’s by Anita Pernell Arnold, an African-American social worker, who established multi-cultural training institutes in Philadelphia and Cleveland. When I look back at those times –I was a visiting faculty member at both venues, teaching courses about Irish- and Italian-Americans, my cultural heritage – I can see more clearly now that Pernell-Arnold’s intent was to level the playing field, to demonstrate that inter-group differences were cultural rather than innate, that each hyphenated American ethnic group’s social worth was equal one to the other. Racism, which would have involved examining the social and institutional forces that drove it, was not discussed.

We didn’t think we had the language — and certainly lacked the will – to talk about it. We were still in thrall then to the rhetoric of Nixon’s “Southern Strategy”, which played on white Southerners’ resentment of black Southerners’ restored citizenship; of Reagan’s “welfare queens”, which depicted African-Americans as welfare state freeloaders; and Bush I’s “Willie Horton”, all-black-men-are- violent-criminals, video. And then we saw Rodney King – who died a few days ago, on June 17 at the age of 47 – on a home video get the hell beaten out of him by LAPD cops, renowned for their hatred of blacks and Latinos; we saw an all-white jury in Simi Valley, at the outer reaches of L.A. County, set free the four white cops charged with assaulting Mr. King; and then we saw South Central LA erupt in rage and flames, a self-destructive act and the hallmark of an oppressed, victimized people. Now those of us who needed it had the proof, on videotape, of institutionalized violence against people of color, and the pictures and their graphic portrayal of specific acts of violence gave us the words and the moral imperative to begin speaking out.

It took nearly twenty years after Rodney King’s beating, but in 2010 two landmark books were published, Michelle Alexander’s The New Jim Crow: Mass Incarceration in the Age of Colorblindness, and The Protest Psychosis: How Schizophrenia Became a Black Disease, by Jonathan Metzl. Both are “must” reading for anyone in this country concerned with social justice. Both document the purposefully discriminatory treatment meted out over the past forty years to African-American men caught up in the criminal justice and public mental health systems, two of the principal agencies of social control in our society. Metzl tracks the evolution of the application of the diagnosis of schizophrenia to African-American men in a state forensic psychiatric hospital outside of Detroit in the early 1970’s. To sum up his hypothesis, the behavior of African-American men at that time, when many were protesting their continued oppressed status despite the restoration of their civil rights, was pathologized and criminalized solely because they were African-American men. I’ll discuss Metzl’s work and its present-day implications in the latter part of this article.

Alexander’s work has garnered greater notoriety because of the forcefulness of the arguments she presents and the sheer weight and drama of her corroborating statistics. Her fundamental contention is that Jim Crow, or a racial caste system, is alive and well in 21st Century America. Her proof?
• “There are more African-American adults under correctional control today … than were enslaved in 1850 …
• As of 2004, more African American men were disenfranchised (due to felon disenfranchisement laws) than in 1870, the year the 15th Amendment was ratified, prohibiting laws that explicitly deny the right to vote on the basis of race.
• A black child born today is less likely to be raised by both parents than a black child born during slavery …
• … a large majority of African-American men in some urban areas have been labeled felons for life. (In the Chicago area, the figure is nearly 80%.) … They can be denied the right to vote, automatically excluded from juries, and legally discriminated against in employment, housing, access to education, and public benefits, much as their grandparents and great grandparents were during the Jim Crow era.”

Bureau of Justice Statistics data from yearend 2010 support Alexander:
• Black non-Hispanic males had an imprisonment rate … that was nearly 7 times higher than white non-Hispanic males …
• Black non-Hispanic females … had an imprisonment rate nearly 3 times that of white non-Hispanic females …
• An estimated 7.3% of black males ages 30-34 were in state or federal prison.

Critics have countered that African-Americans simply engage in more criminal and violent behavior. Alexander’s response? “… The main driver has been the War on Drugs. Drug offenses alone accounted for about two-thirds of the increase in the federal inmate population and more than half of the increase in the state prison population between 1985 and 2000, the period of our prison system’s most dramatic expansion.” She quotes H.R. Haldeman, White House Chief of Staff for Richard Nixon, who called for the first “war on drugs”: “[T]he whole problem is really the blacks. The key is to devise a system that recognizes this while not appearing to.” Reagan declared another war on drugs in 1982 and persuaded Congress to fund it. As per Alexander, “… The drug war was part of a grand and highly successful Republican strategy of using racially coded political appeals on issues of crime and welfare to attract poor and working class white voters who were resentful of and threatened by desegregation, busing and affirmative action …”

Too conspiratorial for you? Peter Dale Scott, social critic and author of Deep Politics and the Death of JFK (1996), has co-authored three books (1987, 1998, 2003) that detail the role of the CIA in shepherding heroin shipments from the Golden Triangle in southeast Asia (Burma, Thailand, Laos), through Marseilles (the French Connection) into the U.S. in the 1950’s, ‘60’s and ‘70’s; and in coordinating the smuggling of cocaine from Colombia through Nicaragua and into the U.S., with the proceeds from its sale funneled to Iran for guns for the anti-Sandinista contras in the 1980’s. His third book tracks the travels of raw heroin from Afghanistan to Pakistan to purchase CIA-supplied guns for the Afghani mujahedeen in the 1990’s. And where did all those drugs wind up? I can’t help remembering the scene in “The Godfather, Part II,” when Mafia overlords are discussing where to unload the heroin they’re bringing into the country? One of them says, “We’ll sell it to the schwarzes … they’re animals!” From Coppola’s and Puzo’s imaginations, of course, yet plausible. Although a good deal of heroin wound up in Harlem (c.f. Ridley Scott’s “American Gangster’) most of those drugs wound up all over the U.S., evidence, as per Dale Scott, of the widespread corruption that pervades this country.

Fortunately, there has been some pushback from advocates and affected family members. In 2010, with the passage by Congress of the Fair Sentencing Act, the Federal criminal penalties for possession of crack cocaine were reduced to a level more in line with those for powder cocaine. For the preceding quarter century, Federal prison sentences had been much more severe for possession of crack, a cheaper drug presumably favored in poor, often black communities. Scientific evidence accumulated since the 1990’s revealed that both forms of cocaine were equally addictive, removing the rationale for the sentencing disparities and making clear, as the advocates contended, the unmistakable racial bias of the original sentencing law, the inaptly named Anti-Drug Abuse law of 1986. In New York State, the harshness of the Rockefeller drug laws, passed in 1973 with stiff criminal penalties for possession of even small amounts of heroin, were somewhat mitigated in 2009 after a ten-year long campaign by inmates’ families, with sentencing judges allowed the option of sending first-time drug felons to serve their sentences in treatment rather than correctional facilities. The effects of these changes have yet to be felt, absent corroborating data, and should not expected to be dramatic. As per data preceding these changes …
• As of 2008, 22% of all African-American incarcerated in state and Federal prisons had been convicted of drug possession – as compared with 14.5% of white inmates;
• As of 2009, 12,000 or 22% of New York State’s prison population had also been convicted of drug possession, with 5,000 or 9% charged with class ‘B’ felonies or possession of one bag or one gram of heroin or cocaine.

To sum up the foregoing and Alexander’s basic thesis, the Federal government, aided and abetted by the state governments, has systematically denied the civil rights of the great majority of African-Americans, particularly African-American men, for the past one hundred and fifty years. Individuals whose rights it was the government’s responsibility to protect, have been and continue to be viewed as threats to the government and to the established social order and have been accordingly marginalized. Which is the same story that Jonathan Metzl has to tell.

He begins his story at Ionia State Hospital, a state forensic hospital outside of Detroit, in the 1960’s, a time marked by fundamental changes in psychiatry and Ionia’s patient population as well as in the larger society and those patients’ social environment. The peaceful and quiescent 1950’s gave way to civil unrest in the ‘60’s and ‘70’s. For African-Americans living in big city ghettos, the Civil Rights and Voting Rights acts failed to improve their lives, to open doors to promised opportunity, to a valued place in American society. Black nationalism and black power seemed to offer the only avenues through which urban blacks could voice their anger and disillusion and give meaning to their lives. I wrote above how the American political establishment, the Nixons and Reagans, responded to this challenge with their wars on drugs. For ordinary Americans, dissent was viewed as insane behavior, which was soon transformed into criminal behavior.

Prior to the 1960’s, patients institutionalized at Ionia and diagnosed with schizophrenia, as per DSM I criteria, were largely white women who evidenced schizophrenia’s negative symptoms – social withdrawal, anhedonia, blunted affect. With uncanny timing, the DSM II, published in 1968, introduced a biological explanation for serious mental illness and emphasized Schneiderian first rank or positive symptoms in diagnosing schizophrenia – hallucinations, delusional thinking, paranoid ideation and aggressive, hostile behavior. Black protests, particularly after Martin Luther King’s and Bobby Kennedy’s murders in 1968, grew more volatile; angry black men began to be arrested and, when their anger didn’t subside in Michigan’s jails or prisons, were transferred to Ionia’s forensic units. Where they were diagnosed with schizophrenia by psychiatrists who, confronted by angry black men, were blind to their own anxiety and to their roles as agents of institutionalized racism.

Anxiety, racism and the DSM II were not confined to Ionia; black men in mental health facilities across the country who evidenced any psychotic symptoms were invariably diagnosed with schizophrenia. For the past forty years, even with the advent of successive DSMs — III, IIIR, IV and IV TR – and presumably more sophisticated diagnostic methodology, the “over-diagnosis” of schizophrenia in African-American men has continued and gained increasing attention from mental health researchers. The Kaiser-Permanente Schizophrenia study, conducted in California from 1981 to 1997, examined 19,000 live births that took place during that time frame and determined that African-Americans, whether from poor or working or middle class families, were 3.27 times more likely than whites to one day be labeled as having schizophrenia. The researchers did conjecture that poverty and, in their words, “status discrimination such as segregated neighborhoods, differences in educational systems, opportunity structures and racist climate” might constitute “causal pathways” to schizophrenia for African-Americans, but the concluded that their data did not allow them to “examine these pathways.” The study also failed to examine clinician bias in the over-diagnosis of schizophrenia and accepted without question the construct validity of schizophrenia as an illness.

A similar study published in 1999 and conducted in Michigan and Maryland with 665 study subjects hypothesized that treatment venue might offer an explanation for over-diagnosis. Its researchers concluded that hospitalized African-Americans, whose symptoms were presumably more exacerbated, in contrast to those treated in out-patient settings, were more likely to be diagnosed with schizophrenia than white patients and less likely to be diagnosed as suffering from affective disorders. Issues of poverty, racism and clinician bias were not addressed.

NIMH’s National Comorbidity Survey, conducted almost annually since 1992, reported the statistically significant prevalence of schizophrenia among African-Americans as compared to whites. The earlier surveys i.e., those conducted since 1992 over the next several years, began to conclude that an explanation for the phenomenon of “over-diagnosis” could be found in the cultural differences between African-American patients and their treating clinicians. Specifically, they posited the existence of a culturally-rooted barrier blocking ready communication between African-American patients and their predominately white therapists: on the one hand, the reticence of African-Americans to talk about their problems to individuals outside their social milieu; and the tendency of American-Americans to view such individuals with suspicion, largely a consequence of their unhappy personal experiences with “outside” authorities; and, on the other, white therapists’ lack of knowledge about the black experience in America. The surveys’ authors, endorsed by the NIMH, invariably recommended multi-cultural training to promote mental health providers’ cultural sensitivity and cultural competence.

Only recently – the 2011 National Comorbidity Survey and William Lawson’s presentation at the 2012 APA Conference – have researchers suggested that over-diagnosis of schizophrenia in African-Americans might not be due solely to the misapplication of diagnostic criteria to a socially anomalous population but to incompetence and racial bias on the part of treating clinicians. Specifically, they cited the following:
• insufficient data gathering by clinicans;
• their assumption that first rank symptoms evidence only schizophrenia and not affective disorders as well;
• stereotypical notions of African-Americans by clinicians;
• the great social distance that exists between African-American patients and those who presume to treat them.

As I pointed out at the outset of this article, multi-cultural solutions are polite ways to avoid addressing the issue of institutionalized racism, whose existence none of these studies acknowledge.
Admitting the presence of bias in providers is a first step but doesn’t go far enough — racism is so intrinsic to the public mental health system that many of us who work in that system appear to be unmindful of it. Perhaps more importantly, none of these studies consider the possibility that schizophrenia, that most pejorative and damaging of diagnostic labels, and one whose construct validity lacks supporting data, is not a mental illness but a tool of social control. Metzl’s principal contention is that not only did schizophrenia become a black man’s disease but has been criminalized, with its primary treatment venues found in the nation’s jails and Federal and State prisons. To illustrate …
1. By the late 1970’s, at the height of deinstitutionalization, Ionia was converted from a state hospital to a state prison.
One can’t fail to wonder how many of its patients eventually shifted status from patient to prison inmate.
2. More to the point, in a 2005 survey conducted by the Bureau of Justice Statistics, a total of 1.25 million individuals incarcerated in Federal and state prisons and local jails reported some evidence of emotional disturbance, presumed indicative of mental illness: 56% of all inmates in State prisons, i.e., 700,000 individuals; 44% of all Federal prison inmates – 70,000 persons; and 64% of inmates of local jails – 480,000 persons.

In my experience, many if not most practitioners and peer/survivors in the public mental health system have some awareness of the foregoing. Most, perhaps nearly all, seem to have failed to connect the dots.

So what can practitioners and peer/survivors do to combat institutionalized racism in the public mental health system and the larger social system? For starters, they can employ what I term the “dripping on the rock” strategy in public mental health, challenging every schizophrenic diagnosis given a person of color. During the many years I directed a case management program in New York City, we would ask ourselves whether the schizophrenia diagnosis of a client new to us was “bona fide”, i.e., had sufficient supporting data, or more properly represented the sequelae of poverty, substance abuse and trauma. Which, more often than not, proved to be the case. I recommend that same approach to all practitioners and to peer/ survivors labeled with schizophrenia.

A consideration of the diagnosis would then set us off to obtain as much information about our new client as possible, avoiding easy assumptions and documenting our suppositions, by happy coincidence, a practice utilized by Dr. Lawson and his colleagues. Ultimately, the validity of the diagnosis itself must always be questioned and its utilization as a tool of social control constantly exposed. In a nutshell, don’t accept anything at face value!

Finally, remember that the public mental health system is integral to and reflective of the larger social system. Accordingly, public mental health won’t rid itself of racism or racial bias until the larger society does. I think we’re a long way off from that. In the interim, opportunities to challenge racism and oppression will present themselves and must be recognized and accepted whenever and wherever they do, whether within or outside of public mental health. I think of what’s happening here in New York City, of the silent march of several thousand persons down 5th Avenue this past June 16 to protest the NYPD’s “Stop and Frisk” policy aimed at young men of color in New York’s poorer neighborhoods. The fight to stop “Stop and Frisk” appears to have gained public support and political momentum consequent to mounting opposition to it. Just one example of how, in the end, it’s important not to mourn or lament but to organize!

References:

Agus, Z.S., “Psychosis May be Overdiagnosed in Blacks,” Medpage Today, http://www.medpagetoday.com/MeetingCoverage/APA/, May 9, 2012

Alexander, M., The New Jim Crow: Mass Incarceration in the Age of Colorblindness, The New Press, New York & London, 2010

, “The New Jim Crow,” http://www/huffingtonpost.com/post, February 8, 2010,

, “The New Jim Crow: How the War on Drugs Gave Birth to a Permanent American Undercaste,” http://www.tomdispatch.com/post/,
March 25, 2012,

Barnes, F., “Anti-Drug Abuse Act of 1988,” http://www.articledoctor.com/drug-abuse/, January 16, 2009,

Bourjolly, J.N., Pernell-Arnold, A., et al, “The Journey Toward Intercultural Sensitivity: A Non-Linear Process,” Journal of Ethnic & Cultural Diversity in Social Work, Vol. 14, No. 3/4, 2005

Bresnahan, M. et al, “Race and Risk of Schizophrenia in a U.S. Birth Cohort: Another Example of Health Disparity,” International Journal of Epidemiology, Vol. 36, #4, pp. 751-8, http://ije.oxfordjournals.org/content/, published online April 17, 2007,

Bureau of Justice Statistics, U.S. Department of Justice, “Mental Health Problems of Prison and Jail Inmates,” December 14, 2006, revised

, “Correctional Population in the United States, 2010, December, 2011
, “Prisoners in 2010,” February 9, 2012, revised

Carney, J., “Poverty & Mental Illness: You Can’t Have One Without the Other,” http://www.madinamerica.com/post, March 7, 2012

, “Poverty & Serious Mental Illness: Connecting the Dots,” http://www.madinamerica.com/post, March 12, 2012

Coppola, F.F., Puzo, M., “the Godfather, Part II,” 1974

Drug Policy Alliance, “New York’s Rockefeller Drug Laws: Explaining the Reforms of 2009,” http://www.drugpolicy.org

Dwyer, J., “Altering a Law The Police Use Prolifically,” The New York Times, http://www.nytimes.com/, June 6, 2012

Franklin, K., “How the Black Man Became Schizophrenic,” http://www.psychologytoday.com/blog, November 21, 2010

Haberman, C., “Thousands March Silently to Protest Stop-and-Frisk,” The New York Times, http://www.nytimes.org, June 18, 2012

Hunter, J., Marshall, J., Scott, P.D., The Iran-Contra Connection: Secret Team and Covert Operations in the Reagan Era, South End Press, 1987

Insel, T., “Reducing Disparities in Mental Health Equity: Closing the Gaps,”, http://www.nimh.nih.gov/about/director/, June 18, 2010

Kaplan, T., “Cuomo Seeks Reduction in Stop-and-Frisk Arrests,” The New York Times, http://www.nytimes.org, June 4, 2012

Kessler, R.C., et al, “Lifetime and 12-Month Prevalence of DSM-III R Psychiatric Disorders in the United States: Results from the National Comorbidity Survey,” Archives of General Psychiatry, January, 1994, Vol. 51, #1, http://www.archpsyc.jamanetwork.com/article

, “Lifetime Prevalence and Age-of-Onset Distributions of DSM IV Disorders in the National Comorbidity Survey Replication,” Archives of General Psychiatry, June, 2005, Vol. 62, #6, http://www.archpsyc.jamanetwork.com/article

, “The National Comorbidity Survey (NCS) and its extensions,” in Tsuang, M.T., et al, eds., Textbook of Psychiatric Epidemiology, pp. 221-241, John Wiley & Sons, Ltd., United Kingdom

Lane, C., “How Schizophrenia Became a Black Disease: An Interview with Jonathan Metzl,” http://psychologytoday.com/blog/, May 5, 2010

Lawson, W., et al, “Cultural Mistrust & Psychopathgology in African Americans,” presentation, American Psychiatry Association, annual convention, May 2012

Marshall, J., Scott, P.D., Cocaine Politics: Drugs, Armies and the CIA in Central America, U. of California Press, 1998

Medina, J., “Police Beating Victim Who Asked ‘Can We Get Along?’ ,”
The New York Times, http://www.nytimes.org, June 18, 2012

Metzl, J., The Protest Psychosis: How Schizophrenia Became a Black Disease, Beacon Press, New York, 2010, http://www.beacon.org/productdetails

, “How Mental Illness Became a Crime,” http://bigthink.com/ideas/, February 19, 2010

Neighbors, H.W., et al, “Psychiatric Diagnosis of African-Americans: Diagnostic Divergence in Clinician-Structured and Semistructured Interviewing Conditions,” Journal of the National Medical Association, Vol. 91, #11, pp. 601-12, 1999

New York Sate Office of Mental Health, “Cultural Competence Strategic Plan, 2010-2104,” http://www.omh.ny.gov/

Powell, M., “Arguments for Most Police Stops, and the Math, Don’t Hold Up,” The New York Times, http://www.nytimes.org, May 29, 2012

Scott, P.D., Drugs, Oil and War: The United States in Afghanistan, Colombia and Indochina, Rowman & Littlefield, Inc. 2003

Scott, R., “American Gangster, 2007

Schuessler, J., “Drug Policy as Trace Policy: Best Seller Galvanizes the Debate,” The New York Times, http://www.nytimes.org, March 6, 2012

Stuart, H., Arboleda-Flores, J., “Community Attitudes Towards People with Schizophrenia ,” Canadian Journal of Psychiatry, Vol. 46, #3, pp. 245-52, April, 2001

Thomas, P., “Black and Mad,” http://www.madinamerica.com, April 16, 2012

The Washington Post, “The Fair Sentencing Act Corrects a Long-Time Wrong in Cocaine Cases, editorial, August 3, 2010, http://www.washingtonpost.com/