Interviewer-Perceived Honesty Mediates Racial Disparities in the Diagnosis of Schizophrenia

Background and Purpose: African Americans are disproportionately diagnosed with schizophrenia, and the factors that contribute to this disparity are poorly understood. Disparities in mental health services are prominent in African Americans, who receive less services, more coercive methods of care, and poorer quality of treatment. Differences in the mental health services received by African Americans have led to poorer outcomes in this population, and one of the most consistent disparities observed is the increase in the diagnosis of schizophrenia. Unfortunately, little is known about the contributors and potential mechanisms behind the over-representation of schizophrenia diagnoses in the African-American community. Therefore, this study examined the impact of racial differences in sociodemographic characteristics, clinical presentation, and interviewer perceptions of honesty on disparities in the diagnosis of schizophrenia in African Americans.  

Method: Seven hundred and fifty-two participants from the MacArthur Violence Risk Assessment Study were recruited by consecutive psychiatric inpatient admissions; African Americans (n = 215) and whites (n = 537) were administered structured diagnostic, sociodemographic, and clinical measures while hospitalized. Interviewer questions about their perceptions of the honesty of participants during diagnostic interviews were also administered and its potential impact on racial disparities in the diagnosis of schizophrenia was examined. The analytic approach examined: (1) differences in diagnostic rates of schizophrenia between African Americans and whites; (2) potential contributors to the effects of race on schizophrenia diagnosis; and (3) the indirect effect of race on schizophrenia diagnosis by sociodemographic, clinical and perceived honesty characteristics.

Results: African Americans were over three times as likely to be diagnosed with schizophrenia (n = 97, 45%) compared to whites (n = 101, 19%), and disparities in sociodemographic and clinical characteristics modestly contributed to disparities in diagnostic rates. Given that clinical and demographic characteristics could not account for the increased diagnosis of schizophrenia in African Americans, and a series of logistic regression models were employed to examine whether perceived honesty during the research interview was a potential contributor. Results showed participants were nearly 1.5 times as likely to receive a schizophrenia diagnosis if the interviewer perceived them to be dishonest during diagnostic assessments. Interviewer perceived honesty significantly predicted racial disparities in schizophrenia diagnoses when accounted for (all p < .01), and markedly reduced diagnostic disparities between African Americans and whites. Mediator analyses confirmed that interviewer-perceived honesty was the only consistent mediator of the relationship between race and schizophrenia diagnoses (p = .011). 

Conclusions and Implications: The results of this research show interviewer perceptions of honesty are significant and strong mediators of racial disparities in the diagnosis of schizophrenia in African Americans. Indeed, interviewer perceptions of participant honesty are important contributors to disparities in the diagnosis of schizophrenia among African Americans, and may be reflective of poor patient clinician relationships. The findings of this study signal a critical area for social workers to focus on developing better methods toward facilitating trusting relationships between patients and clinicians in order to improve the assessment and treatment of minorities seeking mental health care.