CLINICAL HANDBOOK OF SCHIZOPHRENIA

60. Schizophrenia in African Americans 619individuals with schizophrenia should be blamed and punished for violent behavior. EuropeanAmerican families are more likely to feel burdened and rejecting toward the familymember with schizophrenia. Cultural factors may therefore be more important thensocioeconomic status in determining whether family members will be caretakers.Although the idea that family dynamics “cause” schizophrenia has been discredited,family relationships can certainly affect the course of the illness. However, factors thatcontribute to poor outcome differ in European American and African American families.High emotionality and family intrusiveness have been shown consistently to predict pooroutcome in European Americans with schizophrenia. This does not appear to be the casein African Americans. Critical comments by relatives that were perceived as expressedcriticism by European American and Latino family members with schizophrenia were notperceived consistently as criticism by African Americans with schizophrenia. Moreover,in European Americans, family intrusiveness and critical comments, elements consideredimportant in families with high emotionality, showed no association with outcome. Presumably,such behavior was interpreted as displaying more concern in African Americanfamilies.The take-home message is that family factors do play an important role in outcomesof African Americans with schizophrenia. African Americans tend to be supportive andto continue family involvement, but they tend to be fearful of the mentally ill. Moreover,the relationships seen in family dynamics and schizophrenia in European Americans maybe very different in African Americans. Behavior that is considered toxic in other culturesmay be protective in African American cultures. In conclusion, culture is important infamily interactions. However, findings about the relationship between schizophrenia andfamily members in European American families simply may not apply to African Americansand other ethnic minorities.TREATMENT AVAILABILITYAfrican Americans have more illness burden, because they do not have the same access toservices and often receive suboptimal treatment. African Americans are more likely to behomeless or in prison, settings in which treatment is suboptimal. Hospitalization is morecommon, especially involuntary admissions, and the disposition after discharge is oftenmedication-only or emergency room care. Preferential treatment such as day treatment orcase management are less likely to be available.Racial differences in income may contribute to the lack of treatment access. AlthoughAfrican Americans have 60% of the income of European Americans, they haveonly 10% as much family wealth because of slavery and later job discrimination. Only recentlyhas wealth accumulation become widely available. As noted earlier, direct costs forthe treatment of schizophrenia exceed the median family income of African Americans.Yet African Americans with schizophrenia are more likely to be cared for within the family.Without disposable income, patients sometimes have to choose between necessitiesand medications. Family members can access only the most rudimentary care.Although income is important, other factors play a part. As noted earlier, issues suchas misdiagnosis persisted even when income was controlled. The Surgeon General’s Reportnoted that when income was taken into account, ethnic disparities still persisted.Moreover the National Comorbidity Study Replication also reported less access to carefor ethnic minorities, even when income was controlled. When we look closely atpharmacotherapy we find similar provider and patient issues that contribute to misdiagnosis.