Schizophrenia diagnoses illustrate racial disparity
The share of U.S. nursing home residents who are recorded as having schizophrenia has soared over the past decade. As The New York Times reported last month, the change is driven in part by a surge of questionable diagnoses.
A 2012 government effort to reduce unnecessary antipsychotic drug use in nursing homes included an exemp- tion for residents with schizo- phrenia. Since then, the diagnoses have grown by 70%. Experts say some facilities are using the schizophrenia loophole to continue sedating dementia patients instead of providing the more costly, staff-intensive care that regulators are trying to promote.
The impact of this has been more severe on Black residents, a new study in the Journal of the American Geriatrics Society has found. Since the new rules went into place, Black Americans with dementia have been 1.7 times as likely as their white nursing home neighbors to be diagnosed with schizophrenia, said Shekinah A. Fashaw-walters, a public health researcher at the University of Minnesota and the study’s lead author.
Black nursing home residents are already more likely to live in facilities that rank lower in numerous quality measures, she said, and now face higher health risks of being misdiagnosed as schizophrenic to justify antipsychotic prescriptions. For residents with Alzheimer’s disease and other forms of dementia, antipsychotic drugs increase the risk of infections and falls, and double the risk of death, studies have shown.
“I wanted to look at that increase in schizophrenia by race to see if this policy had a differential effect,” she said.
The findings align with past research on schizophrenia diagnoses. Among all age groups, clinicians are already more likely to misdiagnose a patient as schizophrenic — and more likely to prescribe antipsychotics — if they are Black, said Stephen Strakowski, vice dean of research at the Dell Medical School at the University of Texas at Austin.
“When clinicians talk to a Black or white patient who look otherwise similar symptom wise, they overemphasize psychotic symptoms, delusions and hallucinations, relative to other symptoms in Black patients compared to how they do with white patients,” he said.
“So it wouldn’t be a terrible surprise that if you now incentivize the diagnosis, the difference will be magnified.”
Experts have long been concerned about nursing home drugging. The National Partnership to Improve Dementia Care began in 2012 after years of research showed that antipsychotic medications were widely used in nursing homes despite warnings from the Food and Drug Administration about the potential harms.
The partnership includes federal and state agencies, nursing homes, advocacy groups and caregivers. It supports caring for dementia patients without drugs. This approach often requires substantial staffing and additional training, whereas antipsychotic medications can make it easier for nurses and aides to handle difficult-to-carefor residents and costs less.
The partnership called on state inspectors to look more closely at prescribing practices and to issue citations for unnecessary drug use. The prescription rates are counted in official statistics that the government uses to help rate facilities, a fivestar system that serves as a consumer guide for families choosing a nursing home.
On the surface, the partnership has had a significant impact, boasting a hefty reduction in the share of residents being given antipsychotic medications. But The Times’ report found that more than half of the officially reported reduction in drug use was attributable to the increase in schizophrenia diagnoses from the loophole in the new rules.