CLINICAL HANDBOOK OF SCHIZOPHRENIA

622 VIII. SPECIAL TOPICSered a partner in developing a reasonable dosing plan. Culture, ethnicity, and the patient’sindividual risk profile must be considered. Family history and family members must be consulted.As much as possible, rapport should be established regardless of ethnicity.CONCLUSIONSchizophrenia is a devastating disorder for anyone, but especially for ethnic minorities.Limited access to treatment increases illness burden for economically depressed families.When treatment is available, misdiagnosis is common; other disorders, mislabeled asschizophrenia, are treated inappropriately. Genetic factors are important in schizophrenia,as is the family environment. Consideration of cultural factors means that findingsabout family environment in European American families do not apply to ethnic minorities.Suboptimal treatment of African Americans with schizophrenia is not simply a consequenceof socioeconomic factors. Excessive dosing with older medications is commonand cannot be accounted for by biological factors. The physician–patient relationship,willingness of the physician to engage the patient, and individualized treatment are crucialto optimal pharmacotherapy. Race and ethnicity, their cultural determinants, andtheir interaction with socioeconomic and biological factors must be considered in the diagnosisand treatment of schizophrenia.KEY POINTS• Overdiagnosis of schizophrenia is common among African Americans, with affective disordersoften misdiagnosed as schizophrenia, mainly due to a failure to get adequate information,clinician bias, and cultural factors.• For a proper diagnosis of schizophrenia in African Americans and other ethnic groups, allsources of information should be considered, including adherence to DSM-IV criteria, andtaking cultural issues into account.• Several studies have shown putative gene associations for schizophrenia in African Americans(e.g., polymorphisms of the synapsin III and NOTCH 4 genes); however, genes shouldonly be considered in the context of environmental factors.• Despite limited resources, African American families are more likely than European Americanfamilies to become caregivers for family members with schizophrenia.• High emotionality and family intrusiveness have been shown to predict poor outcome in EuropeanAmericans with schizophrenia, but not in their African American counterparts.• African Americans have less access to health care (even after income is controlled), agreater rate of involuntary hospitalizations, and lower use of preferential treatments, suchas day treatment or case management, than European Americans.• African American patients are more likely to receive first-generation antipsychotics, higherdoses of medications, and more depot medication than European Americans, whereas Hispanicsand Asians receive lower dosages.• African Americans, Asians, and Hispanics show reduced activity of the cytochrome P450isoenzyme CYP450 2D6 compared to a majority of European Americans; this suggestshigher plasma levels of the antipsychotic drugs, and thereby a need for lower dosages inthe ethnic minority groups.• Asians and Hispanics are more likely to develop antipsychotic-induced movement disorderssuch as acute dystonia, whereas African Americans have a greater risk of developingtardive dyskinesia with first-generation antipsychotics than do European Americans.• To reduce mental health care disparity, African Americans (as well as other ethnic minoritygroups) should be made to feel welcome in the mental health system; treatment should beindividualized, and cultural factors should be considered.