This transcript has been edited for clarity.
Hi. I'm Stephen M. Strakowski. I'm the Joyce and Iver Small Professor of Psychiatry at Indiana University in Indianapolis, and I have an appointment as a professor of psychiatry and behavioral science at the Dell Medical School at the University of Texas at Austin.
Today I wanted to talk about a recent paper that came out that highlights an ongoing challenge for us in psychiatry, namely that there continue to be racial inequities in how we prescribe antipsychotics, particularly in patients with mood disorders.
I'm going to share a few slides just to help the conversation. This is the paper that came out from a very good group at Mount Sinai in New York, led by Dr Medina. They were using their large health system electronic records to look at prescribing patterns, particularly of antipsychotics in people with schizophrenia as the primary focus. They found something that has been reported for 30 years, which is that if you're Black or Hispanic, you have a higher rate of being prescribed first-generation rather than the newer second-generation drugs.
In this conversation today, I really want to focus instead on their secondary analysis, which was in people with mood disorders, where the same types of inequities were observed, and for me, are even more concerning.
To give you background on this manuscript, like I said, this is from a very good Mount Sinai health system in New York City. As I'll talk about, it's not unique to them, so it shouldn't be perceived that way. The investigators extracted over 200,000 records from their electronic health record with about 19,000 people with bipolar disorder, which is our focus today. These are people who were all given a clinical diagnosis of bipolar disorder in the record.
I'm going to focus on just non-Hispanic, White, Black, and Hispanic individuals, as that's where most of the inequities were seen. You can see in this slide that about 40% of the sample was White, 18% Black, and 14% Hispanic.
The findings were fairly dramatic in that, if you were Black or Hispanic, you had a significantly higher risk of being prescribed first-generation antipsychotics compared with White folks, and this included haloperidol, fluphenazine, and chlorpromazine. As you can see in this slide, the odds ratios were around 1.7 to 1.9, which are meaningful and significant, and again, you can see the significance was very high. This was not just a chance finding.
Additionally, the antipsychotic doses, when prescribed in Black and Hispanic individuals, were significantly higher than in White folks. Then there was an overall lower use of thymoleptics, specifically antidepressants and mood stabilizers. This manuscript did not report lithium prescribing. I don't know whether that was because it was infrequent, which was a conversation we had in a prior Medscape video where, in the United States, we probably significantly underutilize lithium for bipolar disorder; or whether because the primary focus was on schizophrenia, that it simply wasn't extracted from the record.
As I mentioned already, unfortunately this is nothing new. This inequity in medication choice in people with mood disorders, generally, and bipolar disorder, specifically, if you are Black, has for 30 years had excessive rates of antipsychotic prescribing.
Coincidentally, last year, a similar large dataset was examined by the group at the University of Mississippi by Dr Tchikrizov and colleagues. They found virtually the same thing as this Mount Sinai sample in two large datasets — one national dataset and one local at University of Mississippi. They reported the same findings: excessive use of first-generation antipsychotics in people with bipolar disorder. In this case, they did look at lithium, and there was a much lower rate of using lithium, lamotrigine, and antidepressants in a mood disorder sample.
Furthermore, 20 years ago, our research group found virtually the same thing. We followed a group of patients who had been hospitalized for a first manic episode and saw that the Black individuals were over twice as likely to continue to receive antipsychotics after discharge, even in the absence of psychotic symptoms, and were again much more likely to receive first- rather than second-generation antipsychotics.
Somewhat unsurprisingly, the adherence rates then were lower. Again, these drugs have side effects and they can be significant, so it's something for us to think about as we consider the prescription of the older antipsychotics, which I'm going to talk about more in a second. We also replicated this in an adolescent sample, so it wasn't something that developed over time in chronic patients, but it was true right at the beginning.
There are dozens of other reports for the past 30-plus years showing this same general pattern in schizophrenia and mood disorders, where Black individuals are just more likely to be given antipsychotics and at higher doses.
Now, in 2024, the real question is, why are these being prescribed, at all, for anybody? In the very good CANMAT bipolar disorder treatment guidelines from 2018, the only first-generation antipsychotic mentioned was haloperidol as a second-line treatment for acute mania, but it is not considered a good choice for maintenance therapy or treatment of depression, and the latter it actually may worsen. If there is an indicated use, it's limited, given the other choices that we have available now.
My colleague Paul Keck and I, in the recent Schatzberg and Nemeroff psychopharmacology text [The American Psychiatric Association Publishing Textbook of Psychopharmacology, 6th ed], recommended against using these first-generation antipsychotics generally, because of the problem that even if haloperidol is used in a narrow way for acute mania, there's unfortunately a tendency to continue to prescribe the drug long past any utility it might provide.
Additionally, there's an assumption that the first-generation antipsychotics don't cause the same metabolic problems, but for the low-potency drugs, that's probably not true vs the newer drugs. The high-potency drugs and all of them in general have a much higher risk for extrapyramidal symptoms and side effects, and then, as I think of them, non-reward side effects, including apathy, motivation, and depression, because they're full antagonists in the dopamine system within our reward pathways.
There's some old, largely not proven suggestion that the excess of smoking in these individuals is an attempt to override that block of the reward system. I can't prove that's true, but it certainly makes sense from a face validity perspective. Regardless, most of us who are working specifically in bipolar most of the time really do not recommend the use of first-generation antipsychotics for long-term care, and generally don't recommend them at all because of the tendency for them to persist after they've been used for short-term care.
Now back to the other question: Why is this happening that Black patients, and now more recently Hispanic individuals, are getting higher doses of these drugs and why are they more frequently relied upon? Well, there's unfortunately a racist background that arose out of the Jim Crow laws and that got perpetuated into the civil rights era in the 1960s. Jonathan Metzl describes this very nicely in his book, The Protest Psychosis, where the diagnosis of schizophrenia during that period largely shifted from quiet White individuals to being applied more and more often to Black individuals, particularly those involved with protests, particularly in the South.
Accompanying that as the antipsychotics came to market, because they were new back in those times, was a use of these then-called major tranquilizers to manage what was perceived as aggression and hostility in Black people, which was almost certainly, and has been discussed by Metzl and others, to be a misperception based on stigma and bias.
Accompanying that was then an overdiagnosis of Black compared with White people with schizophrenia that we've talked about in a prior Medscape video. All of that was leading to a bias that antipsychotics were specifically more necessary in Black individuals in the absence of any data whatsoever suggesting that's actually true.
Equally concerning is that recently there's been increased use of these medications in Hispanic individuals. Again, I don't know why that's happening, but I have to worry that culturally there is this racist portrayal of people from Mexico and Central and South America as being dangerous and aggressive, as these refugees are moving out of horrendous situations where they live to try to immigrate into the United States. This racist portrayal — not only is it inaccurate that these are mostly violent and dangerous people, which is simply not true, but it is then perpetuated into how we think about taking care of these individuals.
How are we going to solve this? The good news — I talk about this often — is that the people I meet that are in mental health care, the vast majority, really want to provide equitable care and are always unhappy when they see that they're not. Unfortunately, inequitable care has been demonstrated virtually everywhere it's been looked at.
Despite our good intentions, we still are vulnerable to the same biases as the rest of society. Again, since the Civil Rights Act, and certainly in healthcare, there really has not been a good national strategy to correct these inequities. As far as I'm concerned, it's really up to us. It's up to us to try to change how we think about how we care for people and keep these inequities in mind.
How do we do that? How do I do that? First, look honestly at your own biases and stigmas. We all have them. It is not possible to live in a society like the one we live in and not have them. We're all vulnerable to these.
Look honestly at your practice, look at how you're prescribing, and then ask why. Why am I giving this drug to this person? Ask it again and again. There's the old, lean method of performance improvement where you ask “why” six times until you get it. Understand why you're doing this. Why is this particular patient in front of me today with bipolar disorder getting a first-generation antipsychotic? This is not a good long-term strategy, so we really need to challenge it within our own practice.
What were the assumptions that led to this prescription in the first place? Did I start it or did someone else start it and I've just been reluctant to change it? I think there's often a belief that if everything's okay, we shouldn't touch it. Sometimes that's not true because what is okay might be improved by removing something that's causing side effects, such as amotivation or anhedonia, that we're not even really attending to.
As we do that, then, is there a better option? I do a large amount of consulting for people with bipolar disorder, and often the better option is to cut down the number of medications. Regardless, clinical judgment is important here, but we need to challenge ourselves as to why we are prescribing something that most experts really discourage using in people with bipolar disorder, which was highlighted in this Medina paper.
I do believe, despite the absence of a national strategy, in general, for most things in healthcare, that by attending to our own biases and by keeping a close watch on our prescribing patterns, asking questions of what we're doing, we can self-correct many of the inequities that we see in mental health care.
Some of it is built into systemic racism in our culture that's much harder for us to tackle and can be overwhelming. Managing my individual practice is something I know I can do. I would ask everyone who's watching today to think about that. I really do believe that we can change how these kinds of things happen, and that future reports from groups like the one at Mount Sinai and others can see this inequity go away.
Today, my challenge for all of us is to look at how we prescribe and practice, try to avoid bias whenever we can, and in this case, really challenge why we are using these medications that probably aren't a great choice for people with bipolar disorder.
I hope that this has been instructive and helpful. I thank all of you who come and look at these videos that I do. I appreciate your ongoing support, questions, and comments. Thank you very much.
COMMENTARY
Racial Bias in Antipsychotic Prescribing: A Call for Equity
Stephen M. Strakowski, MD
DISCLOSURES
| November 12, 2024This transcript has been edited for clarity.
Hi. I'm Stephen M. Strakowski. I'm the Joyce and Iver Small Professor of Psychiatry at Indiana University in Indianapolis, and I have an appointment as a professor of psychiatry and behavioral science at the Dell Medical School at the University of Texas at Austin.
Today I wanted to talk about a recent paper that came out that highlights an ongoing challenge for us in psychiatry, namely that there continue to be racial inequities in how we prescribe antipsychotics, particularly in patients with mood disorders.
I'm going to share a few slides just to help the conversation. This is the paper that came out from a very good group at Mount Sinai in New York, led by Dr Medina. They were using their large health system electronic records to look at prescribing patterns, particularly of antipsychotics in people with schizophrenia as the primary focus. They found something that has been reported for 30 years, which is that if you're Black or Hispanic, you have a higher rate of being prescribed first-generation rather than the newer second-generation drugs.
In this conversation today, I really want to focus instead on their secondary analysis, which was in people with mood disorders, where the same types of inequities were observed, and for me, are even more concerning.
To give you background on this manuscript, like I said, this is from a very good Mount Sinai health system in New York City. As I'll talk about, it's not unique to them, so it shouldn't be perceived that way. The investigators extracted over 200,000 records from their electronic health record with about 19,000 people with bipolar disorder, which is our focus today. These are people who were all given a clinical diagnosis of bipolar disorder in the record.
I'm going to focus on just non-Hispanic, White, Black, and Hispanic individuals, as that's where most of the inequities were seen. You can see in this slide that about 40% of the sample was White, 18% Black, and 14% Hispanic.
The findings were fairly dramatic in that, if you were Black or Hispanic, you had a significantly higher risk of being prescribed first-generation antipsychotics compared with White folks, and this included haloperidol, fluphenazine, and chlorpromazine. As you can see in this slide, the odds ratios were around 1.7 to 1.9, which are meaningful and significant, and again, you can see the significance was very high. This was not just a chance finding.
Additionally, the antipsychotic doses, when prescribed in Black and Hispanic individuals, were significantly higher than in White folks. Then there was an overall lower use of thymoleptics, specifically antidepressants and mood stabilizers. This manuscript did not report lithium prescribing. I don't know whether that was because it was infrequent, which was a conversation we had in a prior Medscape video where, in the United States, we probably significantly underutilize lithium for bipolar disorder; or whether because the primary focus was on schizophrenia, that it simply wasn't extracted from the record.
As I mentioned already, unfortunately this is nothing new. This inequity in medication choice in people with mood disorders, generally, and bipolar disorder, specifically, if you are Black, has for 30 years had excessive rates of antipsychotic prescribing.
Coincidentally, last year, a similar large dataset was examined by the group at the University of Mississippi by Dr Tchikrizov and colleagues. They found virtually the same thing as this Mount Sinai sample in two large datasets — one national dataset and one local at University of Mississippi. They reported the same findings: excessive use of first-generation antipsychotics in people with bipolar disorder. In this case, they did look at lithium, and there was a much lower rate of using lithium, lamotrigine, and antidepressants in a mood disorder sample.
Furthermore, 20 years ago, our research group found virtually the same thing. We followed a group of patients who had been hospitalized for a first manic episode and saw that the Black individuals were over twice as likely to continue to receive antipsychotics after discharge, even in the absence of psychotic symptoms, and were again much more likely to receive first- rather than second-generation antipsychotics.
Somewhat unsurprisingly, the adherence rates then were lower. Again, these drugs have side effects and they can be significant, so it's something for us to think about as we consider the prescription of the older antipsychotics, which I'm going to talk about more in a second. We also replicated this in an adolescent sample, so it wasn't something that developed over time in chronic patients, but it was true right at the beginning.
There are dozens of other reports for the past 30-plus years showing this same general pattern in schizophrenia and mood disorders, where Black individuals are just more likely to be given antipsychotics and at higher doses.
Now, in 2024, the real question is, why are these being prescribed, at all, for anybody? In the very good CANMAT bipolar disorder treatment guidelines from 2018, the only first-generation antipsychotic mentioned was haloperidol as a second-line treatment for acute mania, but it is not considered a good choice for maintenance therapy or treatment of depression, and the latter it actually may worsen. If there is an indicated use, it's limited, given the other choices that we have available now.
My colleague Paul Keck and I, in the recent Schatzberg and Nemeroff psychopharmacology text [The American Psychiatric Association Publishing Textbook of Psychopharmacology, 6th ed], recommended against using these first-generation antipsychotics generally, because of the problem that even if haloperidol is used in a narrow way for acute mania, there's unfortunately a tendency to continue to prescribe the drug long past any utility it might provide.
Additionally, there's an assumption that the first-generation antipsychotics don't cause the same metabolic problems, but for the low-potency drugs, that's probably not true vs the newer drugs. The high-potency drugs and all of them in general have a much higher risk for extrapyramidal symptoms and side effects, and then, as I think of them, non-reward side effects, including apathy, motivation, and depression, because they're full antagonists in the dopamine system within our reward pathways.
There's some old, largely not proven suggestion that the excess of smoking in these individuals is an attempt to override that block of the reward system. I can't prove that's true, but it certainly makes sense from a face validity perspective. Regardless, most of us who are working specifically in bipolar most of the time really do not recommend the use of first-generation antipsychotics for long-term care, and generally don't recommend them at all because of the tendency for them to persist after they've been used for short-term care.
Now back to the other question: Why is this happening that Black patients, and now more recently Hispanic individuals, are getting higher doses of these drugs and why are they more frequently relied upon? Well, there's unfortunately a racist background that arose out of the Jim Crow laws and that got perpetuated into the civil rights era in the 1960s. Jonathan Metzl describes this very nicely in his book, The Protest Psychosis, where the diagnosis of schizophrenia during that period largely shifted from quiet White individuals to being applied more and more often to Black individuals, particularly those involved with protests, particularly in the South.
Accompanying that as the antipsychotics came to market, because they were new back in those times, was a use of these then-called major tranquilizers to manage what was perceived as aggression and hostility in Black people, which was almost certainly, and has been discussed by Metzl and others, to be a misperception based on stigma and bias.
Accompanying that was then an overdiagnosis of Black compared with White people with schizophrenia that we've talked about in a prior Medscape video. All of that was leading to a bias that antipsychotics were specifically more necessary in Black individuals in the absence of any data whatsoever suggesting that's actually true.
Equally concerning is that recently there's been increased use of these medications in Hispanic individuals. Again, I don't know why that's happening, but I have to worry that culturally there is this racist portrayal of people from Mexico and Central and South America as being dangerous and aggressive, as these refugees are moving out of horrendous situations where they live to try to immigrate into the United States. This racist portrayal — not only is it inaccurate that these are mostly violent and dangerous people, which is simply not true, but it is then perpetuated into how we think about taking care of these individuals.
How are we going to solve this? The good news — I talk about this often — is that the people I meet that are in mental health care, the vast majority, really want to provide equitable care and are always unhappy when they see that they're not. Unfortunately, inequitable care has been demonstrated virtually everywhere it's been looked at.
Despite our good intentions, we still are vulnerable to the same biases as the rest of society. Again, since the Civil Rights Act, and certainly in healthcare, there really has not been a good national strategy to correct these inequities. As far as I'm concerned, it's really up to us. It's up to us to try to change how we think about how we care for people and keep these inequities in mind.
How do we do that? How do I do that? First, look honestly at your own biases and stigmas. We all have them. It is not possible to live in a society like the one we live in and not have them. We're all vulnerable to these.
Look honestly at your practice, look at how you're prescribing, and then ask why. Why am I giving this drug to this person? Ask it again and again. There's the old, lean method of performance improvement where you ask “why” six times until you get it. Understand why you're doing this. Why is this particular patient in front of me today with bipolar disorder getting a first-generation antipsychotic? This is not a good long-term strategy, so we really need to challenge it within our own practice.
What were the assumptions that led to this prescription in the first place? Did I start it or did someone else start it and I've just been reluctant to change it? I think there's often a belief that if everything's okay, we shouldn't touch it. Sometimes that's not true because what is okay might be improved by removing something that's causing side effects, such as amotivation or anhedonia, that we're not even really attending to.
As we do that, then, is there a better option? I do a large amount of consulting for people with bipolar disorder, and often the better option is to cut down the number of medications. Regardless, clinical judgment is important here, but we need to challenge ourselves as to why we are prescribing something that most experts really discourage using in people with bipolar disorder, which was highlighted in this Medina paper.
I do believe, despite the absence of a national strategy, in general, for most things in healthcare, that by attending to our own biases and by keeping a close watch on our prescribing patterns, asking questions of what we're doing, we can self-correct many of the inequities that we see in mental health care.
Some of it is built into systemic racism in our culture that's much harder for us to tackle and can be overwhelming. Managing my individual practice is something I know I can do. I would ask everyone who's watching today to think about that. I really do believe that we can change how these kinds of things happen, and that future reports from groups like the one at Mount Sinai and others can see this inequity go away.
Today, my challenge for all of us is to look at how we prescribe and practice, try to avoid bias whenever we can, and in this case, really challenge why we are using these medications that probably aren't a great choice for people with bipolar disorder.
I hope that this has been instructive and helpful. I thank all of you who come and look at these videos that I do. I appreciate your ongoing support, questions, and comments. Thank you very much.
Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
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