Black men are three to four times more likely to be diagnosed with schizophrenia than white men. Asian Americans are more likely to suffer symptoms of depression than whites, but far less likely to be diagnosed with a depressive disorder. For many years, autism was widely believed to only impact males, but more recent research finds that girls and women who meet the criteria are simply going undiagnosed.
Unfortunately for those seeking help for mental health issues, we can’t just get a blood test to find our status. While biology and genetics undeniably play a part in the development of psychiatric disorders, there are no simple biological markers to test for – at least not as far as modern science is able to measure.
Because of that, who you are – and when and where – still impacts how your mental health issues are perceived, diagnosed, and treated.
While the scientific method is all about objectivity, science is only as objective as the people who conduct it.
Humans pick the variables to examine and the means of measurement, and they interpret the data – and humans are not objective. And for as far as psychiatric science has come, it will always be imprecise. But there is a lot that we can do to make the process less biased.
Psychiatric diagnosis is effectively putting a label on a cluster of behaviors and symptoms that is causing a person distress. In the scheme of history, this is a science in its infancy. Psychiatric medicine became recognized as its own branch of medicine in the mid-1800s and to call it a science at that time would be… extremely generous.
Early psychiatry was largely clinicians using their personal judgments and trying to find consensus based on ideas that prevailed at the time. There wasn’t any unified system of classification across the field and the popularity of doctor’s theories had more to do with their social status than the strength of supportive evidence. There was also little understanding that biology played a role.
From today’s lens, we can find many early psychiatric ideas laughable. Diagnoses of hysteria as an exclusively female disease obviously reflect a culture of women being treated as second-class citizens. The 19th century label of drapetomania or “disease causing slaves to run away” is absurd, beyond being offensive. And we can see that the prevailing notion that autism only occurred in the children of the super wealthy and educated is clearly a reflection of who was able to seek professional help, not a reflection of actual incidence.
The first attempts to officially classify mental disorders was thanks to the 1920 US Census, when a diagnostic manual was developed with just 21 diagnoses, most of which were psychotic disorders. Psychiatrists largely ignored this manual and didn’t make their own until decades later. Even then, the notion of diagnostic reliability or validity didn’t enter the picture for several decades more. It wasn’t until the 1970s that the American Psychiatric Association ditched the psychodynamics model for empiricism, that is: doing research to see if their theories were correct.
Since the 1980s, the field has been far more scientific and the categories of diagnosis reflect not only an increased understanding of the biological basis behind illnesses, but also of the impacts of trauma. Also gone are the labels of hysteria and the pathologizing of homosexuality, both relegated to the dustbin of bigoted history.
The fifth revision of the Diagnostic and Statistical Manual – the most recent one – overhauls a lot of the classification systems, considers patients across the lifespan more, and is approached as a living document meant to be continuously revised with greater understanding.
Psychiatry must continue to learn, reconsider, and change and it must become more culturally competent in the process. While categorizations of disorders – especially those with a genetic basis – should theoretically be universal, there is still a lot of difference in the way people experience symptoms and are viewed by clinicians. There are also variations in how a given disorder will manifest in different cultures, as well as the thresholds for considering something to be “abnormal” or “unhealthy.”
Take, for example, hyperactivity. Rates of prevalence among kids varies from 1 to 20%, depending on the study – and kids in Hong Kong are twice as likely to be diagnosed as children in the U.S. This has far less to do with the actual incidence than differing thresholds for how much aggression and emotional expressiveness parents are willing to tolerate before seeking professional help. Similar patterns can be seen with Conduct Disorder and Oppositional Defiant Disorder. While the DSM lays out criteria for labeling a kid with these disorders, the cultural background of both patients and clinicians will impact how these things are expressed and interpreted.
Culture, race, gender and other demographics are going to color every facet of a mental health issue, from the way people describe their symptoms to the level of distress that their behavior causes in daily life.
It’s important to consider the context when diagnosing or treating a mental illness, as well: the same person will react very differently while living in a refugee camp than in the suburbs.
So what can we do to make mental health more inclusive and accurate? In addition to learning the science and art of clinical practice, professionals must also be trained in cultural competency and seek to understand how racism, homophobia and other systems interact with mental illness. Research must be conducted by diverse groups of scientists and on populations that reflect the wide variation of the real world. Critically, patients must also be free to seek the assistance of therapists who understand not only the complex impacts of their identities, but are aware of how their own biases will seep into their work.
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