Schizophrenia, epidemiologists, and race? Not a good mix.
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. ”> 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. #
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.