CLINICAL HANDBOOK OF SCHIZOPHRENIA

CHAPTER 60SCHIZOPHRENIA INAFRICAN AMERICANSWILLIAM B. LAWSONSchizophrenia is considered the most severe psychiatric disorder. It has a poor prognosis,an unknown etiology, and an age of onset in the late teens and early 20s, when manyindividuals finish their education and begin their careers. Current treatments are mostlypalliative, with uncertain recovery and rarely substantiated cures. Individuals and theirfamilies often face a lifetime of illness that is associated with individual and societal morbidity,shortened lifespan, and high suicide rates. Recent advances have led to improveddiagnostic accuracy, a better understanding of genetic risks and psychosocial stressors,and improved treatment that has made recovery an attainable goal. This chapter indicatesthat race and ethnicity impact the diagnosis, course, and treatment of this illness throughbiopsychosocial factors that are only beginning to be appreciated. The focus is on AfricanAmericans, for whom there is a more extensive literature than for other ethnic minorities.EPIDEMIOLOGYAfrican Americans have always been viewed as being overdiagnosed with schizophrenia.Even recent clinical reports show that African Americans are at as much as a tenfoldincreased risk over other ethnic minorities despite improved diagnostic accuracy andwidespread use of the DSM-III and DSM-IV. Lawson, Hepler, Holladay, and Cuffel(1994) reported that African Americans in both inpatient and outpatient settings were diagnosedwith schizophrenia at higher percentage rates than African Americans in theoverall population. Rates of mood disorder for African Americans, and both schizophreniaand affective disorders for European Americans were the same as rates in the generalpopulation. Strakowski and colleagues (2003) reported higher rates of schizophrenia forAfrican Americans in inpatient and outpatient settings. The higher rates were often associatedwith correspondingly lower rates of affective disorders.The findings have generally been assumed to reflect affective disorders misdiagnosedas schizophrenia. These differences often disappeared with the use of structured interviews,which presumably minimize bias. Large-scale, door-to-door epidemiological sur-616