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Schizophrenia, epidemiologists, and race? Not a good mix.

December 2, 2009

Nigel picked up the November issue of Scientific American to read on the train, particularly interested in the cover story on chronic pain research. (Another story entirely!) I was leafing through it, and one piece initially looked promising: JR Minkel’s Putting Madness in Its Place: Can the Environment Explain Schizophrenia’s Hereditary Patterns?. A good bit of this references a July article online at Nature (no link offered), put out by the same publishing group.

In the latest attempt, three crack teams of investigators pooled genomic data from 8,000 schizophrenics of European ancestry but could lay claim to only a handful of weak genetic risk markers…
In particular, devotees of genetics might want to cede a little ground to their colleagues in epidemiology, who over the past decade have amassed a provocative, interlocking set of studies implicating urban birthplace and migrant status as persistent risk factors.

I was with them until they mentioned epidemiology. Huh?

And the too-predictable biopsych explanations begin.

Researchers believe the potential for schizophrenia starts to emerge during early brain development, beginning in the womb…

Although the nature of the exposure remains obscure, researchers were able to narrow down its timing: Danes who lived in urban centers for the first 15 years of life had the most elevated risk…

A second wave of findings has documented that immigrants to European countries are at heightened risk of schizophrenia as compared with native-born residents. Second-generation immigrants show increased risk relative to their parents, and rates are highest among those of African heritage. In a study of three cities in the U.K., Afro-Caribbeans were nine times as likely as the general population to be treated for schizophrenia…Despite the consistency of the findings, epidemiologists who work in the field say scientific journals in the U.S. have shown reluctance to consider papers that explore the relation between race and schizophrenia…

Hence, it was not until 2007 that Michaeline Bresnahan, Ezra Susser and their colleagues at the Columbia University Mailman School of Public Health cautiously published data from a cohort of 12,000 Californians enrolled in the Kaiser Permanente health plan, which showed that the rate of hospital admission for schizophrenia was twice as high for African-Americans as for whites, even after controlling for socioeconomic status of the parents. Because the cohort was part of the same health plan, reduced access to health services was unlikely to account for the discrepancy, Susser says…

…those born into more densely populated neighborhoods are at twofold to threefold greater risk of schizophrenia than those born in less dense areas, irrespective of race. Residents of more run-down or overcrowded city neighborhoods could be more exposed to toxic chemicals and infections, she says, and may have less access to social capital that would blunt the effects of a predisposition to mental illness acquired early in life.

In an attractive synthesis, such neighborhood-level risk factors might impart lasting epigenetic changes—the chemical overwriting of the genome in response to environmental cues. If true, the roots of schizophrenia would lie where geography and genetics meet.

I know this is coming from an epidemiological perspective, but I’m still gobsmacked. Looking at environmental factors, these researchers head straight down the rabbit hole and start dreaming of epigenetic changes from toxic chemicals and infections.

Remember, this author admits that “the condition’s genetic underpinnings have stubbornly resisted discovery. In the latest attempt, three crack teams of investigators pooled genomic data from 8,000 schizophrenics of European ancestry but could lay claim to only a handful of weak genetic risk markers.”

Surely that’s a blow to biopsych hypotheses of origin, eh? Maybe the genetics-based chemical imbalance hypothesis of schizophrenia is about as reasonable as when it’s applied to depression? (That article is excellent.) Could they possibly admit that they have no freaking clue what is going on with mental illnesses in general, or maybe that they’ve been ignoring it while it’s been staring them in the face?

Of course not. Silly me.

I continue to be amazed–reasonably given some experience, or no–at these researchers’ ignorance of other, more plausible explanations for racial and immigrant-status differences in diagnosis. Epidemiologists may not have been writing about this a lot, but people in other fields certainly have.

The information, and lines of thinking, in one article from the American Psychiatric Association are hardly new: Issues in the Psychiatric Treatment of African Americans. That link leads to a section on “Psychiatric assessment and evaluation”. What do the authors have to say about this?

Issues that create particular concern in the assessment and evaluation of psychiatric conditions among African Americans include diagnostic bias and selection of appropriate screening instruments. Clinicians must also be aware of the impact of the patient’s psychosocial context on the assessment process. Many African Americans live on marginal incomes in high-crime areas where high rates of drug abuse and unemployment produce chronic stresses…

Since the 1970s studies have reported overdiagnosis of schizophrenia and underdiagnosis of affective disorders among African Americans, compared with the overall prevalence of these disorders in the psychiatric inpatient population (11,12,13,14,15,16,17). However, when diagnoses were based on structured clinical interviews and Research Diagnostic Criteria or diagnostic criteria from the Schedule for Affective Disorders and Schizophrenia, African-American inpatients were shown to have rates of schizophrenia and depression similar to those of whites admitted to the same inpatient units (18,19,20).

Hmm, so we have overdiagnosis of schizophrenia, along with admission that being under chronic stress might have something to do with whatever problems this population is showing.

Kinda like Stress of racism can cause premature births for black moms, historical/multigenerational trauma is believed to cause an awful lot of chronic health problems for a variety of minority groups, and so on (and so on). I went into some of this in Measuring Up?!, and turned up some research directly linking the stress of racism to Type 2 diabetes and other conditions.

I can’t help but be reminded of the Bonkers Institute’s Therapeutic Efficacy of Cash in the Treatment of Anxiety and Depressive Disorders: Two Case Studies. Along with the author’s exposé of NHS cartoon brochures for kiddy antipsychotics, which must be seen to be believed! I wonder how many of the kids getting them are not from White British backgrounds? Here’s an appalling report on How schools fail black boys, focused on London.

MIND in the U.K. also offers an excellent view of The mental health of the African Caribbean community in Britain. (Interesting on the social control front: “Furthermore, Fernando has already argued that the knowledge base of psychiatry grew at the same time when slavery and colonisation were at its highest. [25]”> A lot of it sounds very similar to the The mental health of Irish people in Britain factsheet I linked to before (since it more closely mirrors my own situation as a lighter skinned immigrant from a colonized background): “As well as poor physical health, Irish people in Britain have a high incidence of mental health problem – well above the rates for other migrant groups (with the exception of psychosis in the African-Caribbean population)… a high number of people admitted with mental health problems also have a physical disability.”

In the U.S., the almost 67% of Native Americans living in urban settings (PDF), especially women, also have a high rate of physical and mental health problems and overdiagnosis. From this page, “Suicide is the second-leading cause of death among AI/AN people age 10 to 34 (CultureCard, 2009). Available evidence suggests that mental illness, mental dysfunction, or self-destructive behavior affects approximately 21% of the total AI/AN population, costing an estimated $1.07 billion and incalculable human suffering (Duran et. al, 2004).” It’s hard to tell how they get those figures other than for suicide rates, since “Native Americans are routinely omitted from many studies. Two major US prevalence studies—the Epidemiologic Catchment Area Study 1 and the National Comorbidity Survey 2—do not report data on Native Americans, or indicate that statistics on this group are difficult to specify (Duran et al., 2004). In the National Healthcare Disparities Report, only 42% of the measures could be used to assess mental health disparities among Native Americans (Moy et al., 2006).” We are not even supposed to be around anymore, so there’s no need to study our health. If that’s not marginalization, I don’t know what is.

I wonder how all these similarities have come about?

Research documents that many members of minority groups fear, or feel ill at ease with, the mental health system (Lin et al., 1982; Sussman et al., 1987; Scheffler & Miller, 1991). These groups experience it as the product of white, European culture, shaped by research primarily on white, European populations. They may find only clinicians who represent a white middle-class orientation, with its cultural values and beliefs, as well as its biases, misconceptions, and stereotypes of other cultures. #

Fancy that.

And could it possibly be even more stressful moving into a seemingly chaotic, noisy, overcrowded, overwhelming urban center if you have not been accustomed to living in such an environment? Much less when you run into a lot more overt racism in this new environment? Could this make it more difficult for you to regulate your emotions and thoughts, while you feel constantly bombarded?

Tim Desmond makes some excellent points: Do people suffer from psychiatric disorders/diseases or do people experience varying degrees of human suffering in their own idiosyncratic ways? . Maybe we should reconsider the way we’re looking at the whole thing.

Looking at the epidemiologists’ take on mental health issues, I can’t help but think of the (ludicrous) mercury in vaccines hypothesis of autism. Anything to avoid looking at the kind of social conditions people are living under, much less questioning whether trying to make everyone act or be the same* is a good thing! Surely all we need is more Balance in a Bottle.

The racial/ethnic angle is particularly galling. Gods forbid that we should admit that racism is hurting people. It’s surprising that more members of minority racial and ethnic groups are not breaking under all the stress. Still, we’re far more likely to be deemed crazy and put on (expensive**) dangerous medications for it, sometimes even paid for by the state. It’s hard not to see social control in action here.

Edit: I just wrote another post, Racism 101: poverty, race, and health threats, about a major source of anger I forgot to mention here.


* And you can bet that’s by upper middle class, dominant culture, White male standards, oh my.

** My cousin’s son is one of the (non-White) “doped to the gills on Medicaid” statistics in Virginia. Pretty much since he started school, he has been turned into a zombie. He started out “disruptive”, and couldn’t even follow a conversation the last time I saw him.

5 Comments leave one →
  1. December 3, 2009 12:54 am

    Given the extent to which white people see black, Latin@ and Native American people as so much angrier and more aggressive than similarly-behaved white people (and also given the stigma attached to people with schizophrenia, that they are violent and unpredictable), higher rates of schizophrenia diagnosis in black people do not surprise me at all.

    I think another thing that gets diagnosed in black people a lot — in this case, black children, mostly boys — is Oppositional Defiant Disorder. I think that’s an indication of whose acting-out is socially acceptable: white boys are supposed to be rambunctious, energetic, domineering, but black boys who act similarly are Trouble, and seen as miniature thugs.

    Kristina Chew also has an interesting (though old) article on about differences in how autistic young adults are treated based on gender, size and color. Her son is getting to be very big, and she’s worried that, if he ever has a meltdown in public, authority figures might deem him a Serious Threat and try to restrain him violently. Big, dark-skinned young men with mental illnesses or developmental disabilities are at a huge risk for being attacked or killed by authority figures thinking they’re a threat.

    • urocyon permalink
      December 8, 2009 12:51 am

      Excellent points! The “irrational anger” (in the eye of the beholder)==craziness bit did get worked into another post on marginalization, but I completely forgot to mention the perception of more physical threat from particularly non-White men and boys.

      Yep, I’m glad Oppositional Defiant Disorder was not a popular diagnosis when I was a kid (not sure if it existed under that name yet). I’ve thought more than once about how often it surely gets inappropriately applied, based on social expectations, as you point out.

      Thanks for the link to Kristina Chew’s article. That would be worrying. 😐

    • urocyon permalink
      December 18, 2009 1:57 pm

      I ran across an interesting writeup of a study on this sort of thing: Racial Bias Kicks in Quickly.

      Despite that egalitarian attitude, according to new Northwestern University research, subconscious — or implicit — bias can emerge subtly but quickly from its hiding places in the psyche and cause even well-meaning whites to look at identical facial expressions of African Americans and European Americans and see greater hostility in the African American faces.

      Or take whites’ perceptions of racially ambiguous faces that combine both African American and European American features. If the expression on the racially ambiguous face is hostile, European Americans are more likely to identify it as African American. . .

      A self-fulfilling prophecy may be among the most troubling consequences.

  2. Kelly Butler DVM and epidemiologist by vocation if not specific training permalink
    December 8, 2009 7:10 pm

    You have made some very interesting connections.

    First may I suggest that the reason that “the condition’s genetic underpinnings have stubbornly resisted discovery” is very likely that epigenetics has only been “discovered” these past 10 years or so. Scientists need to be able to understand the alphabet before they can read the message.

    Epidemiology is a critical tool to piece together information, but as you are no doubt aware, it is important not to confuse causality with correlation – do umbrellas cause rain? Is schizophrenia more common in racial groups? (Hint – the answer is no in both cases, but it sometimes looks like yes when its raining – not being patronizing – one is about as likely as the other)

    You have also touched on some important connections between stress and mental health. Stress at a larger level might be considered child abuse. For interest, look at this list of adult outcomes of child abuse –
    (page 69)
    Psychological and behavioural
    Alcohol and drug abuse
    Cognitive impairment
    Delinquent, violent and other risk-taking behaviours
    Depression and anxiety
    Developmental delays
    Eating and sleep disorders
    Feelings of shame and guilt
    Poor relationships
    Poor school performance
    Poor self-esteem
    Post-traumatic stress disorder
    Psychosomatic disorders
    Suicidal behaviour and self-harm

    These ARE the challenges in Aboriginal communities including Native Americans/Native Indians as they are in Maoris, Aborigines and other Aboriginal peoples whose children were abused. (the definition of abuse is in the same chapter noted above)

    The reason that it can be observed is that someone is counting. We are counting in Canada and they are counting in Australia and New Zealand.

    On chemical imbalance – absolutely – the job of DNA is to set out the pattern for proteins that are to be made. High levels of stress – specifically high levels of glucocorticosteroids in the brain – cause a diminishment of glucocorticosteroid receptors – the brain gets overwhelmed and shuts down the receptor sites. The result is that some proteins don’t get made.. This is an epigenetic effect that is passed down to the next generation and the next ad infinitum with some epigenetic effects identified to date. In some cases such a switch can be reversed, but I don’t know about the possible schizophrenia application..

    Many social scientists have observed that the disposition to poor school performance, aggression and drug/alcohol abuse (the whole of the WHO list of adult outcomes of child abuse has not been tracked) seen in extremely poor neighbourhoods in the US has been reversed with an early intervention known as Head Start. 50 years of evidence.

    One might suggest that mainly African American children were the beneficiaries.. does that mean they were more disposed? Or maybe it had to do with poverty – and the resultant high stress on single moms or families, and not just inadequate but appalling early child care.. The WHO might rightfully call that abuse. Not the intention of even the most loving mom who has to go out to work to feed those children.

    Again, you hit another important link – yes, the Irish have that ugly history of being “drunken, brutal/aggressive” people. That is also my background. Poverty pushed those colonized people to the edge in the 19th century when they left their youngest children with the Church orphanages once they were about 4 or 5 years of age. The interesting thing about epigenetics – again, its intergenerational nature.

    There certainly has been racial bias in overdiagnosing mental health problems in people of certain races – when you expect to see things, you likely will see them.

    So, no, it is not about race. We are just beginning to understand what mental health is about.. The challenge that I am having right now in bringing my epigenetic hypothesis to the scientific literature is that some clinicians do not know enough about epidemiology to connect the dots across cultures and across disciplines to see the impact of abuse (you may read stress here as that is the chemical basis) No doubt you can understand that the list above has generated a lot of “experts” in each field – drug abuse, alcohol abuse, poor school performance, suicide and so on.

    It is tough to knit things together now that the quilt of childhood challenge has been pulled apart. But it is critical because the list of challenges above can be reversed.. not sure about schizophrenia. That will be for another mind. Thanks for your insights.

  3. Dr Scott Kanner permalink
    March 5, 2011 6:11 pm

    Its all about vitamin d status….

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