A study by Eack and colleagues reported in this issue found that African Americans were more than three times as likely as whites to receive a schizophrenia diagnosis. Study clinicians were asked,“Did the patient appear to be responding honestly?” Data analyses indicated that the disparity was strongly related to perceived honesty. Apparently, the clinicians did not trust African Americans’ responses to queries about their symptoms and may have made diagnostic inferences based on a suspicion of symptom denial, poor insight, or uncooperativeness.

Diagnosis of psychotic disorders has been subject to different types of bias over the years. International studies documented an overdiagnosis of schizophrenia in the United States compared with England. In those early studies, a key observation was that psychiatrists trained in America gave more attention to psychotic symptoms and less attention to mood changes in making a diagnosis. In the 1980s, the Epidemiologic Catchment Area study reported similar rates of schizophrenia across US racial-ethnic groups, but clinical studies began documenting an excess of schizophrenia diagnoses among African Americans, even when structured interviews or blinded assessments were used, which seemed to result from inherent biases. Clinicians seem to “overvalue” psychotic symptoms among African Americans and this skews diagnoses toward schizophrenia.