Skip to main content

Advertisement

SpringerLink
Log in

Racial Implicit Associations in Psychiatric Diagnosis, Treatment, and Compliance Expectations

  • Empirical Report
  • Published:
Academic Psychiatry Aims and scope Submit manuscript

A Correction to this article was published on 05 April 2021

This article has been updated

Abstract

Objective

Racial and ethnic disparities are well documented in psychiatry, yet suboptimal understanding of underlying mechanisms of these disparities undermines diversity, inclusion, and education efforts. Prior research suggests that implicit associations can affect human behavior, which may ultimately influence healthcare disparities. This study investigated whether racial implicit associations exist among medical students and psychiatric physicians and whether race/ethnicity, training level, age, and gender predicted racial implicit associations.

Methods

Participants completed online demographic questions and 3 race Implicit Association Tests (IATs) related to psychiatric diagnosis (psychosis vs. mood disorders), patient compliance (compliance vs. non-compliance), and psychiatric medications (antipsychotics vs. antidepressants). Linear and logistic regression models were used to identify demographic predictors of racial implicit associations.

Results

The authors analyzed data from 294 medical students and psychiatric physicians. Participants were more likely to pair faces of Black individuals with words related to psychotic disorders (as opposed to mood disorders), non-compliance (as opposed to compliance), and antipsychotic medications (as opposed to antidepressant medications). Among participants, self-reported White race and higher level of training were the strongest predictors of associating faces of Black individuals with psychotic disorders, even after adjusting for participant’s age.

Conclusions

Racial implicit associations were measurable among medical students and psychiatric physicians. Future research should examine (1) the relationship between implicit associations and clinician behavior and (2) the ability of interventions to reduce racial implicit associations in mental healthcare.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

Change history

References

  1. Lin M-Y, Kressin NR. Race/ethnicity and Americans’ experiences with treatment decision making. Patient Educ Couns. 2015;98(12):1636–42.

    Article  Google Scholar 

  2. Elster A, Jarosik J, VanGeest J, Fleming M. Racial and ethnic disparities in health care for adolescents: a systematic review of the literature. Arch Pediatr Adolesc Med. 2003;157(9):867–74.

    Article  PubMed  Google Scholar 

  3. Saha S, Freeman M, Toure J, Tippens KM, Weeks C, Ibrahim S. Racial and ethnic disparities in the VA health care system: a systematic review. J Gen Intern Med. 2008;23(5):654–71.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Nelson A. Unequal treatment: confronting racial and ethnic disparities in health care. J Natl Med Assoc. 2002;94(8):666.

    PubMed  PubMed Central  Google Scholar 

  5. Meghani SH, Byun E, Gallagher RM. Time to take stock: a meta-analysis and systematic review of analgesic treatment disparities for pain in the United States. Pain Med. 2012;13(2):150–74.

    Article  PubMed  Google Scholar 

  6. Van Ryn M, Burgess D, Malat J, Griffin J. Physicians’ perceptions of patients’ social and behavioral characteristics and race disparities in treatment recommendations for men with coronary artery disease. Am J Public Health. 2006;96(2):351–7.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Sequist TD, Fitzmaurice GM, Marshall R, Shaykevich S, Safran DG, Ayanian JZ. Physician performance and racial disparities in diabetes mellitus care. Arch Intern Med. 2008;168(11):1145–51.

    Article  CAS  PubMed  Google Scholar 

  8. Epstein AM, Ayanian JZ, Keogh JH, Noonan SJ, Armistead N, Cleary PD, et al. Racial disparities in access to renal transplantation—clinically appropriate or due to underuse or overuse? N Engl J Med. 2000;343(21):1537–44.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Blanco C, Patel SR, Liu L, Jiang H, Lewis-Fernández R, Schmidt AB, et al. National trends in ethnic disparities in mental health care. Med Care. 2007;45(11):1012–9.

    Article  PubMed  Google Scholar 

  10. Kristofco RE, Stewart AJ, Vega W. Perspectives on disparities in depression care. J Contin Educ Health Prof. 2007;27(S1):18–25.

    Article  Google Scholar 

  11. U.S. Department of Health and Human Services. Mental health: culture, race, and ethnicity: a supplement to mental health: a report of the surgeon general. Rockville: Substance Abuse and Mental Health Services Administration (US); 2001.

  12. Chien PL, Bell CC. Racial differences in schizophrenia. Dir Psychiatry. 2008;28(4):297–304.

    Google Scholar 

  13. Schwartz RC, Blankenship DM. Racial disparities in psychotic disorder diagnosis: a review of empirical literature. World J Psychiatry. 2014;4(4):133–40.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Barnes A. Race and hospital diagnoses of schizophrenia and mood disorders. Soc Work. 2008;53(1):77–83.

    Article  PubMed  Google Scholar 

  15. Neighbors HW, Jackson JS, Campbell L, Williams D. The influence of racial factors on psychiatric diagnosis: a review and suggestions for research. Community Ment Health J. 1989;25(4):301–11.

    Article  CAS  PubMed  Google Scholar 

  16. Hall WJ, Chapman MV, Lee KM, Merino YM, Thomas TW, Payne BK, et al. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review. Am J Public Health. 2015;105(12):e60–76.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Eack SM, Bahorik AL, Newhill CE, Neighbors HW, Davis LE. Interviewer-perceived honesty as a mediator of racial disparities in the diagnosis of schizophrenia. Psychiatr Serv. 2012;63(9):875–80.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Neighbors HW, Trierweiler SJ, Munday C, Thompson EE, Jackson JS, Binion VJ, et al. Psychiatric diagnosis of African Americans: diagnostic divergence in clinician-structured and semistructured interviewing conditions. J Natl Med Assoc. 1999;91(11):601.

    CAS  PubMed  PubMed Central  Google Scholar 

  19. Neighbors HW, Trierweiler SJ, Ford BC, Muroff JR. Racial differences in DSM diagnosis using a semi-structured instrument: the importance of clinical judgment in the diagnosis of African Americans. J Health Soc Behav. 2003;44:237–56.

    Article  PubMed  Google Scholar 

  20. Nosek BA, Smyth FL. A multitrait-multimethod validation of the implicit association test. Exp Psychol. 2007;54(1):14–29.

    Article  PubMed  Google Scholar 

  21. Gawronski B, De Houwer J. Implicit measures in social and personality psychology. In: Handbook of research methods in social and personality psychology, 2nd ed. New York: Cambridge University Press; 2014. p. 283–310.

  22. Paradies Y, Truong M, Priest N. A systematic review of the extent and measurement of healthcare provider racism. J Gen Intern Med. 2014;29(2):364–87.

    Article  PubMed  Google Scholar 

  23. Sabin J, Nosek BA, Greenwald A, Rivara FP. Physicians' implicit and explicit attitudes about race by MD race, ethnicity, and gender. J Health Care Poor Underserved. 2009;20(3):896–913.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Haider AH, Sexton J, Sriram N, Cooper LA, Efron DT, Swoboda S, et al. Association of unconscious race and social class bias with vignette-based clinical assessments by medical students. Jama. 2011;306(9):942–51.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Haider AH, Schneider EB, Sriram N, Dossick DS, Scott VK, Swoboda SM, et al. Unconscious race and class bias: its association with decision making by trauma and acute care surgeons. J Trauma Acute Care Surg. 2014;77(3):409–16.

    Article  PubMed  Google Scholar 

  26. Maina IW, Belton TD, Ginzberg S, Singh A, Johnson TJ. A decade of studying implicit racial/ethnic bias in healthcare providers using the implicit association test. Soc Sci Med. 2018;199:219–29.

    Article  PubMed  Google Scholar 

  27. Greenwald AG, Nosek BA, Banaji MR. Understanding and using the implicit association test: I. An improved scoring algorithm. J Pers Soc Psychol. 2003;85(2):197.

    Article  PubMed  Google Scholar 

  28. Nosek BA, Greenwald AG, Banaji MR. Understanding and using the Implicit Association Test: II. Method variables and construct validity. Personal Soc Psychol Bull. 2005;31(2):166–80.

    Article  Google Scholar 

  29. Greenwald AG, Poehlman TA, Uhlmann EL, Banaji MR. Understanding and using the Implicit Association Test: III. Meta-analysis of predictive validity. J Pers Soc Psychol. 2009;97(1):17.

    Article  PubMed  Google Scholar 

  30. Schmukle SC, Egloff B. Does the Implicit Association Test for assessing anxiety measure trait and state variance? Eur J Personal. 2004;18(6):483–94.

    Article  Google Scholar 

  31. Greenwald AG, Nosek BA. Health of the implicit association test at age 3. Z Exp Psychol. 2001;48(2):85–93.

  32. Nosek BA, Greenwald AG, Banaji MR. The implicit association test at age 7: a methodological and conceptual review. In: Bargh JA, editor. Frontiers of social psychology. Social psychology and the unconscious: the automaticity of higher mental processes. New York: Psychology Press; 2007. p. 265–92.

  33. Lane KA, Banaji MR, Nosek BA, Greenwald AG. understanding and using the implicit association test: IV: what we know (so far) about the method. In: Implicit measures of attitudes. New York: The Guilford Press; 2007. p. 59–102.

  34. Fiedler K, Bluemke M. Faking the IAT: aided and unaided response control on the Implicit Association Tests. Basic Appl Soc Psychol. 2005;27(4):307–16.

    Article  Google Scholar 

  35. Kim D-Y. Voluntary controllability of the implicit association test (IAT). Soc Psychol Q. 2003;66:83–96.

    Article  Google Scholar 

  36. Cooper LA, Roter DL, Carson KA, Beach MC, Sabin JA, Greenwald AG, et al. The associations of clinicians’ implicit attitudes about race with medical visit communication and patient ratings of interpersonal care. Am J Public Health. 2012;102(5):979–87.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Sabin JA, Greenwald AG. The influence of implicit bias on treatment recommendations for 4 common pediatric conditions: pain, urinary tract infection, attention deficit hyperactivity disorder, and asthma. Am J Public Health. 2012;102(5):988–95.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Allen BJ, Garg K. Diversity matters in academic radiology: acknowledging and addressing unconscious bias. J Am Coll Radiol. 2016;13(12):1426–32.

    Article  PubMed  Google Scholar 

  39. Lokko HN, Chen JA, Parekh RI, Stern TA. Racial and ethnic diversity in the US psychiatric workforce: a perspective and recommendations. Acad Psychiatry. 2016;40(6):898–904.

    Article  Google Scholar 

  40. Metzl JM. The protest psychosis: How schizophrenia became a black disease, vol. xxi. Boston: Beacon Press; 2009. p. 246–xxi.

  41. Blair IV. The malleability of automatic stereotypes and prejudice. Personal Soc Psychol Rev. 2002;6(3):242–61.

    Article  Google Scholar 

  42. Aggarwal NK, Lam P, Castillo EG, Weiss MG, Diaz E, Alarcón RD, et al. How do clinicians prefer cultural competence training? Findings from the DSM-5 cultural formulation interview field trial. Acad Psychiatry. 2016;40(4):584–91.

    Article  PubMed  Google Scholar 

  43. Mian AI, Al-Mateen CS, Cerda G. Training child and adolescent psychiatrists to be culturally competent. Child Adolesc Psychiatr Clin. 2010;19(4):815–31.

    Article  Google Scholar 

  44. Devine PG, Forscher PS, Austin AJ, Cox WT. Long-term reduction in implicit race bias: a prejudice habit-breaking intervention. J Exp Soc Psychol. 2012;48(6):1267–78.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Sukhera J, Wodzinski M, Rehman M, Gonzalez CM. The Implicit Association Test in health professions education: a meta-narrative review. Perspect Med Educ. 2019;8(5):267–75.

  46. Amodio DM. The neuroscience of prejudice and stereotyping. Nat Rev Neurosci. 2014;15(10):670–82.

    Article  CAS  PubMed  Google Scholar 

  47. Bromberg W, Simon F. The protest psychosis: a special type of reactive psychosis. Arch Gen Psychiatry. 1968;19(2):155–60.

    Article  CAS  PubMed  Google Scholar 

  48. Metzl J. Controllin the planet: a brief history of schizophrenia. Transition. 2014;115(1):23–33.

    Article  Google Scholar 

  49. Hausmann LR, Myaskovsky L, Niyonkuru C, Oyster ML, Switzer GE, Burkitt KH, et al. Examining implicit bias of physicians who care for individuals with spinal cord injury: a pilot study and future directions. J Spinal Cord Med. 2015;38(1):102–10.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Schaa KL, Roter DL, Biesecker BB, Cooper LA, Erby LH. Genetic counselors’ implicit racial attitudes and their relationship to communication. Health Psychol. 2015;34(2):111–9.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Green AR, Carney DR, Pallin DJ, Ngo LH, Raymond KL, Iezzoni LI, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. J Gen Intern Med. 2007;22(9):1231–8.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Arkes HR, Tetlock PE. Attributions of implicit prejudice, or "would Jesse Jackson 'fail' the Implicit Association Test?". Psychol Inq. 2004;15(4):257–78.

    Article  Google Scholar 

  53. Landy FJ. Stereotypes, bias, and personnel decisions: strange and stranger. Ind Organ Psychol. 2008;1(4):379–92.

    Article  Google Scholar 

  54. Rezaei AR. Validity and reliability of the IAT: Measuring gender and ethnic stereotypes. Comput Hum Behav. 2011;27(5):1937–41.

    Article  Google Scholar 

  55. Blanton H, Jaccard J. Arbitrary metrics in psychology. Am Psychol. 2006;61(1):27–41.

    Article  PubMed  Google Scholar 

  56. Oswald FL, Mitchell G, Blanton H, Jaccard J, Tetlock PE. Predicting ethnic and racial discrimination: a meta-analysis of IAT criterion studies. J Pers Soc Psychol. 2013;105(2):171–92.

    Article  PubMed  Google Scholar 

  57. Blanton H, Jaccard J, Klick J, Mellers B, Mitchell G, Tetlock PE. Strong claims and weak evidence: reassessing the predictive validity of the IAT. J Appl Psychol. 2009;94(3):567–82.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

We would like to thank the following faculty and trainees who reviewed the pilots for this project: Dr. Robert Rohrbaugh, Dr. Kali Cyrus, Dr. Esperanza Diaz, and Dr. Laine Taylor. We would also like to thank Dr. Nix Zelin, Caroline Scott, and Dr. Roberto Montenegro for their support in recruitment. Preliminary data was presented as a poster at the American Psychiatric Association Meeting on May 5–9, 2018 in New York, NY, and the American College of Neuropsychopharmacology on December 10, 2018 in Hollywood, FL, and as an oral presentation at the American Academy of Child and Adolescent Psychiatry on October 22, 2018 in Seattle, WA.

Funding

Financial support for this project was provided by the American Psychiatric Association Minority Fellowship Program sponsored by SAMHSA that was awarded to A.L.T and J.H.T.

Author information

Authors and Affiliations

  1. Yale University School of Medicine, New Haven, CT, USA

    Amalia Londono Tobon, José M. Flores, Isaac Johnson, Angeli Landeros-Weisenberger, Okoduwa Aboiralor, Victor J. Avila-Quintero & Michael H. Bloch

  2. Children’s Hospital of Philadelphia & University of Pennsylvania School of Medicine, Philadelphia, PA, USA

    Jerome H. Taylor

Authors
  1. Amalia Londono Tobon
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. José M. Flores
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jerome H. Taylor
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Isaac Johnson
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Angeli Landeros-Weisenberger
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Okoduwa Aboiralor
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Victor J. Avila-Quintero
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Michael H. Bloch
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Amalia Londono Tobon.

Ethics declarations

Disclosures

A.LT. is supported by NIMH (5T32MH018268-34), the Ariella Ritvo grant. M.H.B. receives research support from Therapix Biosciences, Neurocrine Biosciences, Janssen Pharmaceuticals and Biohaven Pharmaceuticals, but received no support from these sources for the current manuscript. M.H.B. gratefully acknowledges additional research support from NIH. J.H.T is supported by the National Center for Advancing Translational Sciences at the NIH (KL2TR001879) and the Brain and Behavior Research Foundation. Mr. Johnson is supported by the Yale School of Medicine Medical Student Research Fellowship. Dr. Flores receives financial support for his research from NIH training grant T32MH018268. Dr. Landeros-Wisenberger, Dr. Avila-Quintero, Mr. Johnson, and Mr. Aboiralor report no financial relationships with commercial interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Londono Tobon, A., Flores, J.M., Taylor, J.H. et al. Racial Implicit Associations in Psychiatric Diagnosis, Treatment, and Compliance Expectations. Acad Psychiatry 45, 23–33 (2021). https://doi.org/10.1007/s40596-020-01370-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40596-020-01370-2

Keywords

Search

Navigation