A prominent story appeared on the front page of the Washington Post on June 28, 2005. "Racial Disparities Found in Pinpointing Mental Illness" read the headline above an article that was at once shocking and sadly familiar. Researchers had examined the largest American registry of psychiatric patient records looking for "ethnic trends" in schizophrenia diagnoses. As the Post described it, schizophrenia, "a disorder that often portends years of powerful brain-altering drugs, social ostracism and forced hospitalizations…has been shown to affect all ethnic groups at the same rate."
"Racial schizophrenia" arose not from individual racism, but from cultural shifts that defined the thoughts, actions and even politics of black men as insane.
And yet, the large government study uncovered striking categorical differences in its analysis of 134,523 case files: doctors diagnosed schizophrenia in African American patients, and particularly African American men, four times as often as in white patients. The Post cited the study's lead author, John Zeber, who explained that doctors overdiagnosed schizophrenia in African American men even though the research team uncovered no evidence that "black patients were any sicker than whites." According to Zeber, "the only factor that was truly important was race."
Paradoxically, we live in an era when the opposite is supposed to be the case: race should be entirely unimportant to psychiatric diagnosis. Present-day psychiatry believes that mental illness results from disordered brain biology at levels that are presumably the same in people of all races and ethnic backgrounds. And psychiatrists consider schizophrenia to be the most biologically based of the mental illnesses. Textbooks routinely claim that, as a biological disorder, schizophrenia should occur in one percent of any given population, or one out of every hundred persons regardless of where they live, how they dress, who they know, or what type of music they happen to prefer.
Yet, in the real world, one percent is a delusion. Not only do stories such as the Post article appear with regularity—they persist over time. For instance, throughout the 1980s and 1990s, a host of articles from leading psychiatric and medical journals showed that African American patients were "significantly more likely" than white patients to receive schizophrenia diagnoses, and "significantly less likely" than white patients to receive diagnoses for other mental illnesses such as depression or bipolar disorder.
My research tells the story of how these race-based imbalances came to be. I look closely at changing twentieth-century American assumptions about race and schizophrenia through sources including American medical journals, newspapers, popular magazines, pharmaceutical advertisements, and medical charts. What I find, surprisingly, is that the very idea of "racial schizophrenia" came about only in the 1960s and 1970s. And, that far from resulting from the racist intentions of individual doctors or the symptoms of specific patients, racial schizophrenia resulted from a much wider set of cultural shifts that defined the thoughts, actions, and even the politics of black men as being inherently insane.
For instance between the 1920s to the 1950s, mainstream American medical and popular opinion often assumed that patients with schizophrenia were largely white, and generally harmless to society. Psychiatric textbooks depicted schizophrenia as an exceedingly broad, general condition, manifest by "emotional disharmony," that negatively impacted white people's abilities to "think and feel." Authors of research articles in leading psychiatric journals described patients with schizophrenia, and, all too often, their "schizophrenogenic mothers," as "native-born Americans" or immigrants of "white European ancestry."
Leading mainstream American newspapers in the 1920s to the 1950s similarly described schizophrenia as an illness that occurred "in the seclusive, sensitive person with few friends who has been the model of behavior in childhood," or that afflicted white women or intellectuals. In 1935, for instance, the New York Times described how many white poets and novelists demonstrated a symptom called "grandiloquence," a propensity toward flower prose believed to be "one of the telltale phrases of schizophrenia, the mild form of insanity known as split personality." Meanwhile, popular magazines such as Ladies' Home Journal and Better Homes and Gardens wrote of unhappily married, middle-class white women whose schizophrenic mood swings were suggestive of "Doctor Jekyll and Mrs. Hyde."
A series of transformations occurred during the American civil rights era of the 1960s and 1970s. During this vital period, new clinical ways of defining mental illness unintentionally combined with growing cultural anxieties about social change. Meanwhile, reports about new "psychochemical" technologies of control merged with concerns about the "uncontrolled" nature of urban unrest. As these historical contingencies evolved, the American public, and at times members of the scientific community, increasingly described schizophrenia as a violent social disease—even as psychiatry took its first steps toward defining schizophrenia as a disorder of biological brain function.
As but one example, in 1968, psychiatry published the second edition of the "Diagnostic and Statistical Manual" (DSM)—the "official" source of psychiatric diagnoses. That text recast the paranoid subtype of schizophrenia as a disorder of masculinized belligerence. "The patient's attitude is frequently hostile and aggressive," the DSM-II claimed, "and his behavior tends to be consistent with his delusions." My evidence shows that growing numbers of research articles used this language to cast schizophrenia as a disorder of racialized aggression. In the worst cases, psychiatric authors conflated the schizophrenic symptoms of African American patients with the perceived schizophrenia of civil rights protests, particularly those organized by Black Power, Black Panthers, Nation of Islam, or other activist groups. Advertisements for new pharmaceutical treatments for schizophrenia in the 1960s and 1970s depicted similar themes. An Archives of General Psychiatry ad for the antipsychotic drug Haldol showed an angry black man with a clenched, Black Power fist whose symptoms of social belligerence required chemical management (see illustration above).
Meanwhile, mainstream white newspapers described schizophrenia as a condition of angry black masculinity, or warned of crazed, black, schizophrenic killers on the loose.
Changing notions of schizophrenic illness in the 1960s impacted persons of many different racial and ethnic backgrounds. Some patients became schizophrenic because of changes in diagnostic criteria rather than in their clinical symptoms. Others saw their diagnoses changed to depression, anxiety, or other conditions because they did not manifest hostility or aggression. Emerging understandings of the illness shaped American cultural fears about mental illness more broadly, particularly regarding cultural stereotypes of persons with schizophrenia as being unduly hostile or violent.
In no way is my research meant to suggest that schizophrenia is a socially fabricated disease, or, worse, that people's suffering is somehow inauthentic. As a psychiatrist, I have seen the tragic ways in which hallucinations, delusions, and other symptoms can rupture lives, careers, families, and dreams in profoundly material ways. I know that such symptoms afflict persons of many different social, economic, and racial backgrounds, most all of whom are deeply aware of the sense of loss that their disease represents. I also strongly believe that persons diagnosed with schizophrenia and other mental illnesses benefit from various forms of treatment or social support, and that our society should invest more in the care and well-being of the severely mentally ill.
At the same time, I believe that the material reality of schizophrenia is shaped by social, political, and, ultimately, institutional factors in addition to chemical or biological ones. And, I believe that well-intentioned efforts to correct present-day stigmatizations and racial imbalances are at times undermined by the still-present past. Findings such as those from the Washington Post reflect the ongoing salience of American racial history, and the ongoing need for doctors, patients, policymakers, and others, to better understand this history in order to create better conditions in the present-day.
Far from being static or timeless, stigmatizations of mental illness change over time, and reflect anxieties about race, gender, and class in addition to anxieties about mental illness. Only during the civil-rights era did emerging scientific understandings of schizophrenia become enmeshed in a set of historical currents that marked particular bodies, and particular psyches, as crazy in particular ways. The tensions of that era then changed the associations that many Americans made about persons with schizophrenia. Ultimately, recent American racial history altered more than the meaning of mental illness: it changed the meaning of mental health as well.
This essay is adapted from Jonathan Metzl's book The Protest Psychosis: How Schizophrenia Became a Black Disease (Beacon Press, 2010). He is associate professor of psychiatry and women's studies, and director of the Culture, Health, and Medicine Program at the University of Michigan. He is also the author of the book "Prozac on the Couch."
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