Racial and Ethnic Issues in Diagnosing, Treating Bipolar Disorder
By Arline Kaplan © 2000 (All Rights Reserved)
Many African-Americans with bipolar disorder remain hidden in the correctional
system. Others being treated in mental health settings are often misdiagnosed
as having schizophrenia, antisocial personality disorder, intermittent explosive
disorder or attention-deficit/hyperactivity disorder (ADHD), said psychiatrist
William B. Lawson, M.D., Ph.D., professor of psychiatry at Indiana University.
"Recent data shows that African-Americans are far more likely to be misdiagnosed
as having schizophrenia or not recognized as being ill at all and being incarcerated
in the prison system," said Lawson, past president of the Black Psychiatrists
of America. Earlier research (Mukherjee et al., 1983) showed these phenomena,
and more recent studies by Stephen M. Strakowski, M.D., and colleagues (1996)
at the University of Cincinnati College of Medicine and James Jackson, Ph.D.,
and his group at the University of Michigan in Ann Arbor (Neighbors et al.,
1989), showed the same phenomena, Lawson said.
Large-scale epidemiological studies, he added, indicate that the rate of bipolar
disorders is probably the same across ethnic groups (Robins et al., 1984).
"Yet, we consistently found in inpatient settings [state and veterans affairs
hospitals] that African-Americans had a disproportionate amount of schizophrenia
diagnoses and far fewer diagnoses of bipolar disorder," said Lawson who
is also chief of psychiatry and mental health service at the Richard L. Roudebush
Veterans Affairs Medical Center.
Asked whether the symptom profile of African-Americans with bipolar disorder
might be different than other ethnic and racial groups, Lawson responded, "That’s
one interpretation. We just did a large-scale study…in which we looked
at genetics of bipolar disorder. Basically, we found African-Americans were
rated as having more psychotic symptoms. Now why this is, we don’t have
a clue. [We don’t know] whether they are presenting symptoms in different
ways or whether they are more willing to talk about psychotic symptoms. Also,
African Americans are less likely to report to depressive symptoms. But it is
unclear whether they are unwilling to describe depressive symptoms or are interpreting
them in other ways."
Data from the large-scale study was presented at the 152nd annual meeting of
the American Psychiatric Association in Washington, D.C. (Lawson, 1999), and
additional data was presented at the 153rd annual meeting of APA in Chicago.
"We looked at 500 Caucasians and 30 African Americans, all diagnosed as
having bipolar disorder. We used multiple diagnostic techniques to be sure that
we had clear-cut bipolar disorder," Lawson said. "Then, we used standard
rating scales—the Andreasen Scale for Positive Symptoms and the Andreasen
Scale for Negative Symptoms."
In the assessment of positive symptoms, Lawson and his colleagues found "more
hallucinations and delusions among African-Americans. However, in the assessment
of negative symptoms and other symptoms associated with bipolar disorder, they
didn’t find any ethnic differences.
Lawson and his colleagues also found that African-Americans were more likely
to be prescribed antipsychotics. Other researchers have similar findings, he
said, including Strakowski at the University of Cincinnati College of Medicine
and Tony Strickland, Ph.D., associate professor in the department of psychiatry
and human behavior at the Drew University of Medicine and Science in Los Angeles.
"Sometimes the antipsychotics were in addition to mood stabilizers and
sometimes they were used alone. Right now, we are looking at whether there is
a tendency for African-Americans to be on antipsychotics alone. We also found
that African-Americans were less likely to be on lithium, but it did not reach
statistical significance," Lawson added. "We’re investigating
exactly why are African-Americans are more likely to be on antipsychotics. Is
it because they may not tolerate lithium as well or is there some other reason
that’s going on."
Lawson and his colleagues are seeking to ascertain whether the atypicals provide
a greater benefit for African-Americans.
"We also found that African-Americans had more hospitalizations…so
we have to look at the treatment environment to see if in fact African-Americans
are receiving the same kind of treatment as their Caucasian counterparts, and
if they are not, why not. Then, we need to look at some other ethnic groups,
such as Latinos and Asians," Lawson added.
In his own practice, Lawson said he has not found big differences among the
racial and ethnic groups he treats for bipolar disorder.
"University systems tend not to show as great a racial disparity, and I
suspect that university hospitals tend to be more conscious of the use of DSM-IV,
tend to adhere to practice guidelines and are more likely to use newer medications.
So our experience has been relatively positive," he said. "We often
evaluate very carefully whether the patient needs to be on antipsychotics. We
found some [patients] do well when transferred to one of the anticonvulsant
mood stabilizers, when formerly they were just on lithium."
Researchers at other universities are also investigating racial and ethnic differences
in bipolar disorder. At the University of Cincinnati, Melissa P. DelBello, M.D.,
and colleagues examined the racial differences in the psychopharmacological
treatment of adolescents with bipolar disorder.
They retrospectively reviewed the hospital records of 60 Caucasian and 14 African-American
patients with a discharge diagnosis of DSM-IV bipolar disorder. There were no
differences in age, sex, number of days hospitalized, number of episodes of
seclusion or restraints and number of PRN medications received between the two
groups.
"Comorbidities were similar between racial groups as far as ADHD, conduct
disorder, and oppositional defiant disorder. There were no differences in psychotic
symptoms; 14% of the African-Americans and 18% of the Caucasians were diagnosed
as having psychotic symptoms," DelBello said. The difference between the
groups was "that those who are African-American, despite not being more
psychotic, received more antipsychotic medications."
Among Caucasian patients, 43% received antipsychotic medications. Among non-Caucasian
patients, 68% received antipsychotic medications. There are several possible
explanations, DelBello said. One is that because of cultural differences, clinicians
perceived African-Americans to be more aggressive and more psychotic, and prescribed
the antipsychotics.
"In another study submitted for publication, we looked at all adolescent
admissions to our inpatient unit (1,001 subjects over three years), and found
that after controlling for socioeconomic status, African-American males were
getting more psychotic disorder diagnoses versus Caucasian patients who were
getting more affective disorder diagnoses. These diagnoses were clinical diagnoses,"
she said.
To determine whether misdiagnosis is occurring or whether actual epidemiological
differences exist, DelBello said that prospective studies should be done with
structured interviews.
In the adult population, ethnic differences in the rates of utilization of mood
stabilizers and antipsychotics were examined by Dale D’Mello, M.D., associate
professor, department of psychiatry at Michigan State University and David Lyon,
D.O., a resident in the department of psychiatry at Michigan State University.
They completed a naturalistic retrospective review of the medical records of
91 patients (69, European-Americans; 17, African-Americans; two, Hispanic; two,
Oriental; one, Native American) who were hospitalized during the calendar years
of 1996 and 1997 with acute mania (D’Mello and Lyon, 1999). All met the
DSM-IV criteria for bipolar mania.
D’Mello and Lyon then abstracted demographic data (age, gender and ethnicity)
and length of stay from the hospital record, and obtained details of discharge
pharmacotherapy from the pharmacy log. They entered the data into a statistical
software program (MYSTAT) for analysis. Only European-Americans and African-Americans
were included in the analysis.
"In our study, we didn’t find any difference among the groups in the
utilization of antipsychotics," D’Mello said. That finding differed
from studies by others as well as one of D’Mello’s group’s prior
studies that found minority patients—Hispanic and African-Americans—were
much more likely to receive antipsychotics.
The significant finding in their study, D’Mello said, was that African-American
patients with acute bipolar mania were five times more likely to receive mood
stabilizer combinations than their European-American counterparts.
"Nearly half (47%) of the African-American patients received a combination
of mood stabilizers, usually lithium and Depakote [divalproex] or Depakote and
Neurontin [gabapentin]…. The European-Americans received these combinations
only 10% of the time," he said.
D’Mello added that the findings suggest, "there may be both ethnic
differences in the expression of bipolar disorder and…ethnic differences
in the pharmacokinetics (the way the body deals with Depakote) that have yet
to be unraveled…. That is the study that needs to be done in the future,
looking at blood levels and doses and ethnic differences in metabolism."
With regard to lithium, ethnic differences have been identified in the way the
body metabolizes or excretes it. For instance, D’Mello said, African-American
patients tend to develop higher serum and tissue levels of lithium when given
the same dose as European-Americans (Chang et al., 1984). Hence, African-Americans
may be more sensitive to lithium. That African-Americans may develop higher
levels of lithium on equal doses may relate to the fact that they absorb sodium
more efficiently from the proximal tubule in the kidney, leading to sodium,
and hence, lithium retention (D’Mello and Lyon, 1999). In fact, the higher
rate of volume-dependent hypertension in African-Americas has been attributed
to this genetically determined trait (Blaustein and Grim, 1991)
Strickland and others (1995) studied the lithium RBC/plasma ratio (LR) in 34
bipolar patients (22 Caucasians and 12 African-Americans) on therapeutic doses
of lithium. The African-Americans demonstrated a higher LR as well as increased
reports of side effects (p <0.05). African-Americans, the investigators concluded,
may be more susceptible to the side effects associated with lithium treatment,
and consequently, may need lower doses.
However, generalizing from one non-Caucasian group to another may be unwarranted.
Shelley (1987) systematically examined possible ethnic difference in the pharmacokinetics
of lithium in Caucasian and Afro-Caribbean volunteer subjects. The two groups
did not differ with regard to weight, age or renal function. Rates of absorption
were similar, but there was a nonstatistically significant trend toward more
rapid distribution and elimination, smaller area under the serum curve and greater
urinary excretion in the Caucasian group. No differences existed in side effects.
When asked about the value of these kinds of ethnic studies, D’Mello cited
issues of patient safety and efficacy. If one ethnic group has a preferential
or robust response to one mood stabilizer versus another, it is important for
the clinician to know that, he said. Similarly, if African-American patients
develop lithium toxicity at conventional therapeutic serum levels, a physician
who is not aware of that may wonder about the response and the patient’s
sensitivity.
Finally,
D’Mello said, "the discovery of ethnic specific differences in pharmacokinetics,
pharmacodynamics and drug response may in the future advance the rational selection
of psychotropic medications."
References
Blaustein MP, Grim CE (1991), the pathogenesis of hypertension, black-white
differences. In: Cardiovascular Disease in Blacks (Cardiovascular Clinics 21:3),
Saunders E., ed. Philadelphia: F.A. Davis Co.
Chang SS, Pandey GN, Zhang MY et al. (1984), Racial differences in plasma and
RBC lithium levels. In: Scientific Proceedings of the American Psychiatric Association’s
annual meeting, pp239-240.
Chung H, Mahler JC, Kakuma T (1995), Racial differences in treatment of psychiatric
patients. Psychiatr Serv 46(6):586-591.
DelBello MP, Soutuillo CA, Ochsner JE et al. (1999), Racial differences in the
treatment of adolescents with bipolar disorder, New Research 379. Presented
at the 152nd annual meeting of the American Psychiatric Association, May 18.
Washington, D.C.
D’Mello DA, Lyon DE (1999), Ethnic variance in the treatment of acute mania,
New Research 579. Presented at the 152nd annual meeting of the American Psychiatric
Association, May 19. Washington, D.C.
Lawson WB (1999), Ethnicity and treatment of bipolar disorder. Presented at
the 152nd annual meeting of the American Psychiatric Association, May 19. Washington,
D.C.
Mukherjee S, Shukla S, Woodle J et al. (1983), Misdiagnosis of schizophrenia
in bipolar patients: a multiethnic comparison. Am J Psychiatry 140(12):1571-1574.
Neighbors HW, Jackson JS, Campbell L, Williams D (1989), The influence of racial
factors on psychiatric diagnosis: a review and suggestions for research. Community
Ment Health J 25(4):301-311.
Robins LN, Helzer JE, Weissmann MM et al. (1984), Lifetime prevalence of specific
psychiatric disorders in three sites. Arch Gen Psychiatry 41(10):949-958.
Shelly RK (1987), Are there ethnic differences in lithium pharmacokinetics and
side effects: Int Clin Psychopharmacol 2(4):337-342.
Strakowski SM, McElroy SL, Keck PE Jr., West SA (1996), Racial influence on
diagnosis in psychotic mania. J Affect Disord 39(2):157-162.
Strickland TI, Lin KM, Fu P et al. (1995), Comparison of lithium ratio between
African-American and Caucasian bipolar patients. Biol Psychiatry 37(5):325-330.
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