Pathways to Care for African Americans With Early Psychosis

Differences in rates and patterns of mental health treatment have been observed between African Americans and whites. In the report titled Mental Health: Culture, Race, and Ethnicity ( 1 ), then-Surgeon General David Satcher highlighted the racial, ethnic, and cultural disparities in mental health services for African Americans. This population tends to be underrepresented in out-patient care and overrepresented in inpatient and emergency care. Failure to receive outpatient care early during episodes of mental illness contributes to increasing rates of hospitalization, lengths of stay, long-term functional disability, and poor outcomes among African Americans. Routes of access to psychiatric services are often less desirable among African Americans, with higher rates of involuntary civil commitment and police involvement. Moreover, when African Americans receive mental health care, the care is often of lower quality compared with the care that whites receive. Despite these and other well-documented disparities in mental health care for African Americans, little is known about the nature and extent of treatment delays for those who have psychotic illnesses. This article describes factors contributing to treatment delays among African Americans with psychotic illnesses and emphasizes the need for further research.

Treatment delays in early psychosis

Psychotic illnesses cause significant disability and have devastating effects on the lives of affected individuals and their family, friends, and community. Studies of mostly non-African-American patients have revealed that delays in obtaining appropriate treatment in the course of psychotic illnesses are common and occur from the onset of the illness and first helper contact ( 2 , 3 ) and between the first helper contact and successful treatment ( 4 , 5 ). Not uncommonly, patients experience psychotic symptoms for one to two years before appropriate treatment is initiated ( 4 , 5 ). Research further suggests a link between the duration of untreated psychosis and treatment outcomes, with longer durations of untreated psychosis being associated with poorer short-term and long-term treatment outcomes ( 6 , 7 ). The interval between the onset of psychosis and treatment may also be a period of increased suicide risk—nearly 50 percent of patients in one study reported suicidal ideation during this period ( 8 ).

Factors contributing to treatment delays

Although research examining the pathways to care for African Americans with psychotic symptoms is vastly undeveloped, treatment delays have been reported to be similar to findings among whites and other ethnic groups ( 9 ). However, contrary to findings for whites, findings for blacks of Caribbean and African origin show more complex and aversive pathways to the hospital ( 10 ). Compared with white patients who experience relatively straightforward pathways, few black patients are admitted for treatment after a single consultation, and many follow tortuous routes that often involve the police ( 10 ).

Among the providers who are reported to be most successful in obtaining treatment during the early course of a psychotic illness is the general practitioner or family physician ( 2 ). Involvement of the general practitioner also has been associated with more desirable routes to care, including less likelihood of police involvement and compulsory admission ( 11 ). Among patients with psychotic illnesses, there is evidence that African Americans are more likely than whites to make contact with a general practitioner but are less likely to be referred for psychiatric care ( 10 ). This finding is consistent with other findings in the mental health literature that suggest that the mental health needs of African-American patients do not receive adequate attention from primary care physicians ( 12 ).

Various cultural and ethnic factors influence help-seeking behaviors and thus affect the length of time to treatment for African Americans with psychotic illnesses. Knowledge about mental illness and mental health services and social attitudes and perceptions may be important mediators of help-seeking behavior among patients and families ( 13 , 14 ). Early psychotic symptoms have been attributed by African Americans to depression, lack of motivation, and relational stress, which may reflect insufficient knowledge of psychotic symptoms ( 9 ). African Americans also may exhibit higher distress thresholds, as decisions to seek help have been reported to hinge on the emergence of behaviors that are unbearable or that create a social disturbance ( 9 ). This apparent lessened tendency to seek help may be related to greater stigma in the African-American community, as mentally ill individuals are more likely to be viewed as morally inferior ( 15 ). African Americans more strongly endorse folk, supernatural, spiritual, or mystical beliefs as causes of illness, which have been associated with lower rates of mental health service use ( 15 ). They also are less likely to perceive themselves as having a mental health problem ( 10 ) and are more likely to fear mental health treatment ( 1 ).

Summary and recommendations

Reducing treatment delays among African Americans with psychotic illnesses requires further examination of factors influencing the duration of untreated psychosis. Although existing studies suggest that treatment delays are common among African Americans ( 9 ), most investigations have been conducted with African-Caribbean patients in the United Kingdom ( 2 , 10 , 11 ), which raises the question of the translatability of these findings to African Americans residing in the United States. Given the higher than expected rates of schizophrenia diagnoses and other well-recognized disparities in access, treatment, and quality of mental health services for African Americans ( 1 ), further examination of the role of ethnicity in treatment delays among patients with recent-onset psychosis is warranted.

Efforts to engage African Americans in research must be undertaken to identify and minimize barriers to successful early intervention. Increasing the research base with African Americans will require community educational efforts, with particular attention to overcoming the reluctance and mistrust based on past research abuses and other negative historical experiences with the health care system. Initiatives to increase the public's mental health literacy and awareness of treatment interventions for early psychosis also warrant support. Finally, carefully designed educational interventions targeting emergency and general practitioners and family physicians are needed to improve knowledge of early psychosis and familiarity with local referral processes for mental health services. The specific content of these interventions must increase awareness of racial, ethnic, and cultural influences on health beliefs and behaviors.