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The ostensibly objective diagnostic tools on which doctors rely may themselves be biased against blacks. Strakowski notes that the entry on schizophrenia in the clinician's bible, the DSM-IV, instructs the diagnostician to look first for the presence of hallucinations and delusions. Mentally ill African-Americans "tend to have more severe psychotic symptoms, ones that have historically been thought to be specific to schizophrenia but clearly are not," says Strakowski. "So when African-Americans present with these symptoms, the clinicians tend not to notice other kinds of signs, and they make a diagnosis of schizophrenia." (Why blacks are more likely to exhibit these behaviors isn't known; Strakowski speculates that they may receive medical care later in the course of their illness -- whatever it may be -- when its symptoms have become more florid.)

It seems clear that bias of one sort or another plays an important role in the disproportionate number of diagnoses of blacks with schizophrenia. Indeed, several large epidemiological studies, employing very careful screening procedures, found that the incidence of schizophrenia varies little among ethnic groups worldwide. But scientists haven't ruled out the possibility that African-Americans actually suffer from the illness at a higher rate, or that the illness manifests itself differently in black patients. Poor prenatal care, the stresses of poverty and discrimination and reduced access to medical services may encourage the development of the disease in those who are vulnerable, or influence its course in those who are afflicted.

More controversial still, there is some evidence that differences between blacks and whites concerning schizophrenia may have a genetic basis. In a study published last year by a consortium of universities organized by the National Institute of Mental Health (NIMH), the authors reported that some of the genes thought to predispose individuals to schizophrenia were found in different locations on African-American and European-American chromosomes. That discovery, they wrote, "lends credence to the notion that these genetic differences, together with differences in environmental exposures, may contribute to the reported differences in disease prevalence, severity, comorbidity and course that have been observed in different racial groups in the United States and elsewhere."

Still, none of these hypotheses has yielded solid answers to the question of why blacks are more frequently diagnosed with schizophrenia. "There have been concerted efforts for short periods of time to try to investigate it, but they don't seem to ever continue long enough to understand the problem," says Strakowski.

We simply don't know why it happens.

Why aren't more scientists studying the potentially dangerous relationship between race and schizophrenia? It was just this question that perplexed Richard Lewine, Ph.D., director of the schizophrenic disorders program at Emory University.

Last spring, Lewine published a survey he conducted on how schizophrenia studies handle race. His statistics were stunning: Between 1994 and 1996, under 3 percent of the articles about schizophrenia that appeared in leading psychiatric journals reported the results of race analyses. Over 83 percent failed to even note the racial breakdown of the group examined. "The empirical study of schizophrenia has been, especially during the 'decade of the brain,' the study of white men," Lewine concluded in the March issue of Schizophrenia Bulletin.

"It's as if everybody is ignoring it," Lewine marvels. That's despite a much-heralded revision of the rules under which research grants are given by the NIMH and other agencies of the National Institutes of Health (NIH). Starting in 1993, the guidelines declared, "The NIH must ensure that women and members of minorities and their subpopulations are included in all human subject research." And yet, to judge from the studies produced since then, the rule change has had very little impact -- "unless we assume that prior to the NIMH initiative, researchers paid no attention whatsoever to race," as Lewine dryly notes.

Next page | "I really have found some race differences in my data, but I'll be darned if I'm going to publish them"