Psychiatry & Psychotherapy Podcast - Overdiagnosis of Schizophrenia in Black Patients

Episode Date: March 25, 2022

Inaccurate diagnosis of schizophrenia and/or missed diagnosis of affective disorders can lead to inappropriate and inadequate treatment; worsened outcomes can follow. Because schizophrenia is a complex condition with a broad range of signs and symptoms that also occur in other mental disorders, it can be difficult to differentiate it from other serious mental disorders, especially mood disorders. Notably, these other conditions should actually be ruled out before arriving at a diagnosis of schizophrenia.  In this episode, Danielle Hairston, M.D. and Chantel Fletcher join the podcast to discuss the issue of overdiagnosis of schizophrenia in Black male patients, especially. By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video. Link to The Next 72 Hours Podcast.

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CME while listening to this podcast? Go to Psychiatrypodcast.com, sign up, sign in, take the test, and the certification is emailed to you in seconds.

All right, welcome back to the podcast. Before we begin, I want to make an announcement. that we are continuing to have webinars. So if you hear this a year from now, you could go on to Psychiatrypodcast.com backslash webinar and see what we have in the future. We have two currently, one April 22nd and one May 1st. The April 22nd will be going over the big five. You know, you will be able to understand your own personality. We will be sending people before the webinar a one-hour assessment where you can do the gold standard on the big five. And then May 1st, Dr. Danny is going to be doing one on racial trauma.

And she is an expert in this. And any of the proceeds for her webinar will go to support her podcast. So I'm hoping that we can raise enough funds to support her for the next year. Editing is expensive. And this will be helpful to her. So if you go to that, all proceeds will go to her. And now on to the episode. All right, welcome back to the podcast.

I am joined today with Dr. Danielle Harrison. She is a program director at Howard in Washington, D.C. And I'm also joined with Chantelle Fletcher. She is a now fourth year medical student going into psychiatry. None of us have any conflicts of interest. And today we'll be talking about the overdiagnosis of schizophrenia and psychotic illness in black patients. Dr. Harrison, do you want to start us out with kind of like the big picture, like what the,

you know, why this topic interests you? So let me just say I'm excited to be back in the space. So thank you for inviting me back to the podcast. I think that many people might not know that there's an overdiagnosis of schizophrenia in black males especially, and this has many, many implications. It has a big impact, and it's rooted in a lot of historical things that we'll talk about. I really started with something, I can say it started, but it went back farther. If you go back into history, there's Draptomania, which was a diagnosis. that stated that enslaved people who wanted to be free must be psychotic, so they must be crazy,

even if they were released later. The notion of wanting to be free, wanting to express yourself definitely deemed you as insane and you need to be in a mental asylum. Then fast forward to the 1960s, where we had what was called the protest psychosis. Shout out to Jonathan Metzel for writing a great book there. And we see a shift from schizophrenia as being a diagnosis or a disease or disorder of weak, quote unquote, weak minded white women suffering from hysteria who couldn't take care of their children, couldn't take care of their families, to now being associated with black men who wanted to voice their distrust for the system, who wanted to voice their needs in the civil rights era. And that's when we saw a shift of schizophrenia being one disorder to moving to a

black man's disorder and used to describe people who were quote unquote aggressive, belligerent. That's even where we see ads for how doll being used to describe someone who is belligerent and needs to be controlled. That's the indication for howled all. So it's a lot. It's a lot. Historically and even now contemporarily, currently we see the continued overdiagnosis since the 70s has been studied. We see higher doses of antipsychotics in black male patients and black patients, period. Shantel even brought it to my attention that there's the overdiagnosis of paranoid specifically of the previous, you know, DSM-5 doesn't have that anymore, but previously characterized as paranoid schizophrenia in black people. So it's ongoing. It's something that we need

to consider. It's something that has been studied for at least 60 years or so. And I think it's important that if you are treating patients, especially black patients, you are aware of what's going on. Yeah. And shout out, shout out Dr. Danny to your new podcast as well. You know, one of the best ways of learning about sort of cultural aspects is to do a deep dive into someone else's world. and I think your podcast has a great job of that. Oh, thank you. It's kind of like you're listening into a coffee shop conversation of like, you know, what it's like to experience life as a black person, racism, what's going on in our culture,

and from your perspective as an expert as a psychiatrist. And so, yeah, I recommend that as well as we kind of diet. into this. Well, thank you. Yeah. That means a lot coming from you, an expert podcaster. Um, so we really tried to look at the intersection between racism, mental health, lived experience as a black person, and really tried to target all aspects. Um, so it's called the next 72 hours. And, uh, we interview people with lived experience. We interview experts and thought leaders in the field who talk about what it's really like to be a person who either is seeking or somehow has been involved in the mental health system. We also talk about things you might not have

traditionally thought about as mental health, but women's reproductive rights and how that impacts mental health, especially for black women. So thank you for listening. And I, yeah, I'm proud of my work. And my co-host is Dr. Nwasey, and she's also a black psychiatrist that I know from undergrad, so we've known each other for quite some time, and we're happy to be branching out into this podcast world like you. Yeah, yeah, I'm sure. I'm sure some people go over and listen to it after this episode, and I'll put the link in my show notes.

So if you go to my show notes, you can just pop over and check out our podcast. Okay, so let's get back to this topic. Yeah, when I was looking at this data, one thing that jumped out to me was that higher doses of antipsychotics were also given in to African-American men compared to white men, compared to Hispanic men in this one study. Chantel, do you want to mention that data point? Yeah, so I also found that very interesting. And I guess piggybacking off of what Dr. Harrison was saying earlier,

I did think myself, like, this has something to do with their perception of them being more aggressive because that is something I have heard growing up. I mean, black men are often labeled as being more aggressive. And in my study with Arnold, the one that's called sex, ethnicity, and antipsychotic medication use in patients with psychosis, they did find that African-American men were indeed given higher doses of medication than also African-American women. And then white men and white women. They were also given specifically higher doses of howled all, as Dr. Harrison mentioned earlier. And it was pretty alarming to me because they didn't necessarily find differences in symptomatology. It's just they just found that for whatever reason they were receiving higher doses of this upon discharge.

Yeah, and we do know the reason, Chantelle. It's really, as I talked about earlier, it's rooted in bias, whether we want to say that this bias is an individual bias or a systemic bias. But it's really an accepted cultural norm. I've had a psychiatrist tell me that they learned in training that black men needed higher doses of antipsychotics and that they tolerated higher doses. Oh, my gosh. When in fact, what we know is that black men are actually more susceptible and at higher risk for developing extrapraminal symptoms with higher doses, especially when you're

psychotropic naive. And there's no factual basis that black men or black people need or require higher doses of medications and antipsychotic. So it is related to something and that something is systemic, what they're taught, hidden, or, you know, the quiet curriculum. And also what's happened historically, like I said, since the 1960s, schizophrenia has been classified as a disorder of black men that needs to be controlled and that their aggression needs to be treated. And starting back then in the 60s, there you saw an influx in the number of

black men who were admitted to asylums to state mental health hospitals. So it's not just the doses of medications, it's also the level of care. So you see it with involuntary hospitalization. I think Chantal, you saw that as well, higher rates of involuntary hospitalization for black people. They're less likely to be offered therapy as a treatment. things like that. Yeah, just for my audience to know, the odds ratio was actually 8.1 that they were more likely to get a higher dose

of an antipsychotic. But that's not like an odds ratio of like 1.2 or something like that, which would be like, maybe there's compounding variables, maybe we should look at that. Like 8.1. You know, it's like so high.

Yeah. Significant. That's definitely, you can't say that this is other mitigating factors. It's definitely significant. And it's something that has seen, not just in this study, but across multiple studies since the 1970s. People have looked at this. And it's constantly reproduced. So it's data that we continue to see even in the late 2000s.

Yeah, I found that pretty alarming. And I did wonder to myself, like, I wonder what the clinicians prescribing those doses would say if we were to ask them, why were they giving these men such high doses versus that of other patients. Because with studies, we can find the answers, but I do sometimes wonder about the human aspect and trying to personalize the data. And I try to place myself in that setting and really try to pay attention to,

what about this patient that you consciously are aware of is telling you, hey, they need such a high dose? So actually they have looked into what the psychiatrists were thinking in doing chart reviews and looking at their notes. And they noticed that psychiatrists, psychiatrists begin documenting perceived hostility, aggression, belligerence, and establishing their need for increased medication and the use of seclusion and restraints. So that's how they were documenting that.

And it's a trend that we started to see as, again, in the early 60s. Perceived, a key word there. Perceived is a key word. Yes, absolutely. I'm always like trying to train my medical students, nurses, document exactly what you see and don't try to put your own thoughts on what you're observing. Like in the chart, right? So patient batting his hands at some in the corner,

nothing else is in the corner that he's batting his hands at, you know? So it's so unhelpful when I see in the chart like patient aggressive. It's like, what does that mean? Like, what does it mean? Exactly. Yeah, I think for my students and residents also, and, you know, that I do consult. So a lot of times when we get a consult for agitation or aggression, and I say, what is it that you're observing? What is this agitation or aggression?

Because we don't want to go ahead and document that someone is, quote, unquote, aggressive or agitated when it's that they are confused. they're altered and they keep getting up out of the bed and walking out of the room, walking to other people's rooms and become, you know, physically entangled with people because they're confused. But is that, is that aggression or is that agitation or is that a manifestation of their altered mental status or of their delirium? Delirium. So it's important.

So I agree with you, Dr. Peter, on that. Like, what are you documenting? In fellowship, I had attending who you. used to say, I don't care what you feel, Dr. Harrison. I shouldn't see what your feelings are in the notes, but it's what are you actually observing. Yep. Yep. And part of me also when I think about, like,

well, why would some, you know, protest or be angry? Well, that's why they're protesting? Or, like, why would someone who's being involuntarily committed, and let's say they're high, you know, because there's this higher rate, is that leading to them being really upset, that they're being committed against their will and desires? And, you know, so maybe the anger is appropriate at times,

if there is anger, you know? I don't know if you have any thoughts on that. Yeah, so what they were saying at that time was that people were angry because they were fighting for their civil rights and against racial discrimination. So I think that that warrants anger. And also we see an issue with what's perceived as anger. Like if someone, some people manifest their depression as anger, you know, some people, anxiety comes out as irritability.

So if you don't ask questions and you don't do a complete interview and figure out why are you seeing these symptoms? Why are you seeing these signs? It's easy to go down a road of, oh, this person is angry or, or this person is angry, or this person is agitated? Did they experience some trauma? Is there a reason that they have this reaction? What is going on in their lives? And if you just do a superficial, like, okay, I know black people, black men are angry,

check, black women are angry next. It's easy to go down that path and somehow reach this diagnosis of a psychotic disorder of schizophrenia without actually looking into what's happening with their mood symptoms. One of the articles that Dr. Fletcher found was it talks about healthy and reasonable paranoia and cultural mistrust can be understandable given the sequelae of dealing with racism. Can you talk a little bit about what you found there, Chantal? Yeah, so they found that at times, let's say if they were interacting with a white health care provider, it's not necessarily that they have something personally against a provider all the time. It's just when you're used to being judged a certain way, it makes you less trusting of the person that you're talking to.

And basically, in that setting, anything you're saying can be used against you. And they're used to being, you know, misunderstood, labeled as aggressive, labeled as other, labeled as behaving poorly in some way. And they've dealt with, like, you know, just stereotyping, I guess disenfranchisement. And so it makes sense that, hey, they wouldn't necessarily view this society as being for them. they wouldn't necessarily view the health care system as always being on their side. Right. So I think it's important to consider who you see right in front of you. They come with the whole history.

Like you don't know what their family members have experienced. You don't know what the impact of generational trauma is. You don't know if they've seen their family member, their uncle, their mother, their aunt, their father being mistreated in the medical system. You don't know if they've seen someone previously involuntarily admitted against their will for something that didn't necessarily warrant that. So, yeah, there is a mistrust. There's these communities, black communities, have been historically oppressed and marginalized and forgotten about. So, and sometimes intentionally harmed, admittedly, intentionally harmed. So when you're asking, oh, why so doesn't someone trust me or why do they have this mistrust, I didn't.

do anything. You have to think about the context of the history and what's going on in our society and in these families and what's been happening for generations. Yeah. I think that there are valid and understandable reasons to have mistrust. And I think if there is mistrust, then as a provider, you can empathize with their entitlement to the mistrust. And that if they feel like you are not understanding something about them, then you will be open to be corrected or you will be open to understand or learn more. I'm just thinking the nature of like inpatient work, it's often really hard because a lot of patients are forced against their will to be there.

And there's something about the power structures that makes it really hard for anyone to be in that situation, let alone someone who maybe authority figures haven't been something that they can like trust in the past. or historic trust. So I think that needs to be taken into consideration as well. Like how do we optimize their free will and their free decision making? Any thoughts on that, Dr. Harrison? Yeah, there's a huge power dynamic, especially if you're in a situation where it's a white doctor, black patient, given the history of this country, or even another non-white physician.

a black patient. It's they're mistrusting or there's a distrust and it's deserving. Like they should have this mistrust. Like they call it a healthy paranoia. I think in the Whaley article that Shantel

found like it makes sense. Like this is not an symptom of psychosis. This is not paranoid schizophrenia. This is a reaction to what's happened in your life and what's happened in this country. What you've see in the news, what you've seen over history. So, you know, who wouldn't be mistrusting? And I think that

it's important to know that the oneness is not on the patient. It's not the patient's job to fix this. It is our health care system and the physicians who see these patients job to say, this is what's happening. I understand that. I understand what's going on. If this is something you're experiencing, you're completely entitled to that feeling. And I'm going to try my best to show you that I am here and to show my empathy and to do the best that I can to provide you the best evidence-based medicine and provide you with the optimal care because that's what you deserve. I know what's happened in history. And I'm going to try my best on this one-to-one level to write that. Yeah.

And I also think it's important for mental health care providers to consider, I guess, even block one. to consider even in non-mental health setting, like, let's say from primary care or just any other doctor's office, I can't tell you how many times, like, I've come into a room and I see a black patient and, like, their whole demeanor, they're like, it's like they seem happy to see me. And there are people who, I mean, in mental health, like, there's already that added stigma in society. And then even though, you know, you're being treated by someone that doesn't necessarily take away the feelings of, like, the fears of, like, being judged, being misunderstood, or like, oh, man, are they going to think I'm crazy? So, I mean, this goes beyond mental health.

And so consider that added layer, like now you have that context on top of the mental health. It creates a very, you can be a very frightening situation for patients. Like they don't feel like they have power. And they also don't feel like they're understood. They're like, they feel like an other in some senses, well, many senses. Yeah. Right. I think that the, so the positive in what you said is that I can't say there's not too many bigger cheerleaders for black medical students.

and trainees than like an older black woman who sees a black student or trainee come in because they know the history. They know what it took to get to this point. They know that they did not see black physicians when they were younger. So they are proud of you. And you're a stranger, but they are proud of you. They're happy to see you. And that is sometimes the best feeling that you have going through the grueling struggle of medical school and residency. And I think that it's important to understand that it's not just the patients who are experiencing this. You know, the students and residents and early career physicians also experience this. Shantel, do you see this paragraph that I'm highlighting here on the Google Doc? I think this

might be worth reading. And then I would like to hear some examples of what this might be so I can better understand this. Okay, yeah. This is your paragraph that you wrote, so you can read it from your perspective. Okay, good. Okay, I'll just, yeah. So yeah, I appreciate in that particular article, just the mention of how idioms and complex slang linguistic patterns and personal experiences can be misinterpreted. I mean, you know, with idioms themselves, like, they're already abstract in nature and oftentimes culture-specific, like, quick detour. Like, my parents are from Jamaica, and sometimes my mom will say some idiom like what does that mean and like you know it's important to ask what it means sometimes otherwise like especially if you're in a certain setting like okay this person's

crazy like what does that mean that doesn't make any sense so that's in one way one thing I'm mentioning but I guess back to the paragraph so it's understood it means understandable that they can be misinterpreted particularly when it's specific to a culture that's unfamiliar to the listener I mean even in everyday conversation people have different ways of describing you know their inner experiences, even things that happened outside of their own mind, like things happened to other people. So, I mean, just down to basic communication, it's important to ask questions and not jump to conclusions, especially in settings where conversation is like the main tool you have to evaluate something. And then I also went on to say, like, you know, people may have experiences

that can be difficult to relate to, but they're a part of the common human experience nevertheless. And so it's prudent to err on the side of caution and ask for clear. verification rather than assuming that the statement they're making is simply nonsensical. And one example I have from that in speaking with another medical student who was on psychiatry in a different state. They told me that they had a patient who was in there and he was talking about his experience. Like he was being interviewed and he mentioned that he was ear hustling. And the interviewer was white and then I guess she kind of thought it was an example of

disorganized thing. She's like, ear hustling. What does that mean? like, you know, takes notes like, okay, they said this thing. They just nonsensical statement. And ear hustling just means eavesdropping. And to be honest, I had not heard that term before the student mentioned it to me. But then I thought of, I'm like, okay, ear hustling. Okay, that makes sense. And like, I don't know, it made sense to me. But then like to the physician evaluating them, it literally seemed like, okay, this person really has issues. Like, like, you're probably

already thinking about the type of dose of medication you're giving them based on the statement. And it's like, this is a slang term. This has a meaning. You can go an urban dictionary if you don't want to ask them, but it does have a meaning. And it just means eavesdropping. But even something as innocuous as that, I mean, think of just a diagnostic implication. Like this person is literally labeling as disorganized behavior. So to me, I thought that was pretty alarming.

I mean, yeah, that's one major example I have. Yeah. Dr. Harrison, do you have any examples as well? to educate us on like what? Yeah, I can think of an example. It's funny that Chantel said she hasn't heard of Ear Hustle. There's a good podcast called Ear Hustle. Oh, I need to listen to that one.

You do. It's good. It's about the carciful system. Writing it down there. In California, actually, nonetheless, making a podcast from prison. But, yeah, I can say that I can think of a couple things. So as I said, I do consults throughout the hospital. I'm always trailed by students, residents who are always walking through the hospital and we went to go see a patient. And so people

will appreciate this for the culture. There's now a statement that people say, like, you don't want smoke. Like, you don't want smoke means like you don't want to start with me or you don't want to fight or you don't want to get into it with me. So you don't want smoke, Right, that's a current idiom person to language. So we had a patient who was psychotic and disorganized. And we were talking to her. And then the patient said, you know, you don't want smoke. And I said, okay, we need to get out of this room.

Like, let's get out of here. And one of our students who was not black or not from the black community, I asked her, do you know what? you don't want smoke means. Like, do you know why we have to get out of this room at this time? Because next, the patient might knock my head off. And she said, oh, no, I thought it was like about substances, like drugs, maybe. And I was like, no, it didn't.

But so that was a point that, you know, a good teaching to explain that, you know, people might not know those little cultural nuances. And, you know, I happen to be a millennial, but there are things that I don't even from the, what are the people after me, Gen Z? Yeah. Yes, Gen Ziers. I don't know what they're talking about all the time. So that was, that's one.

And then also, I think there has been documented and people have taught that you know when someone is manic or they have bipolar disorder, they might come in with a lot of bright colors, like matching in the same color from head to toe and then have the same like red hair. red lipstick, red outfits. And I think that people believe that that is a sign of mania. And I've had to explain, like, no, my patient is stable. She really just likes matching. Like when she comes into the clinic, she likes to change her hair. She likes to go with blue hair, blue lipstick, blue shoes all the way down to the socks. But that's what she wants to do. She's stable. She doesn't. Yeah, she doesn't need any higher doses of medications or mood stabilizing. there's this is not a sign of mania. This is just a sign of her really showing who she is to her culture.

Like this is not something that we need to be concerned about. But what you should pay attention to is when you see her, she's not doing that. She seems like she's not put together. Like maybe that's a sign that something's going on that she's not herself. Now, those are things that are important to learn. And those are important teachable moments as well. Yeah. Yeah, I definitely think seeing the pattern and then,

noticing the break in it. And I guess to me, that speaks to, I guess the benefit of having some continuity, the patient actually getting to know them instead of just assuming that's weird, that must be off. When that could just be their baseline, it's just something you don't understand. That's really good. We should put a perfectly stated, Shantel, but you just don't understand. We should put a list of these things in the blog so people can take a look at them. Oh, sure. Yeah. Good idea. I think one point is like if someone says something, that seems disorganized. It may be like, you know, can you now, after listening to this, think to yourself, okay,

are they just using a phrase that's, I'm not, I'm just not in that culture. I have no idea what that phrase means, you know, and be curious, write it down, maybe look it up in urban dictionary. And then on top of that, so if you're hearing these statements that don't make sense, and then on top of that, you're hearing like a little bit of paranoia, but the paranoia is like distrust in a system and you know authority figures it's like the combination of those two things may make you lean more towards the paranoid schizophrenia and just realize like those things may be actually normal and so you may be missing the mood disorder like bipolar you may be missing depression you may be

missing generalized anxiety disorder. And so hopefully after hearing this, you can start to step back and sort of deconstruct your own thought process, how you're getting there, and be more sensitive to the person's culture. Yeah, and I think a word on the paranoia, I actually remember being on the unit one time, and then we had a patient who actually, this patient was white, but he was talking about how my neighbors, they hate me, they hate me. they try that they harass me, they don't like me because I'm gay.

And I noticed that a lot of the team members were like, okay, yeah, this is part of his paranoia. And I thought to myself, well, what he's saying isn't really bizarre. Like, it's technically possible. And then later on, like his neighbor or a friend of his confirmed, oh, yeah, no, they hate him. Like, they are homopholes and whatnot. I'm like, okay, so this whole time it was being labeled as paranoia. When it wasn't really something bizarre, it's not like he was saying aliens were coming to get him. So, like, I mean, if that's even happening with, like, white patients and then,

on top of what goes on with black people, it makes me think it's very conceivable that, you know, they'd be labeled as being paranoid when they're wondering or being concerned, but even realistic basic things. Like I've had friends who've been followed around in stores for, you know, who knows. I mean, we know why. But like, it's like, what's the reason? And then, like, if you were to tell someone who doesn't understand that, they're like, okay, like, you need to just relax. I was like, well, no, sometimes these things can be real. You really need to listen and, like, think about it. Like, is this really abnormal? Like, what does this mean? Don't jump those, don't jump to conclusions on it. Yeah. So just, I use the word paranoid because of this one study

that you brought up, that specifically the paranoid subtype of schizophrenia is more commonly diagnosed. So I'm not saying that they are paranoid for having distrust. I'm saying that there will be more easily diagnosed as paranoid. I want to make that clarification. I just want to like specify that like, I'm saying that we could misdiagnose them. And that's what's happening or people are misdiagnosing them, right, based off of these things. Yes, it can lead to overdiagnosis. And also missed diagnoses, I think that we've said misdiagnoses. A lot of times you miss trauma.

I think that that's something that's significant, that you are focusing you being a psychiatrist is focusing on these quote unquote paranoid delusions. An important part of delusions is that we know it's not something that's shared. So if black people are worried about going outside and being stopped or pulled over by the police and they're saying that I don't trust this person, I don't trust this system, this authority figure, that's a real feeling. That's not paranoia. That's a real cultural norm that is the result of systemic racism and structural racism that's been going on since the inception of this country. So yeah, you need to ask about these things. I think you need to be comfortable asking about racism. You need to be comfortable asking about trauma. And I think I've said this before that there are other uncomfortable situations other uncomfortable topics like

interpersonal or domestic violence. People, that's a hard topic to approach, right? It's hard to ask questions about however it's done and you ask questions about that. So the same thing for racial and social injustice and racism,

it's the same approach, the same way you're able to ask those questions, you have to be able to ask these questions as well. Yeah. Any common ways of phrasing those questions that you think would be helpful for people to hear? So if there is an incident that is in the news that you know that's been in the media, don't ignore it. You can say, like, how did the Ahmad Arbery killing, how did that impact you?

Or were you affected by the result? of that trial, like, did the killing, the murder of George Floyd impact you in any way? And you can say it, even if you're not a black psychiatrist or a black psychologist, you can say and preface it with, I know that I don't know what this is like, but I'm trying to understand so that I can better help you. Is this something that you experienced? Is this something that people in your family experience? Is this something that you're worried about for your children? Yeah. I remember doing that to one of my black patients after to the George Floyd.

And the hardest part for her was how her coworkers who were not black were responding to her and what they were saying about it. And so I think it was helpful for her to have some empathy for how distressing that was and the divide it created. Yeah. And me not being black, you know, I think it's like, be ready to be wrong. You know, that's what I would say. I'm like, I think psychological safety is a good thing to work on here where it's like,

are you safe for someone to disagree with and you openly accept that you may not have all the answers, right? That you're not the expert. Be ready to be wrong and be ready to be uncomfortable. I know that this conversation can take an uncomfortable turn for you and you have to navigate that and you have to figure that out for and within yourself. But know that if you're here to help your patience, it's something that will come up and it's something that needs to be addressed. And you have to be okay with sitting in an uncomfortable space. And eventually it's possible that it won't be as uncomfortable once you are able to grow and get to the point where, hey, I have this knowledge. I'm able to have these conversations without feeling attacked.

Because, I mean, you know, no one likes to be called a racist. And no one wants to be labeled a certain way. But like, we all have shortcomings. No one likes to be wrong. You can be wrong, especially. I mean, not especially, but even as an expert, even as a person in this field, like there's always so much to learn. And so practicing with humility is definitely important. and being able to provide a safe space by explicitly using, you know, statements like, I mean, the fact that you ask your patient about it, that's really powerful and really important.

It's kind of a disarming thing to ask, and it kind of opens the floor to talk about, yes, this is how you really feel. This is how I'm experiencing life after this traumatic event that many people are, you know, sort of invalidating or even maybe saying it was deserved. So I think that's, I don't know, I just find it very important, very powerful. Yeah. Yes, I like that. And, you know, I think what's good about talking about this topic is it's something that we as providers can actually do something about. Like, we may not be able to fix other areas of systemic racism, right? But this is, like, one area that we actually interact with the world with, you know, like this study that showed that more people are diagnosed with schizophrenia.

This is, like, a recent study. This is not something that happened, like, 40 or 50 years ago. And it's like gotten better. Unfortunately, it really hasn't gotten that much better. I don't know. Has it gotten better from your, you probably know about this better than I do, Dr. Danny. Has there been progress in this one domain? No.

In short, no. Unfortunately, like I said, the studies that we've seen 30 and 40 years ago are still reproducible today. Like, we can still see that in studies from the 2000s that when psychiatrists were given, clinical vignettes with the same exact symptoms and the same exact presentation and they only changed the race and gender of a patient. There's still the overdiagnosis two times, twice as likely for a black person to be diagnosed with schizophrenia. And that's in the 2000s. So unfortunately, we see it continue on. It's pervasive. Yeah, it's easier, I think, psychologically, for me to look

like, oh, the judicial system, you know, that's their problem. They're the ones with a systemic racism. They're, they're the bad cops and the bad judges and, you know, like, but to think about it like happening in our own home, you know, in psychotherapy, in psychiatry, in centers, like, the University of Cincinnati, one of these publishers with studies, like, these are places where, you know, their tertiary care centers where education happens. It's like, um, um, you know, um, you're, I don't know if it hits the audience this way, but when it's like, it's easier to like just think that it's another person's problem, right? That like we could just point the finger at someone else. But for me, it's like I like to work on what are the small changes that we can make, right, as providers, as people seeing patients.

Yeah. Any thoughts on that? Just that how it might be psychologically harder. Yeah, I think that to your point. that we can say like, oh, yeah, it's the justice or the carceral or the legal system, or it's the government that is guilty with the systemic racism. However, we see it across the board and psychiatry is not any less guilty than these other entities and these other sectors. Like, this healthcare perpetuates racism all the time, just like housing, just like education, just like food

security and policies. And it's not just the courts. It's not just the police officers. Our specialty and medicine is implicated in this as well. Yeah, it's an unfortunate reality. Yeah. Nowhere is really untouched because, I mean, society is a system and within system, each part interacts with the other.

So it's going to bleed in somewhere. Yeah. Yeah. Yeah, I also think about, like, as we kind of go through this topic, it's like how can we provide value to the people that come into our office? I had a black house cleaner coming to my office who was working for someone else $15 an hour. And for me, it's like how do I create value for this person? And so I kind of took a little bit of a different role with coaching with this person.

I started talking about like, well, what would it look like to launch your own business? Like how would you go about doing that? How would you form your LLC? How much could you get paid if you were to go directly? And it was like these lights were going off in her like, oh, this is like doable, you know? And so, I don't know, just how can we bring value to the people that come into our room is something that's, I think, important, especially if they don't have the perspectives, maybe of how to build a business or, you know, simple things that we may take for granted. And not just the perspective, but the opportunities. So the lack of social or financial mobility for black people in this country is huge.

And it has a huge impact. And so not just that, oh, people don't have that perspective, but people have not had that opportunity. And not just that person hasn't had that opportunity, but their parents did not have that opportunity. and their grandparents did not have that opportunity. Like even when we think about as far as, I'm sure you can say that housing stability is a huge part of your patient's life. We see patients come into the ED because they're unhoused,

they're homeless. A lot of times patients on inpatient are hard to discharge and to do dispo planning because they literally have nowhere to go. And if we think about how did we get to this point, if we think about what opportunities were afforded to who, even when people were freed from slavery, they still had the sharecropping. I don't even know if I can say agreements or contracts where they always still owed the same people who used to own their family members. And they could never come up from that. So you don't have the ability for financial mobility. You don't have the generational wealth to pass down. And even if now you can say that there are white people who don't have generational wealth, but then you still have the opportunity. You still have the opportunities to get these loans. And you have the proof of funds.

And you have all these documents that are needed to go through the grueling process. So when you have a patient who says, I just need a home, I'm depressed because I have nowhere to go. It's not just, oh, well, they weren't business-minded or they weren't taught to. think about home ownership, they never had that opportunity. They were never afforded that chance. So that's what we really need to consider, like, the whole social determinants that are at play. And for me, all social determinants are rooted in racism by one policy or another.

So how do we make an impact when you can't change, like, Dr. Puder and I can't just go, well, I can drive past the White House and the Senate and Congress because I'm here in D.C. But we can't just go and say, all right, hi, it's time to make a change. Like, do this system all over. But what can we do to advocate for our patients and to really have comprehensive evaluations and bring in other collaborators and advocates and community engagement to help our patients in a different way. just what we prescribe or what the prescription is that they get for the day. Have you seen, I recently saw the movie The Banker.

Have you seen that? It was so good. It had, it's a, it's a story about these two black men who own a bank in L.A. And then they end up owning, they own the bank building in L.A. and then they end up buying an actual bank in Texas. And they were really into real estate in L.A. area. And it's a fantastic movie. Where is it on?

I think I watched it on like, I don't know. Maybe I watched it on like iTunes or something. Apple TV or something. Apple TV. The one thing I don't have is Apple TV. Okay, I'm going to. I have every other streaming platform. So the thing that really dawned on me was even in like, I think it was the 60s, like it was really, really hard to get a loan.

And no one wanted to give a black business alone. And it was a whole lot easier. Not even just the 60s, Dr. Peter. Like right now for me to buy my first home and property, me as a several figure physician employed. the grueling process, even for me to get a home loan, it almost deterred me. I almost said, like, I can't continue to go through this just because of the process. So it's still even, yes, the 60s and 2019, it's still difficult. Yeah.

I would hope it wasn't as bad, but I'm, like, not a homeowner. And I've not tried to buy home. So anyway, yeah. But I, oh, yeah, it's, it's a home. horrible. Anyways, in the movie, they end up buying this bank in Texas. It's like the hometown and it's still incredibly racist in Texas. And they do it secretively with like this white sort of like front person. And there's this just kind of like you're just happy that they did this, right? But then they, but then you see the sort of this, this white guy makes a couple moves without

their knowledge and ends up like blaming them as the ones that told them to do it so they like lose everything it's it's really oh gosh i wish i i hope i didn't it's okay i'm still i'm still going i hope i didn't take away the the ending for some people who want to watch it but it's like it gives me like this glimpse and i'm i'm sorry that it's so hard for you to get a home loan at this point. I think it's yeah, it was, it was a grueling process that it can also be like demoralizing.

But to your point that that is something that black business owners had to do a lot in the I guess turn of the century, but even in the later 50, 60s and 70s, has a front

white person to purchase things for them. And then there would be a lot of corruption and scandals because then the white person might say, oh, well, never mind. Like, I'm not going to give you your money back. Or I know I put it in the bank, but I'm not going to give you the information. That happened. That is what really led to people developing, quote, unquote, black Wall Street and other black

driven towns, like in Tulsa. So that was something that people have been doing because that was the only way to get things done. Yeah. Yeah, that happens at one point in the. He's doing so good. He's so smart. He's making moves. And then his business partner dies, who's white. And the wife, the business partner was a gracious person, not racist. His wife, racist. And so he's up against this wall. And it's like he's getting pennies for the dollar from her. Oh, it's painful. Okay. The banker. Yeah, get it. The acting is superb.

Really superb. Yeah, okay. Kind of coming back to this topic, any final things that you would want to put out there as like action points that providers can do? I'm looking at Chantel's list over here, putting it all together, how psychiatrists can do better.

I like all of these things. Be familiar with how symptoms may present differently in other racial groups. I know that all symptoms don't manifest the same way. And even within one racial group, everyone is not a monolith. Things might come across or manifest in different ways. And I think that it is important somewhere I saw in Chantel's notes to note that we know that the psychiatric workforce does not match the makeup of this country. Like there are not enough black psychiatrists.

So it is up to non-black psychiatrists. and the group that dominates this world is white men like you, Dr. Peter. So it's up to you all to make a change and to advocate for your patients, to advocate for equity in treatment. I can't say that everyone advocates for public policies, but that is something that I noticed students doing, and I am here for that. But advocating for your patients, just giving them the treatment,

them the treatment that they're supposed to give, asking yourself, why am I using this high dose of howdoll? Would I use this high dose of howdoll in a white woman? Would I do the same thing? Like, stopping, asking yourself these tough questions. Yeah. And I hope that my listeners can check out your podcast. And I think that that process of sort of binging on, you know, knowledge of people who are in the midst of it can be very, very helpful. And I think we will, you know, in the last podcast I had you on, I said, I'm going to have you back. We're going to have a continued conversation. So, you know, we'll put together another topic.

Maybe if Dr. Fletcher comes to your psychiatry program, she could help you out, get some. You know, I'm excited to see. She's coming over here to the East Coast. we will know in a couple weeks we will know. But yes, thank you for talking about my podcast because I think that it's important to have the perspective of people who are living this and have lived this. And also for the perspective, of course, of people like you and I, people who treat these issues, but people who are involved in public policy, people who are in the legal system, people who are peer advocates and community advocates. So we try to really make it all encompassing the next 72 hour podcast. And yeah, I can come back after, after interview season this time.

Oh, for sure. Yeah. Yeah. No, and I know you're very busy. So I appreciate your time. And I think the next 72 hours, that's it, right? Yes. And so we'll send some people over there.

Thank you. And who does your editing, by the way? So I have a great, great team. And one of them is on break right now. But I have a great podcast team. So one of our editors is Susan, a young black woman. And the other is Karina. And like I said, my co-host is Noezy. And we are, we really work together to produce, like to, you know, come up with the show knows. questions are who is going to find guests but uh susan is our main editist um main producer and then we also have korena who is not a black woman like the rest of us but an ally and uh who's really dedicated to the cause as well all right that's great well thank you so much for coming on oh shantel do you have something else last thoughts i would like to say yes i would like to say it would be awesome if we could get people who actually have power like politicians or whoever to listen to these

podcast. Like, I feel like going on Twitter right now and just spam their profile me, like, listen to this. Listen to this. Yeah. Yeah, I think that could be really great if they could hear what we're having to say. I agree. Well, we've got to get in their ear. You know, so what I would say is if you're a medical student, a resident, and you're on service and you notice the attending or, you know, the person in authority escalating that dose pretty high, you know, see. if you can have a little bit of a voice and be like, hey, are you aware that there's this statistic that, you know, black men are eight times more likely to be put on a higher dose of an antipsychotic and, you know. And just ask it in an inquisitive way. Like, I'm just wondering why we're going so high with this dose because I didn't see us use such a high dose in the patient that we saw yesterday or this morning or last week.

Can you explain that? Like, put them in the spot, but from a point of education. like inquisitive. Like I'm just trying to understand why we're doing this. Make them explain themselves to you. Yeah. Yeah. One other thing.

I also, I think it would be so nice if like they're a little easily digestible education, like pamphlets or just some materials we can give to patients that they can get a better understanding of their diagnosis. Because sometimes I feel like patients will receive a diagnosis, but they don't necessarily know all of, I guess, what goes into it, what other manifestations and other patients may look like. I think if they have education on their own illness, other similar illnesses, like the health care system, it can really help them

navigate better and also advocate for themselves because we won't always be able to be with them. But if we can give them the skills that they will always have with themselves, I think they can also help and get better treatment. And I will say on that, Chantal, that mental health America has done a great job with information for patients. And I think it's digestible and easy to understand. And then as far as so mental health America is a group that I've worked with before. And then also NAMI has good information for how to navigate the mental health care system and having patients not just themselves, but their family members act as advocates. So those two organizations I like to big up because they have good information that I think is accessible.

Well, the digital divide is another topic. but could be excessive. Yeah. And it's easy to understand. Dr. Harrison, are you, last time we talked about like the more public psychiatry organizations and like how you felt like there was room for them to grow in this area? Have they grown in the last year since our last episode? So that is a good question, Dr. Peter.

So a few months ago, I was interviewed by the New York Times for article. And I said that, yes, the organized medicine group that I am a leader in still has room to grow. I think that they are getting better, especially with educating the education piece. I feel like that is improving. People are still not always willing to accept that there's systemic racism in psychiatry or even in our organized medicine organizations. However, there's room. There's a lot of room to grow. And it starts with really accountability.

Like people need to acknowledge the role that psychiatry has had in these issues and in the structures and systems at play here. So yes and no, they're making some steps. Not enough yet, though. Okay. All right. More to be revealed, right? More updates to come. All right.

So good to have you guys on. And we'll leave it there for today. Yeah, thank you. Well, thank you. That was great. You know,