From the Toronto Globe and Mail:

Can racism cause schizophrenia?

Alternatively, can the voices in your head cause you to perceive more racism than actually exists?

Decades of research has found that racialized citizens

“Racialized citizens” are people, frequently not citizens, who are of a non-white race. Since we all know that race does not exist, except we all can tell race just by looking, the term “racialized citizen” means we are not bad whites.

are diagnosed with the disorder at far higher rates – and the single biggest risk factor is having darker skin than most of their neighbours

ERIN ANDERSSEN
PUBLISHED JULY 10, 2021

One of the first patients Kwame McKenzie treated as a psychiatrist in London, England, was a young Black man diagnosed with schizophrenia. Dr. McKenzie, then years away from becoming the director of health equity at Toronto’s Centre for Addiction and Mental Health (CAMH), remembers the father, an African-Caribbean immigrant, trying not to cry while asking questions. Had they done something wrong to make their child so ill? This was their second son now suffering from psychosis, the father explained. How could they stop it from happening to their other children? Dr. McKenzie didn’t have a good answer. He resolved to find one.

That search led him to dig deeper into a curious, and alarming, pattern: In a number of Western countries, including Canada, migrants from Africa and the Caribbean – and their children – are more likely to be diagnosed with schizophrenia than either their native-born white peers or immigrants from other parts of the world. Study after study has pointed to one significant risk factor: skin colour.

Schizophrenia, a disorder characterized by often debilitating hallucinations and delusions, is one of the most severe mental illnesses and among the hardest to treat. It is relatively rare – affecting about one per cent of the population – but its burden on patients, their families and the health care system is huge, especially since the illness most often emerges in the late teens and early 20s. …

If a certain population – a race-specific population – is more likely to be diagnosed with a devastating, life-altering mental illness, that is not just a public health issue, says Dr. McKenzie, a professor at the University of Toronto and chief executive of the Wellesley Institute, a think tank dedicated to improving health equity. It’s a question of human rights and social justice.

The role of race in health care has long been tainted by discrimination, clinician bias and inequitable treatment; the pandemic has only highlighted a problem that has long existed. In Ontario, for instance, Caribbean-African men are more likely to be involuntarily admitted to hospital for psychosis than other populations, often following a police encounter…

But the finding that Black citizens are being diagnosed more often with psychosis is more complex than improving access to care. It goes back more than 50 years and has been the subject of more than 100 peer-reviewed papers. In the United Kingdom and the Netherlands, extensive studies have found rates as much as five times higher in migrants from the Caribbean and Africa than the native-born white population. In Israel, significantly higher rates of psychosis have been found in migrants from Ethiopia. In the United States, African-Americans are more likely to be diagnosed with schizophrenia than white Americans.

Researchers have discovered a similar pattern in Canada. A 2015 Ontario study looking at 10 years of health statistics found higher rates of psychotic disorders in refugees from East Africa and South Asia (95 per cent and 51 per cent higher, respectively) compared to the general population, and an elevated risk among immigrants from the Caribbean and Bermuda.

“This problem is the biggest inequality we have in mental health,” says James Kirkbride, a British psychiatric epidemiologist at University College London who has been studying this issue for 15 years. “We are essentially talking about a disorder that is happening [as much as] 500 per cent more frequently in one group.”

The explanation for this is still being debated. But many researchers have begun to circle one theory in particular – a hypothesis that has ramifications not only for how we diagnose and treat mental illnesses, but what is required to prevent them in the first place. Step back further, and this theory raises uncomfortable questions about the harm inflicted on those deemed by the majority to be outsiders.

What many researchers increasingly believe to be an important risk factor for schizophrenia, this most terrible of brain disorders, is racism.

Well, of course. What else could it be? As Dr. Ibram X. Kendi points out, it would be racist for the cause not to be racism because that would mean that blacks rather than whites are to blame for a problem that is worse among blacks. But we know that reality can’t be racist, only People of Whiteness can be racist.

In his 1961 book The Wretched of the Earth, Frantz Fanon proposed that racism itself caused mental illness, including psychosis.

And who was ever a more dispassionate, neutral, apolitical, scientifically objective theorist than Frantz Fanon?

… Dr. Fanon’s work is often cited in current research. The idea that the experience of racism could be traumatic, that it could harm a person’s mental health, that systemic racism could alter how certain groups are diagnosed and treated, should not be surprising today.

… Some Western researchers advocate replacing it with “psychosis spectrum disorder,” to better reflect the range and severity of symptoms.

Mental health experts believe a number of factors likely contribute to schizophrenia, including genetics, brain chemistry and social environment – although science is still working hard on the finer details. Genes are a large individual risk factor: People with a parent with schizophrenia have a 10-per-cent higher risk of developing the disorder; having an identical twin with the illness increases your risk by about 50 per cent.

But genes don’t tell the whole story. Most people with a close family history don’t develop schizophrenia. And unlucky genes haven’t been able to explain why certain ethnic minority groups have higher rates of the illness. There’s no evidence that migrants, as a group, leave home with a higher risk for psychosis tucked in their biological suitcase.

This was one of the earliest theories for why certain ethnic groups had higher rates of schizophrenia – that migrants were bringing the illness with them from their home countries. Over time, that hypothesis has been refuted by epidemiological studies, which have found no evidence of higher rates in places such as the Caribbean, Surinam and India.

Sounds like a challenging methodological problem.

But it sure makes it sound like immigration from the Third World is a bad idea.

Given the skills and resourcefulness it takes to settle in a foreign country, and the mandatory medical screening often required to get there, migrants should be at lower – not higher – risk of severe mental illness. So perhaps it was the trauma of migrating? But that couldn’t explain why risk remained high among the children of migrants born in the host country.

Slicing and dicing the data, however, revealed a clue: The risk of developing psychosis was not equal among all migrants. Newcomers to Britain and the Netherlands who travelled from within Europe, for example, have been found to have significantly lower risks than those coming from outside the continent. Yet even within that non-European group, people from India or other parts of Asia had significantly lower rates than those from Africa or the Caribbean. This pattern continues, to varying degrees, into the second generation.

Maybe sub-Saharans have a bigger problem with schizophrenia?

The search for a clear explanation has been challenging. A problematic birth or a childhood vitamin D deficiency

Do blacks have higher schizophrenia rates in Minneapolis than in Mississippi due to the latitude difference?

– both associated with a higher risk of schizophrenia – were two possible theories. But Dr. McKenzie says British researchers found that obstetrical complications were not more common among mothers from Africa or the Caribbean

In general, African-American mothers have more obstetrical problems.

, and vitamin D couldn’t explain increased rates among migrants who arrived as adults.

Maybe it was poverty? But poorer countries don’t appear to have higher rates of schizophrenia, and the risk for certain migrant groups remained high, even when researchers adjusted for socioeconomic status.

Maybe it’s being richer and thus able to afford more expensive drugs like cocaine or state-of-the-art marijuana?

Another significant risk factor for schizophrenia is living in a city. Researchers are still figuring out why, but some theorize the frenetic landscape, pollution and sense of isolation even in a crowded place could be contributors.

A closer look at cities, however, produced another finding: In areas with ethnic density – a larger concentration of people from the same ethnic group – the rates of schizophrenia were lower, for both generations. A large-scale Swedish study published in Lancet Psychiatry last year analyzed health data from more than 450,000 migrants and their children over at least 20 years. The study found that for visible-minority migrants, a 5-per-cent decrease in ethnic density was associated with a roughly 5-per-cent increase in psychosis risk – a result not shared by white migrants or their children. Studies in Britain, Denmark and the United States have made similar findings.

Alert Raj Chetty: the Harvard economist who works with colossal datasets of 1040s, imprisonment, SAT scores, etc. has been preaching that the best thing black mothers can do for their sons is to move them far away from other black youth out into white neighborhoods (i.e., keep them far away from joining a black street gang as an adolescent and thus winding up in prison).

I suspect Chetty has better data than most of the studies reported here.

But the implication of this article is that blacks should stick to all black ghettos.

But did psychosis go down in Detroit as it became virtually all black? Really?

In the end, after decades of research, a particular theory emerged. The largest risk factor for psychosis didn’t appear to be country of origin or being poor or having migrated or living in a city. It was having darker skin than most of your neighbours.

Especially if your neighbors are tiny elderly Asians. They just drive you nuts with their punchable faces.

There is one obvious alternative explanation: Doctors are getting the diagnosis wrong. Schizophrenia can’t be confirmed with a blood test or a brain scan, despite the ongoing efforts of neuroscientists. Although there are standardized scales, a diagnosis is often made by excluding other possibilities, along with a clinician’s own assessment. This makes it susceptible to mistakes and bias.

The role of clinician misdiagnosis continues to be a focus of research, especially in the U.S. Some experts suggest diagnostic tools may be pathologizing behaviour that some cultures and religions would not consider an illness. How people enter the mental health care system, and how easily they find good care once inside, differs between racial groups. American research has found that racialized patients are more likely to be diagnosed with schizophrenia than with mood disorders, even when they have symptoms similar to those of white patients. In Canada, schizophrenia also appears to be experienced differently by race: A four-year study found that compared to white patients diagnosed with schizophrenia, African-Caribbean patients spent more time in a recovered state; were less likely to have continuous, unremitting illness; and were less at risk of suicide and self-harm – but more likely to have suffered imprisonment and compulsory admission.

In other words, blacks commit more serious crimes on average, so psychiatrists try more to route them away from prison to psychiatric hospitals by declaring that the only way this strapping 6’3″ young man could have randomly punched that 4’8″ Asian grandmother is because he’s suffering from a mental illness, so we should be nice to him and not send him to prison for a long time but instead to a psychiatric facility until he’s feeling better.

Also, this sure sounds not like schizophrenia, a rather permanent condition (although somewhat controllable with newer pharmaceuticals), but more like temporary drug-induced psychosis.

During her clinical practice, Deidre Anglin, a psychology professor at City University of New York, says she saw examples of colleagues being too quick to diagnose schizophrenia in Black patients, especially those who came in agitated and with a police escort. She says racialized patients, because of their experience in society, including a distrust of the system, may present with a “constellation of symptoms” that aren’t fully reflected in the diagnostic manuals.

Maybe psychiatrists are reluctant to diagnose black men as: “A violent criminal who should be convicted and imprisoned,” so they are more likely to hand out dubious diagnoses of schizophrenia?

Dr. Anglin agrees misdiagnosis plays a role and raises critical questions about race that the field of psychiatry can’t ignore. (The wrong diagnosis could mean, for instance, that a racialized patient doesn’t get the right treatment.)

A wrong diagnosis of schizophrenia can mean a black criminal doesn’t get the just punishment he deserves.

But her work suggests more important factors are the chronic social distress, trauma and discrimination that make mental illness more severe. Psychotic symptoms, she says, are more common even in racialized patients who might be more accurately diagnosed with major depression.

In Britain, she says, some studies have found the link between race and psychosis to be higher than smoking for cancer. “There is no way misdiagnosis alone could capture that much of a difference.“

Dr. Kirkbride describes a British experiment that asked a diverse group of psychiatrists to independently diagnose patients whose ethnicity was hidden. He says higher rates of diagnosis for the racialized groups persisted.

“We all accept that COVID is more prevalent in socially disadvantaged ethnic-minority populations,” he says. “There isn’t a question of misdiagnosis. It is definitely the social determinants of health and the racist pattern of society and people who have been cyclically disadvantaged.”

Blacks initially tended to infect each other more with coronavirus in part because they are more gregarious (which is not a defect except when this stupid pandemic is around). Blacks actually did a pretty good job, better than Hispanics did, of cutting their death rates over the course of 2020, but nobody gives them any credit for learning because that would imply that blacks have agency.

“I think it is exactly the same explanation for psychosis. But we refuse to believe it. It denies an epidemic that isn’t being treated properly.”

Shawn Pendenque went to jail for four months after he wrote an angry letter to judges and court officials. He wonders whether, because he is Black, authorities rushed to charge him with sending death threats instead of suspecting he had a mental illness.

See, you can use schizophrenia to stay out of jail. But next time, don’t threaten judges, they can take that personally. Just punch elderly Asians and plead schizophrenia.

Mr. Pendenque was born in Canada, to parents who had migrated separately from Dominica and met in Toronto. As a child, he was sexually and physically abused, and by 16, he was living on the street. With the help of LOFT Community Services, a group that provides support and housing to at-risk populations, he eventually became a counsellor for youth – many of them also Black – awaiting trial or sentencing.

He penned the angry, rambling letter and delivered it to court officials – telling them they would “be judged and go to hell” for their part in an unjust system – during what was later diagnosed in jail as a psychotic episode brought on by bipolar schizoaffective disorder, a condition that includes the symptoms of a mood disorder and schizophrenia. Looking back, he wonders if the leap to charge him as a criminal, rather than suspect he had a mental illness, was because he was Black.

I thought the rest of the article was about how blacks get diagnosed too often?

He went to jail for four months. “They left me with an orange jumpsuit on my back to start over again.”

Mr. Pendenque, who is now a community worker with LOFT and a mental health advocate, believes that observing the biased treatment of young Black teenagers may have triggered something inside him, perhaps a fault line already created by the childhood trauma he’d experienced. He also describes the incongruity of being given the responsibility of his job and at the same time feeling judged inferior because of his race. It’s an exhausting parallel reality, he says. A mind, already wounded, can only bear so much.

Yet, how could the experience of racism do enough damage to the brain that it could result in a severe mental illness?

Aristotle Voineskos, vice-president of research at CAMH and a specialist in schizophrenia, points to evidence that chronic stress weakens the immune system, which has been linked to the development of psychosis. The “social defeat” hypothesis proposes that the long-term experience of being excluded from the majority group eventually leads to chemical changes in the brain.

But I thought it was inclusion in the majority group via moving to the majority neighborhoods that you were telling us drives blacks psycho.

Dr. McKenzie uses the term “thwarted aspirations,” especially for the second generation, who find themselves denied opportunities in the only country they’ve known. This constant race-based stress is also known as “weathering,” and it’s one way to explain why African-Americans, as a group, die earlier of many diseases than white Americans.

Hitting the crack pipe, in contrast, makes you look young and fresh as a daisy.

A 2014 U.S. study of 644 young, ethnic-minority adults, co-authored by CAMH’s Dr. Anglin, found the experience of racial discrimination was associated with more early, sub-clinical markers for psychosis even when researchers accounted for anxiety and depression.

Or maybe blacks who think whites are being racist to them are more likely to be actually crazy than blacks who don’t hallucinate about racist slights?

Those threshold symptoms included altered perceptions, paranoia and suspicion

So delusional and paranoid blacks notice more racism than sane blacks?

, and most commonly cognitive dissonance, which refers to a person thinking or acting in a way that goes against their own beliefs and values – the way you might, for example, if the system meant to help you worked against you instead.

In May, the first Black Canadian National Survey found that among 5,000 respondents, 70 per cent said they experienced racism “regularly or from time to time.” Two-thirds reported being treated with suspicion in the past year; one-fifth reported being unfairly stopped by police in the past month. Nearly half of those surveyed said they’d been treated unfairly by an employer in the past 12 months.

“You wear a mask to get through the days,” says Myrna Lashley, a psychologist and assistant professor at McGill University’s department of psychiatry.

Wait a minute, I’m confused about masks.

She quotes Dr. Fanon’s writings to explain the toll of racism to those who get to “live above the line,” as he once wrote. “You laugh at jokes that aren’t funny,” she says. “You have to have that famous talk with your children that white people don’t have: ‘Even if you just buy a pack of gum at the store, don’t leave without a receipt.’”

Racism harms overtly, Dr. Lashley says, but it also sabotages a person’s social and physical environment. It understandably causes them to question what’s true, to wonder about the motives of their neighbours. Did that person cross the street to get somewhere or to avoid me? Was I seated in the back of the restaurant because I’m Black? Is that police officer just walking by or following me?

How long can anyone’s brain, especially one already dealing with trauma or the challenge of adjusting to a foreign culture, maintain that hyper-vigilance and stay healthy?

So, what you are saying is that blacks are ticking time-bombs and should be watched carefully? Isn’t that … racist?

“You are holding in that stress all the time. You can’t pill it away. You can’t sleep it away,” says Dr. Lashley. Often, she says, the source of stress – systematic, everyday racism, the micro-agressions [sic] that have macro implications – is dismissed or denied, adding to the trauma. “It becomes the knee on our neck, and we can’t breathe.

Racism makes people question what’s true and the motives of the people around them in a way that can be traumatizing, psychiatrist Myrna Lashley says.

So, when delusional paranoiacs accuse the people around them of being racists out to get them for no good reason, the sane should agree with the insane.

Pile those suffocating, demoralizing, exhausting incidents of discrimination on a life already complicated by a troubled childhood, a family history of illness or isolated-newcomer status, and the research suggests that the narrative is significantly more likely to lead to a diagnosis of schizophrenia.

Yup, ticking time-bombs.

… Also, what kind of racism increases risk the most? More recent studies suggest systematic racism may have a larger effect than the direct experiences of discrimination, says Hannah Jongsma, a senior scientific researcher at the Veldzicht Center for Transcultural Psychiatry in the Netherlands. In a 2020 paper she co-authored, on ethnicity and psychosis, the two largest specific risk factors appeared to be social disadvantage and linguistic distance from the native population – barriers that make it harder to shed one’s outsider status.

Or maybe immigrants who can’t learn Dutch or find work tend to have something wrong with their brains to begin with?

… An older British study, co-authored by Dr. McKenzie, recruited people with no history of psychosis, recorded their experiences with discrimination and their level of perceived racism, and followed them for three years. At the end, the study found a link between the onset of delusional thinking and higher rates of discrimination, from 0.5 per cent for those reporting no discrimination to 2.7 per cent for people reporting more than one type of discrimination. …

They found the delusional report more racism. Okaaaaaaay … well, that proves it, right?