A study by Eack and colleagues reported in this issue found that African Americans were more than three times as likely as whites to receive a schizophrenia diagnosis. Study clinicians were asked, “Did the patient appear to be responding honestly?” Data analyses indicated that the disparity was strongly related to perceived honesty. Apparently, the clinicians did not trust African Americans' responses to queries about their symptoms and may have made diagnostic inferences based on a suspicion of symptom denial, poor insight, or uncooperativeness.

Diagnosis of psychotic disorders has been subject to different types of bias over the years. International studies documented an overdiagnosis of schizophrenia in the United States compared with England. In those early studies, a key observation was that psychiatrists trained in America gave more attention to psychotic symptoms and less attention to mood changes in making a diagnosis. In the 1980s, the Epidemiologic Catchment Area study reported similar rates of schizophrenia across U.S. racial-ethnic groups, but clinical studies began documenting an excess of schizophrenia diagnoses among African Americans, even when structured interviews or blinded assessments were used, which seemed to result from inherent biases. Clinicians seem to “overvalue” psychotic symptoms among African Americans and this skews diagnoses toward schizophrenia.

In England, high rates of psychosis have been reported among Afro-Caribbean immigrants in both epidemiological and clinical studies, even though rates of psychotic disorders in Jamaica are not notably high. Diagnoses of psychosis given to Afro-Caribbeans by white psychiatrists may be based on the notion that the person is “strange, undesirable, bizarre, aggressive, and dangerous.”

Humans have a propensity to label people or things on the basis of initial impressions. A single word or event colors perceptions and serves as a lens or construct that influences judgments. In diagnosing schizophrenia, bias may include elements of discrimination and stigma. In clinical venues, it is likely that schizophrenia may be more stigmatized than other disorders, given historical assumptions about its predominance in lower socioeconomic groups and its having a poor outcome. White clinicians may view black patients with suspicion and fail to understand cultural nuances that may provide clues about other diagnoses.

The disparity does not appear to affect other U.S. minority groups, such as Hispanics. Although structured interviews and instruments that force examiners to focus on objective data are helpful, there is much evidence to indicate that no matter how much we operationalize or structure the process, psychiatric diagnosis is not yet “color blind.” Training that emphasizes awareness of potential biases and detailed vignettes highlighting cultural nuances and types of clinical presentation is essential.