CLINICAL HANDBOOK OF SCHIZOPHRENIA

60. Schizophrenia in African Americans 621treatment, whereas those with increased activity may not show any response at all. Thus,there is no biological reason for the excessive dosing of African Americans.Pharmacological studies provide some support for prescribing atypical antipsychoticsto African Amerians. Second-generation, or atypical antipsychotics, are less likelyto cause extrapyramidal side effects and are believed to cause less tardive dyskinesia.Moreover, some of the newer antipsychotic agents are not predominately metabolizedthrough the CYP450 2D6 system and are instead metabolized through CYP450 1A2,with CYP450 2D6 as a minor pathway. Asians and Hispanics are more likely than EuropeanAmericans to experience movement disorder side effects, such as acute dystonic reactions,when given typical or first-generation antipsychotics. African Americans aretwice as likely as European Americans to develop tardive dyskinesia on typical antipsychotics.African Americans are also more likely than European Americans to experienceacute extrapyramidal symptoms with typical antipsychotics, but these differences disappearwith atypical agents.For ethnic minorities, especially African Americans, the atypical antipsychotics appearto offer a decided advantage when movement disorder side effects are considered.However some of the atypical agents have been associated with unacceptable metabolicconsequences, such as diabetes and metabolic syndrome. These disorders are more commonin African Americans and Latinos. The Clinical Antipsychotic Trials of InterventionEffectiveness (CATIE), a naturalistic federally funded study that compared the atypicalagents to each other and to a typical agent, showed that the atypical agents did not providea great advantage. The CATIE study had 40% African American participation, so insufficientnumbers of minorities cannot be used as an argument against it. Nevertheless,the study excluded those with tardive dyskinesia, limited the dosing range, and involved alimited time period. Regarding ethnic minorities, although better than most studies,CATIE must be considered in the context of differing ethnic needs.The atypical agent clozapine has consistently shown superior efficacy and fewermovement disorder side effects compared to other antipsychotics. Like other atypicalantipsychotics, it is also less available to African Americans, but for different reasons. Itsside effects include the metabolic side effects seen in atypical agents, but this is not thelimiting factor. The difficulty is its greater risk for agranulocytosis, which requires regularblood monitoring. Before taking clozapine, minimal leukocyte counts are recommendeddespite the lack of evidence that preexisting white counts predict agranulocytosis. However,African Americans are known to have normal leukocyte counts whose range mayextend well below listed normal values (i.e., a “benign leukopenia”). As a result, theoverly cautious clinician may choose not to start otherwise healthy African American patientson clozapine.Since pharmacological factors do not explain the differing prescribing patterns seenwith African Americans, what does? As noted earlier, provider attitudes and eithic minorities’perceptions of the mental health system are extremely important. The view that AfricanAmericans are more hostile than they actually are may be confounded by poor communicationsand social, economic, and ethnic distance. Patients who become suspiciousand hostile to the system either choose other alternatives or are less compliant, as shownby the high rate of noncompliance. The solution appears to be straightforward. AfricanAmericans must be made to feel welcome in the mental health system. When physiciansare more willing to consider patients’ ethnic differences, excessive dosing disappears.To summarize, ethnic minorities receive older antipsychotics. African Americans receivehigher doses and more depot medication, probably due more to attitudinal factorsthan to socioeconomic or biological factors. These treatment differences ignore biologicaldifferences that may require lower doses and a greater concern for movement disorder sideeffects. The prudent clinician should individualize treatment. The patient should be consid-