“Either their symptoms or presenting concerns are minimized, and they are not given any care, or they are given a completely different diagnosis and one where the treatment can be detrimental to the progress they need,” says Taish Malone, PhD, a licensed professional counselor with Mindpath Health in Fort Worth, Texas. For instance, people of African descent with bipolar disorder are more likely to receive an incorrect diagnosis than people of European ancestry with the condition, according to an article published in September 2018 in Bipolar Disorders. And Hispanic people with bipolar disorder are less likely to get the treatment they need than white people with the condition, per a small study published in the Journal of Racial and Ethnic Health Disparities. The consequences of bipolar disorder that’s not properly diagnosed and treated can include worsening bipolar symptoms or even suicide, say experts at Sierra by the Sea, a residental mental health treatment center in Newport Beach, California. These disparities have many cultural and societal causes, likely requiring multifaceted solutions. Here’s what researchers know so far about racial and ethnic diagnostic and treatment inequities in bipolar disorder — and ways to solve the problem.
Bipolar Disorder: The Misdiagnosis Problem
Black people with bipolar disorder are more often misdiagnosed with other conditions than white people. One of the most common ones is schizophrenia, according to the aforementioned article published in September 2018 in Bipolar Disorders. Factors that may drive these disparities, wrote the authors of the paper, include racism, discrimination, poverty, mistrust of the U.S. health system, and difficulty accessing health services, among others. These inequities are dangerous, experts say, because medications made to help people with schizophrenia are often different from medications used to manage bipolar disorder. “Misdiagnosis is serious and can lead to individuals being prescribed the wrong psychiatric medication, which can cause many health complications,” says Ernesto Lira de la Rosa, PhD, a psychologist in private practice in New York City, and a media advisor for the Hope for Depression Research Foundation.
Communities of Color Hesitate to Turn to the Mental Health Care System for Help
In the United States, people of color tend not to seek the help they need from the healthcare system. Over time, systemic racism — racism embedded in societal systems and structures that reinforce inequalities and oppression on an institutional level — in the health system has caused mistrust among marginalized racial and ethnic communities, making them less likely to seek the care they need. One well-known example is the U.S. Public Health Service (USPHS) Syphilis Study at Tuskegee, in which 399 African American men who had syphilis were denied treatment on purpose. This mistrust has infiltrated every aspect of seeking care from the U.S. health system among communities of color, and care for bipolar disorder is no exception. Out of 163 people with bipolar 1 or 2 disorder, none of the 26 Hispanic participants were taking mood-stabilizing medication, a crucial component of treatment, compared to 21 percent of non-Hispanic white participants, according to the aforementioned study published in April 2016 in the Journal of Racial and Ethnic Health Disparities. What’s more, Hispanic people with bipolar disorder were less likely to see a mental health professional for manic episodes or go to talk therapy than non-Hispanic white people, the study showed. Studies of Black people with bipolar disorder have produced similar findings. In a study of 167 respondents to the National Comorbidity Survey Replication who had bipolar 1 or 2 disorder, none of the 30 Black people included in the study received minimally adequate treatment to stabilize their mood, compared with 17 percent of white patients in the study. Furthermore, Black people were less likely than white people to have taken mood-stabilizing medication within the previous year. The study was published in February 2014 in Psychiatric Services.
Other Barriers to Care
Systemic racism and mistrust of the health system aren’t the only reason people of color in the United States aren’t getting the care they need. Here are three other possible contributors.
Mental Health Stigma Keeps People From Getting Help
Stigma around mental health is common in Black communities, according to Mental Health America. In fact, many African American adults are not open to discussing mental health issues and view mental health conditions as a sign of weakness, according to a study published in Nursing Research. These perceptions can impede members of these communities from seeking the help they need. This stigma is prevalent in Hispanic and Latinx communities, too, with mental health issues often viewed as a sign of weakness or something to be kept to oneself, Cleveland Clinic experts say.
Lack of Racially Diverse Mental Health Providers Means Fewer People of Color Can See a Professional Who Understands Their Lived Experiences
People who share the same racial or ethnic backgrounds as their doctors are more likely to report a better care experience than those who do not, suggests a study published in November 2020 in the journal JAMA Network Open. However, in 2015, 86 percent of the psychology workforce was white, according to a February 2018 report from the American Psychological Association. In comparison, 5 percent of that workforce was Asian, 5 percent was Hispanic, and 4 percent was Black or African American. Similarly, only 2 percent of the psychiatry workforce is Black.
Lack of Health Insurance Often Means Lack of Access to Care
People in African American or Hispanic communities are less likely to have health insurance than white people, and as a result are often less able to access the mental health care they need, states a report from The Commonwealth Fund, an organization geared toward improving health equity both nationally and internationally.
Solutions to Alleviate Racial Disparities in Bipolar Disorder
While research that raises awareness of racial and ethnic disparities in mental health care is important, experts say that calls for change will be fruitless unless professionals address systemic racism. “Awareness is not enough and reframing from the ground up is needed to adjust the infrastructure of those in the field to have the knowledge, skills, qualifications, compassion, and capacity to effectively serve a population of diverse clients,” says Dr. Malone. Malone suggests that, in aid of that, professionals need to:
Engage in relevant, timely diagnostic training, and keep abreast of knowledge about how bipolar disorder and its variations present in different populations, including marginalized racial and ethnic communitiesContinually reevaluate and adjust their process as needed based on emerging research
In addition, Dr. Lira de la Rosa recommends that psychologists and psychiatrists work with trusted community members and groups in marginalized racial and ethnic communities to help repair the trust that’s been repeatedly broken by systemic racism in the U.S. healthcare system. “These systems need to work with community members in these respective communities to understand the mistrust of the medical and mental health profession,” Lira de la Rosa says. For example, a psychologist or psychiatrist can hold events about mental health stigma and why it’s important to address it at a trusted location within these communities, such as churches or community centers. “They can then work with these communities to increase awareness of mental health disorders and provide referrals for culturally sensitive providers,” Lira de la Rosa adds.
Another Key Step: Train and Equip More Mental Health Providers of Color
People of color with bipolar disorder may feel more comfortable working with psychiatrists and psychologists from their own communities, say Malone and Lira de la Rosa. This is also why it is important that psychiatry and counseling programs are inclusive to students of color, as they can support patients of color. In the meantime, there are many resources to help people find psychiatrists and psychologists of color if they prefer to work with a mental health professional with a similar background to them. For example, the New Hampshire chapter of the National Alliance on Mental Illness (NAMI) recommends the following:
Black Emotional and Mental Health CollectiveInclusive TherapistsInnopsychLGBTQ Psychotherapists of Color DirectoryNational Queer and Trans Therapists of Color NetworkPsychology Today Directory of African American TherapistsTherapy for Black GirlsTherapy for Black Men
