We’re Failing to Treat Early Psychosis Symptoms in Black Children

Onyi Okeke, MD
Onyi Okeke, MD
8 Min Read

Okeke is a child psychiatrist.

A 16-year-old Black boy sits before me in the pediatric emergency department, his mind slipping away. He expressed his paranoid thoughts about food. He will not eat unless it’s prepackaged because he worries that he is being poisoned. He is losing weight — almost 50 pounds in a few short months. He sees no problem in his thought process. He is unsure if I am here to help or just here to force him to take medications and lock him up against his will in an inpatient psychiatric hospital. Unfortunately, it has happened to him before. I cannot say his skepticism is wrong. All I can say is this could have been prevented.

I recently thought about this patient of mine when I heard about Prince Harry and Meghan Markle’s talk on youth mental health in New York City. While as a psychiatrist I am grateful for the increased attention on youth mental health, what remains overlooked is the enormous crisis of Black children who are at risk for psychosis. Quite simply, Black children at risk for psychosis are not getting the medical care they need, despite the fact that early psychosis care is the best option to avoid dire consequences.

A 2021 study in the U.S. involving 3,017 privately insured patients ages 10 to 21 found that white patients were more likely than Black patients to receive behavioral health diagnoses including anxiety, depression, fluctuations in mood, disrupted sleep patterns, irritability, anger, and thoughts of suicide and treatment in outpatient clinics before their first episode of psychosis was identified. Such an early diagnosis means these patients can choose to work with a mental health provider to make a treatment plan that aligns with their treatment goals.

Conversely, the same study showed that Black youths often do not get treatment unless brought to the emergency room. When a mental health concern requires the emergency room, that person is in crisis. That child and their family can no longer control their mental health treatment. Instead, they are at the mercy of the mental health provider they encounter and in a place where Black children are more likely to be physically restrained. This outcome must be avoided.

When early psychotic symptoms occur, also referred to as the prodrome, the child is aware that the lines between fantasy and reality are blurry but still evident. This is the critical juncture for partnership with a specialized clinic for early signs of psychosis. At this stage, that child and their family can choose to participate in their mental health treatment.

Early treatment is vital because it can lead to the prevention of psychosis for many children. Early treatment can resolve these symptoms in two-thirds of children with these experiences. These patients will go on to live a normal life, continue to progress on their developmental trajectory, and never develop a psychotic illness. Unfortunately, even with early detection and screening, one-third of those patients will convert to psychosis. Yet, even these patients can still live healthy lives if adequately treated, managed, and monitored.

Untreated psychosis, however, has devastating results for all people affected. But there are especially dire consequences for affected Black people: increased contact with law enforcement, for instance, which makes them far more likely than their white peers to be harmed or even killed by police officers not trained to manage a mental health crisis. Some horrifying recent examples include Daniel Prude, a 41-year-old man murdered by police during an episode of psychosis, and Walter Wallace Jr., a 27-year-old whose family called 911 seeking urgent medical attention and psychiatric care only to have the police arrive first, resulting in his murder.

Without early treatment, there is an increased risk of death. The first 1 or 2 years after the onset of a psychotic disorder carry the highest chances of death. Even after the first 2 years, an increased risk of accidental death, poisoning, and self-harm remains. Untreated psychosis also reduces the life span by 10-15 years.

To be sure, Black children are diagnosed with higher rates of psychosis than other racial groups. This results from racist practices that pathologize justified “paranoia” or lead to mistrust of Black people. It is also tied to the unconscionable history of racism enacted on Black people by healthcare providers and researchers, and results from poor diagnostic accuracy in Black children. When these symptoms are untreated, a Black child is usually sent to the emergency room by police or emergency medical services. Black children in emergency settings are more likely to be victims of racism by burnt-out doctors. Earlier treatment, on the other hand, usurps the path to emergency treatment and, thus, the subsequent loss of rights for Black children and their families seeking mental health treatment.

There is an incredibly vast gap in health disparities and mental health outcomes of Black children compared to their white peers overall. Unfortunately, for Black patients and their families, the best, short-term strategy to close this gap will require their own initiative. But healthcare providers can try to help too.

Healthcare providers can make a significant impact by first recognizing the racist history in diagnosing and treating psychosis. Thus, we will be more thoughtful in our approach and treatment strategies. When we start to see symptoms of psychosis, we must talk about these observations and discuss the option of specialized care. We must engage with the values of each child and family, especially Black patients who may be hesitant. Listen actively, validate their concerns, and clearly explain the risks and benefits of treatments. By being a committed partner in their health and respecting and supporting their choices, you can help your Black patients and their families feel valued, understood, and cared for.

Onyi Okeke, MD, is a child psychiatry fellow at the Yale Child Study Center at Yale University in New Haven, Connecticut, and a public voices fellow with the OpEd Project.

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