NYT: Why do blacks tend to be more psychotic?

It must be, somehow, the fault of whites.

From the New York Times Magazine:

America’s Hidden Racial Divide: A Mysterious Gap in Psychosis Rates

Black Americans experience schizophrenia and related disorders at twice the rate of white Americans. It’s a disparity that has parallels in other cultures.

By Daniel Bergner

Daniel Bergner is a contributing writer to the magazine, where he has written about, among other things, alternate ways of treating psychotic disorders.

Dec. 3, 2024

… As a growing body of research reveals, Black people in the United States suffer the hallucinations and delusions of psychosis — the voices that seem to emanate from outside a person’s head, the visions, the paranoias, the breaks with common reality — at a rate roughly twice that of white people. In Europe, racial disparities regarding psychosis are yet wider. Even after researchers control for socioeconomic factors and address issues of diagnosis, the alarming racial gaps remain.

Studies suggesting a link between minority or outsider status and psychosis run back about a century. A 1932 study looked at hospital admissions for psychosis in Minnesota. It found that Norwegian immigrants were admitted at twice the rate of native Minnesotans or Norwegians in their home country. By the 1970s, researchers were turning specifically to racial divides in psychiatric disorders, and by the 2000s, the relationship between race and psychosis (which appears to outstrip any correlation between race and more common conditions like depression)

Blacks do not suffer more from depression and have higher self-esteem on average.

was becoming well studied in both the United States and Europe. Yet despite the mounting data, in the United States, until recently, the issue was relegated to the edges of mainstream psychiatry — or perhaps beyond the edges.

“A voice in the wilderness,” Roberto Lewis-Fernández, a professor of clinical psychiatry at Columbia University, says, describing the feeling that work on the issue was long marginalized. He and Deidre Anglin, a leading U.S. researcher into the relationship between psychosis and race, both point to the keen cultural focus on pervasive racism after George Floyd’s murder as one reason for what Anglin calls an “exponential increase in attention” to the striking racial patterns in psychosis.

Though psychiatric disorders have mostly eluded precise scientific explanations, proving too complex for brain imaging and other technology to illuminate, it’s clear that some combination of genetic and circumstantial factors contributes to psychosis. The genetic creates a predisposition. But predisposition is not disease; it is susceptibility, a shifting of the odds that is, researchers assume, equally distributed across races.

Why assume that? We’ve discovered pervasive evidence that schizophrenia and other forms of psychosis are more common in blacks than in other races in all countries with reliable statistics. We also know that schizophrenia is highly heritable.

Paywall here:

The author says in a reply to a comment:

… among identical twins, whose genes are fully shared, if one twin has schizophrenia, the other will have a 40 to 50 percent chance of having the disorder.

Schizophrenia is found in about 1% of Americans, so 40 to 50% concordance among identical twins, while it’s not 100%, is still a big number. (Granted, identical twins tend to have similar childhood experiences.) A 2015 study found:

Genetic factors are believed to play an important role in the causation of schizophrenia. While the lifetime risk in the general population is just below 1%, it is 6.5% in first-degree relatives of patients and it rises to more than 40% in monozygotic twins of affected people. Analyzing classic studies of the genetics of schizophrenia done as early as in 1930s, Fischer concludes that a concordance rate for psychosis of about 50% in monozygotic twins seems to be a realistic estimate, which is significantly higher than that in dizygotic twins of about 10–19%.

Back to this NYT article:

Triggers are needed to profoundly alter the mind. Current explanations for the racial gaps in psychosis tend to zero in on the catalysts of discrimination, denigration and the insidious sense of helplessness — or “social defeat,” as psychiatry terms it — that racism can impose.

So, blacks must have lower self-esteem, right?

Except, they don’t. A 2012 meta-analysis found:

Large-scale representative surveys of 8th-, 10th-, and 12th-grade students in the United States show high self-esteem scores for all groups. African-American students score highest, Whites score slightly higher than Hispanics, and Asian Americans score lowest. Males score slightly higher than females. Multivariate controls for grades and college plans actually heighten these race/ethnic/gender differences. A truncated scoring method, designed to counter race/ethnic differences in extreme response style, reduced but did not eliminate the subgroup differences. Age differences in self-esteem are modest, with 12th graders reporting the highest scores. The findings are highly consistent across 18 annual surveys from 1991 through 2008, and self-esteem scores show little overall change during that period.

Back to the NYT:

The data is strongly suggestive, if short of proving causation. Intuitively, the link is hard to ignore. Experiences of racism seem to stir and amplify the deafening voices of self-condemnation and fears of terrible danger that can be part of the alternate realities of psychosis.

This is the kind of logical delusion that white intellectuals like Daniel Bergner are prone to: they assume that because blacks ought to have lower self-esteem, that they must have lower self-esteem, which is the cause for their tendency toward more psychotic delusions.

The article focuses on a mentally ill nice guy named Earl Miller. I delete most of the sample-size-of-one human interest to shorten the read, but here are a couple of characteristic paragraphs:

… It didn’t help that “the people making the decisions” — about treatment plans, privileges, discharge dates — “were all white.” Or that “the kids who were there for a long time all looked like me.” A hallucinatory voice screamed at him that staff were poisoning his water, his food. “You’re going to die. Look what you did. Nobody wants you. Get out! Get out! Get out!”

Miller’s impoverished, chaotic family was also an essential spark.

It seems like Miller got the fuzzy end of the nature & nurture lollipop.

He learned, on the ward on his 13th birthday, in a phone call with his grandmother, that his mother had moved across the country to Las Vegas. There would be no more visits with her. She once tried to strangle him with a phone cord, he said, but that didn’t mean he wanted her to disappear.

But it’s really white people’s fault. It just has to be.

… Deidre Anglin, who has spearheaded much of the past decade’s research on racial disparities and psychosis, is Jamaican American, the daughter of first-generation immigrants. Her maternal grandmother got herself from Kingston to Brooklyn, worked as a nanny, saved and sent for her family. Anglin’s parents, who eventually settled in a Long Island suburb, had one career in mind for her. “I’m part of the immigrant story,” she says. “My parents were sure I was going to be a physician.” But as an undergraduate at Cornell University, Anglin started “thinking hard about how underaddressed mental health is in the Black community, even though it’s so obvious that if anyone is going to experience mental-health challenges, it’s folks who experience oppression. I shifted gears. Quickly.”

If America is so racistly oppressive, why did your family leave black Jamaica?

… In the United States, Black-white ratios are at least 1.9 to one; some studies show that disparities for nonwhite Hispanics are narrower but still notable. In Europe overall, Black-white differentials hover in the vicinity of four to one. In England, the gap for Black Caribbean and Black African immigrants runs between four to one and more than six to one. In the Netherlands, for Moroccan, Surinamese and Antillean immigrants, the ratio is around three to one.

Among the immigrant groups, one plausible factor is the dislocation and stress that can come with the immigrant journey itself. But while such trauma may seem an obvious trigger, given that many immigrants arrive in their new nations after dangerous journeys and unable to speak the language that surrounds them, researchers have found repeatedly that second-generation immigrants to the United States and Europe develop psychosis at rates at least as high as their parents. Something is happening in the new country.

Of course, it would be fascinating if blacks in Surinam and Jamaica had much lower rates of psychosis, but of course nobody trusts Surinamese or Jamaican data.

For a long while — more persistently in the United States than Europe — misdiagnosis was the dominant explanation for the psychosis disparity between Black people and white people. This line of thought concentrates on schizophrenia, the psychotic disorder with the most vivid connotations of eruptive violence. Boiled down, the theory is that because of racial bias, a practitioner confronted with two similarly hallucinating, delusional and struggling patients, one white and one Black, is much more likely to be deeply frightened or disturbed by the Black patient and to categorize him as schizophrenic. In this way, the thinking goes, the rates of diagnosis become skewed.

Because of course, in the real world, we see that blacks don’t have higher rates of irrational violence…

Except that all the evidence suggests that they do.

Jonathan Metzl, a psychiatrist and professor of sociology and psychiatry at Vanderbilt University, explored and extended this idea in his 2009 book, “The Protest Psychosis: How Schizophrenia Became a Black Disease.” He argues that in the 1960s and ’70s, the clinical application of the schizophrenia diagnosis — and even aspects of the official diagnostic criteria — changed in response to white fears about the civil rights and Black Power movements. Mining records from a Detroit-area psychiatric institution, Metzl traces a transformation: from schizophrenia’s being seen as a largely female — and unthreatening — disease to its becoming a disorder of aggression and a means, whether or not consciously intended, to lock up Black men.

After all, out on the streets of Detroit, there’s no violence, so all these diagnoses of dangerous lunatics in Detroit mental hospitals must be a racist conspiracy.

The misdiagnosis theory is compelling, and some studies have continued to support it. But Anglin and other researchers have removed the issue of practitioner judgment by looking at self-reported hallucinations and delusions that haven’t yet led to diagnosis. Racially divergent rates remain glaring.

A pair of Anglin’s studies focuses on reasons for the difference in rates. In this research, involving a total of over 9,000 subjects, self-reported experiences of racial discrimination correlated tightly with self-reported psychotic symptoms.

If you can’t trust a lunatic’s reports of white racism, who can you trust?

The number of symptoms rose, in close alignment, with the frequency of the discrimination, suggesting causation.

The frequency of discrimination, as reported by people also reporting symptoms of insanity.

It was possible, of course, to take this data and argue that psychosis, which is frequently infused with paranoia, leads to a heightened sense of being subjected to discrimination, rather than discrimination being a trigger for psychosis. Anglin explained that she tries to mitigate this problem by examining the link between discrimination and psychotic symptoms that are distinct from paranoia; she has found that those other symptoms are also in close alignment.

All psychotics, not just paranoid psychotics, report being discriminated against more! Boo-yah, skeptics!

The emphasis on divergent rates as a real phenomenon — and not just a product of misdiagnosis — pushes against a core tenet of contemporary American psychiatry. Since around 1980, mainstream psychiatry in the United States has asserted what’s known as the biomedical model, an approach that tries to understand and treat the brain much like any other organ. The model views psychiatric conditions in predominantly physiological and often genetic terms. This is the case, above all, with psychotic disorders, probably because their symptoms can appear so alien, so much a manifestation of faulty neurological wiring. Under the sway of the biomedical model, American psychiatry’s prevailing assumption has long been that because psychosis is primarily genetic, the prevalence of the disorder should be fairly equal across populations and shouldn’t be overly affected by societal forces.

“… because psychosis is primarily genetic, the prevalence of the disorder should be fairly equal across populations” — because reasons!

“This isn’t the thinking everywhere in the world,” Roberto Lewis-Fernández said when we spoke about American psychiatry’s concentration on what he called “the figure and not the ground — not the context in which the figure sits.” Lewis-Fernández has led marginally successful efforts to widen the lens of the Diagnostic and Statistical Manual of Mental Disorders, the diagnostic bible of U.S. psychiatry, to complicate the biomedical model. “British thinking has been focused for much longer on contextual factors. One reason why the U.S. is more focused on the organism is our incredible focus on individualism. We tend to not want to agree that there is a collective world that impacts some more than others and creates pathology in certain groups.”

More plausibly, Americans are insanely opposed to admitting that genes might have something to do with racial differences.

“I want to say the genetic part isn’t real,” Miller told me, as we talked about causes. “But it’s so clear that predisposition moved down my mom’s side and my dad’s side. I want to say it doesn’t exist, but it’s there.”

His mother, who is white, was diagnosed years ago, he said, with a personality disorder, and his father, who is Black, is a hard-core alcoholic. A cousin on his father’s side has been diagnosed with schizophrenia. Miller’s sister died of a fentanyl overdose in 2018. Miller’s 14-year-old son was asked to leave his school not long ago and spent time on a hospital psychiatric ward at his own request, because of suicidal thoughts. He was then placed in a residential psychiatric program.

… Miller’s son is now home with his mother (the parents separated when the boy was 2), going to a local school and passionate about visual art — but for Miller, his son’s replication of his own past is haunting. He said he wasn’t sure of the boy’s diagnosis. He added: “I don’t know how to ask him if he hears voices. I don’t know if he’d feel safe enough to say.” Miller knows all too well the terror, shame and sense of isolation that come with psychotic symptoms.

It’s common for schizophrenia victims to be related to creative artists. It’s hardly surprising that Sub-Saharans tend, who tend to be fairly creative, are also pretty schizo.