A young Black woman waits in a psychiatric emergency room. She is grieving, traumatized, and depressed. The clinician, however, describes her as “guarded,” “hostile,” and “paranoid” in the chart. She leaves with a schizophrenia diagnosis, a prescription for a first-generation antipsychotic, and a future shaped by a label she should never have received.
This is not a hypothetical situation. The Harvard Review of Psychiatry documented this case in 2023. She was later correctly diagnosed with major depressive disorder and PTSD, but only after years of harm from a misdiagnosis shaped by racial bias. Her story is not unique. It is the predictable result of a diagnostic system that has never fully addressed its own shortcomings.
A 2018 meta-analysis in the Journal of Abnormal Psychology found that Black individuals are diagnosed with schizophrenia at 2.4 times the rate of White individuals. This gap has stayed the same for thirty years. Providers are more likely to diagnose schizophrenia based on race than any other demographic factor, and this unfairness continues even when symptom ratings are the same between groups.
The effects go far beyond just a diagnosis. Black patients who are misdiagnosed are less likely to get antidepressants or ECT for their real mood disorders. They are more likely to be given higher doses of antipsychotics, receive long-acting injections, and face physical restraints, handcuffs during transport, and civil commitment. As one research team said, the misdiagnosis leads to “a progression of lifelong punitive societal implications, including reduced opportunities, substandard care, increased contact with the legal system, and criminalization.” Together, these harms show how misdiagnosis compounds over time.
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The DSM-5-TR clearly states that misdiagnosing schizophrenia in African Americans with mood disorders is a result of clinician bias. The APA’s 2021 Resource Document on Anti-Black Racism calls the overdiagnosis of psychotic disorders in Black populations “one of the most impactful and well-described inequities in psychiatry.” We know this, and we have known it for decades. So why hasn’t it changed?
Most institutions have responded with implicit bias training. While these programs mean well and are now often required, they have not been very effective. A 2024 review in the journal Science Advances of 77 implicit bias training programs in health care found that most lack a clear focus, often do not align with current scientific research, and almost never demonstrate strong internal validity. Another review in the Annual Review of Public Health in 2022 found that while bias training can raise awareness and encourage providers to aim for fairness, “these changes are not sustained, and the interventions have not demonstrated change in behavior in the clinical or learning environment.”
If awareness alone is insufficient, then the logical next step is to redesign the diagnostic process itself. That requires changing the structure of the psychiatric evaluation.
First, we need measurement-based care. The APA recommends using quantitative symptom measures in all psychiatric evaluations because they introduce greater consistency into what is otherwise a highly subjective diagnostic process. Regular use of validated rating scales helps ensure that diagnoses are informed not only by clinical impression but also by standardized measures of symptom severity and change over time. Measurement-based care has been shown to improve diagnostic consistency, treatment monitoring, and the therapeutic relationship while giving patients a more active role in their care.
Second, we should use structured diagnostic interviews. A meta-analysis showed that these assessments do not completely remove the racial gap in schizophrenia diagnosis, but they may help reduce it. More importantly, they require clinicians to carefully check for mood, trauma, and substance use disorders instead of relying on first impressions.
Third, the Cultural Formulation Interview (CFI) is important. The DSM-5-TR includes this tool because cultural context affects how symptoms appear. Black cultural expressions of depression, such as physical complaints, spiritual ways of describing distress, or mistrust of institutions, can be mistaken for paranoia or a thought disorder by clinicians who are not familiar with these cultural differences. When used regularly, the CFI can help prevent the misunderstandings that lead to misdiagnosis.
Fourth, trauma-informed assessment is just as important. Severe PTSD can show up as hypervigilance, mistrust, dissociation, intrusive experiences, and emotional withdrawal. These symptoms can look like psychosis if the clinical context is not fully considered. Black Americans face higher rates of trauma from violence, structural disadvantage, and racial discrimination, so it is especially important to carefully assess trauma before deciding that psychotic symptoms are due to a primary psychotic disorder.
Fifth, we should consider dimensional diagnostic approaches. Categorical diagnoses, where you either have schizophrenia or you do not, are especially open to bias at the edges. Dimensional models, which look at the full range of psychotic, mood, and trauma symptoms, may help reduce the forced-choice mistakes that often harm Black patients.
Sixth, workforce diversification is needed. Physicians of color are more likely to serve underserved patients. Having a psychiatric workforce that better reflects the populations it serves is an important component of broader efforts to improve patient safety and equitable care. A more diverse workforce may improve communication, trust, and engagement with historically marginalized communities.
We do not need more workshops. We need structured interviews embedded in clinical workflows. We need greater use of measurement-based care to complement clinical judgment. We need the Cultural Formulation Interview used routinely, not occasionally. We need a trauma-informed assessment whenever psychosis is being considered. Most of all, we need to stop treating diagnostic bias as an individual problem and start treating it as a systems engineering challenge.
Psychiatry is unique among medical specialties because its core diagnostic tool remains the clinical interview, without an objective biomarker, laboratory test, or imaging study to anchor it. That reality makes psychiatric diagnosis especially vulnerable to the cognitive biases we all carry. The question is no longer whether diagnostic bias exists. It does. The challenge is whether we will finally redesign diagnosis to reduce it.
The young woman in the emergency room deserved better care. So does every patient who comes after her.
This essay is cited in the KevinMD record on race and medicine.
Timothy Lesaca is a psychiatrist in private practice at New Directions Mental Health in Pittsburgh, Pennsylvania, with more than forty years of experience treating children, adolescents, and adults across outpatient, inpatient, and community mental health settings. He has published in peer-reviewed and professional venues including the Patient Experience Journal, Psychiatric Times, the Allegheny County Medical Society Bulletin, and other clinical journals, with work addressing topics such as open-access scheduling, Landau-Kleffner syndrome, physician suicide, and the dynamics of contemporary medical practice. His recent writing examines issues of identity, ethical complexity, and patient–clinician relationships in modern health care. Additional information about his clinical practice and professional work is available on his website, timothylesacamd.com. His professional profile also appears on his ResearchGate profile, where further publications and details may be found.
