Is Bipolar Disorder More Commonly Misdiagnosed in Black People?

Bipolar disorder — a mood disorder with alternating periods of extreme highs (mania) and deep lows (depression) — affects 2.8 percent of U.S. adults. Although Black people experience bipolar disorder at the same rate as white people, decades of research show Black people are more likely to have their bipolar disorder misdiagnosed as another condition.

A review of scientific evidence, published in March 2018 in Bipolar Disorders, found that people of African ancestry with bipolar disorder were more often misdiagnosed with another condition, such as schizophrenia, than people of non-African ancestry.

Several factors contribute to the misdiagnosis of bipolar disorder among Black people, such as conscious or unconscious bias in the healthcare system, stigma around mental health care among Black communities, and difficulty accessing care.

Misdiagnosis can have various health consequences, such as diagnostic and treatment delays, says Joyce Balls-Berry, PhD, an associate professor of neurology at Washington University School of Medicine in St. Louis, and a coauthor of the aforementioned Bipolar Disorders review.

Misdiagnosis can also cause undue stress when it means the person doesn’t have the right medications and the right treatment approach in therapy, adds Dr. Balls-Berry.

Why Misdiagnosis of Bipolar Disorder Is More Common Among Black People

Experts believe a combination of historical, structural, and social factors contribute to higher rates of misdiagnosed and subsequently untreated bipolar disorder in Black people.

Racism in the U.S. Healthcare System

Racism — a system that constructs opportunity and assigns value on the basis of race and unfairly disadvantages certain people and communities, according to the American Public Health Association — has had a complex and lasting effect on medicine and mental health care today.

Conscious or unconscious racial bias appears to contribute significantly to the disparities in bipolar disorder diagnosis among Black people, according to the authors of the Bipolar Disorders review.

Racism in healthcare has caused significant mistrust of the healthcare system among Black communities.

Historical examples of mistreatment of Black Americans may explain some of this mistrust. One of the most well-known examples is the 40-year-long U.S. Public Health Service (USPHS) Syphilis Study at Tuskegee, when the USPHS and Centers for Disease Control and Prevention purposely withheld treatment from nearly 400 Black Americans with syphilis.

Racism in medicine has affected mental health care, too. In the United States, psychiatrists coined the terms “drapetomania” and “dysaethesia aethiopia” — defined in the 1850s as the desire for freedom among people who were enslaved — and framed them as mental illnesses until the 1960s, according to the National Alliance on Mental Illness (NAMI). This was historically used to justify enslavement, per NAMI.

As a result of historical mistreatment, some Black people today may not feel comfortable going to the doctor and sharing their symptoms with a physician, which can lead to misdiagnosis down the road, says Monica Taylor-Desir, MD, MPH, a consultant and community psychiatrist at Mayo Clinic in Rochester, Minnesota, who studies racial disparities related to bipolar disorder. “It’s hard for people to know how to get that help,” she says.

Decreased Access to Care

Socioeconomic factors, like being unable to take time off from work, not having health insurance, or not having access to mental health care in their area can contribute to Black individuals not receiving the care they need, says Dr. Taylor-Desir.

Approximately 25 percent of Black Americans don’t have health insurance, which makes it difficult and expensive for them to find care, according to Mental Health America. Research published in the Journal of General Internal Medicine in January 2022 found that barriers like these led many Black Americans to rely more on primary care and emergency medicine providers for mental health care. Although collaborative and integrative care are becoming more prevalent in these fields, these providers usually have less specialized training in diagnosing and treating conditions like bipolar disorder than a mental health professional would.

Mental Health Stigma

Some Black people are hesitant to acknowledge mental health issues or the possibility they need psychiatric help because of stigma about mental illness in their community, and this can stop someone from seeking care, according to Mental Health America. A study published in Nursing Research showed that about 80 percent of Black Americans are very concerned about stigma related to mental illness.

Cultural Barriers

Only about 4 percent of the psychology workforce identifies as Black, while 86 percent identify as white, and the remainder identify as another racial or ethnic group, according to a report published in February 2018 in the American Psychological Association’s Monitor on Psychology. Among U.S. psychiatrists, only 2 percent identify as Black, the American Psychiatric Association reported in 2021.

These disparities in representation may lead some to believe that mental health professionals don’t offer care that’s culturally competent enough (meaning care that meets the needs of patients with diverse cultural values, beliefs, and behaviors), according to Mental Health America.

Research backs this up. A study published in September 2021 in The Lancet Psychiatry showed that Black or African American people were more likely to prefer providers who had a similar cultural background to theirs and offered culturally competent care.

Misdiagnosis Can Have Serious Consequences

Misdiagnosis can have a multifaceted impact on Black people with bipolar disorder, says Balls-Berry. Research shows misdiagnosis often leads to treatment delays, which in turn increase one’s risk of recurrent and chronic bipolar episodes.

People who are misdiagnosed with another condition may receive psychiatric medication that’s not right for them, according to the aforementioned review in World Journal of Psychiatry.

“[The impact] could be financial,” Balls-Berry says, adding that mental health stigma may also be linked to job loss and employment discrimination, as research shows. “If a person has a misdiagnosis [like schizophrenia] and others find out about the diagnosis and they think that it’s real, that can impact job security,” she says.

What’s more, misdiagnosis often not only affects the patient who’s been misdiagnosed, but the patients who come after them, too, adds Balls-Berry.

“If one patient is misdiagnosed and symptoms are the same then there might be a trickle-down effect again of other patients [of the first patient’s doctor] being misdiagnosed,” Balls-Berry says. “It becomes these cycles that can perpetuate disparities and deprivation.”

3 Tips for Advocating for Yourself

If you suspect you may have bipolar disorder but feel you’ve been misdiagnosed with another condition, here are three expert tips on advocating for your mental health care needs.

1. Tell Your Health Provider About All Your Symptoms

If you suspect you may have a mental health condition like bipolar disorder, it’s important to tell a provider you trust about everything you’re experiencing, says Taylor-Desir. Potential symptoms of bipolar disorder, according to the Mayo Clinic, can include:

  • Feeling abnormally happy, energetic, or irritable
  • Euphoria, or an exaggerated sense of well-being and self-confidence
  • Talking much more than usual
  • Feeling like you need less sleep than normal
  • Easily becoming distracted
  • Racing thoughts
  • Making risky decisions, such as shopping sprees, unwise financial investments, or having unsafe sex
  • Feeling sad, low, or tearful
  • Loss of interest or pleasure in activities you once enjoyed
  • Sleeping too much or too little
  • Increased or decreased appetite resulting in unintended weight gain or loss
  • Fatigue or lack of energy
  • Trouble concentrating, making decisions, or remembering things
  • Suicidal thoughts or behaviors

2. Find Health Providers Who Meet Your Needs

It’s important to find a care team that can best support you and your needs, says Balls-Berry. In doing so, it’s important to look for a culturally competent or responsive provider, adds Taylor-Desir.

When you’re interviewing a potential new provider, Taylor-Desir recommends asking the following questions to make sure they’ll be able to meet your care needs:

  • “How do you see our respective cultural backgrounds influencing our communication and my treatment?”
  • “Have you received training in culturally responsive care?”
  • “How does my cultural background influence diagnosis?”

For visits with a new provider, Taylor-Desir recommends that Black patients:

  • Prepare a list of questions and concerns ahead of time and review this with your provider.
  • Ask questions — and continue to ask questions — about how the provider has chosen your diagnosis.
  • Ask about the recommended treatments, alternatives, and the provider’s experience in treating people with your specific needs and cultural background.
  • Ask about potential side effects of medications.

After meeting with your new provider, Taylor-Desir suggests asking yourself:

  • “Did I feel heard and respected?”
  • “Did my provider effectively communicate with me?”
  • “Is my provider willing to take into consideration and incorporate my strengths, cultural practices, and beliefs into my treatment plan?”

3. Put Your Mental Health Needs First 

“That goes across the board for all Black people,” says Taylor-Desir. “Often we put ourselves last.”

One way to prioritize your own mental health is to be as open as possible with your providers about your emotional needs. “This is important so that your loved ones and care team recognize that your needs may change,” says Balls-Berry.

Another way to do this is to prioritize self-care, which can help you stay well mentally and emotionally, according to Marsell Wellness Center in Ontario, California. Self-care activities can include making time for hobbies and activities that bring you joy, spending time with loved ones, and practicing self-compassion (being kind to yourself and not beating yourself up when you’re struggling), per Marsell Wellness Center.

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