Katrina* spent years attempting to have her mental health accurately assessed, and for years found herself frustrated by repeated misdiagnoses: Doctors wrongly told her she had depression, anxiety, and other mental illnesses. Eventually, she was diagnosed with ADHD, but only after spending over a year trying to find a medical professional who would take her suspicions about being neurodivergent seriously. Katrina is Asian American, and she believes the intersection of her race, gender, and age prolonged her journey toward a diagnosis and caused her significant emotional stress. Unfortunately, she’s not alone.
Misconceptions and misdiagnoses of mental health conditions for Black, Indigenous, and other women of color (BIWOC) are common occurrences, reflected in Katrina’s struggle to get an accurate diagnosis. Underdiagnosis of people of color with ADHD is an ongoing problem—a 2013 study that looked at more than 17,000 children determined that Black children were 69% less likely to receive an ADHD diagnosis than their white counterparts, and Latinx children were 50% less likely.
“I believe being a female adult, and then being Asian, made it harder to prove the symptoms weren’t just my own personal quirks or misfortunes,” Katrina said. “I don’t think I would have received a positive diagnosis for ADHD if I didn’t have a total meltdown from interpersonal issues right before my first appointment, and also lost my phone between my two appointments.”
Dr. Bisma Anwar, whose work centers around normalizing mental health care for people of color, says this particular kind of misdiagnosis can be due to lack of cultural sensitivity training that results in the easy misdiagnosis of BIWOC’s mental distress. ADHD is just one example, often attributed more to boys and men, especially those who are white.
“If the mental health practitioner isn’t getting a full picture, it’s very easy to assign someone that anxiety or depression diagnosis, rather than actually finding out whether it’s ADHD, because then that also requires a visit to a neurologist,” Anwar said. “That’s where these women probably fall through the cracks.”
Medical racism and misdiagnoses
Getting an accurate mental health assessment is often stressful, and the extra steps to getting a diagnosis for neurodivergence related conditions like autism spectrum disorder and ADHD add even more complications. They can also be cost prohibitive or involve confusing health insurance bureaucracy that can be difficult to navigate. But the biggest issue is by far the history of racism in the field of mental health.
“Unfortunately, there is a history of misdiagnosing women of color in the overall healthcare system, which includes the area of mental health,” said Shontel Cargill, assistant clinic director at Thriveworks in Cumming, Georgia.
Cargill cited several reasons why BIWOC are often misdiagnosed, including systemic racism and discrimination in the mental health field, implicit bias, lack of cultural competency and responsiveness, lack of awareness of how trauma impacts communities of color, lack of quality care, and training. Further, it’s not uncommon for doctors and other medical specialists to react dismissively or undermine BIWOC when they share concerns, thoughts, and feelings about their health. The resulting barriers and mistrust prevent many BIWOC from finding support and solutions tailored to their unique needs.
For Katrina, the ADHD diagnosis explained a lot about her life, and the medication she is taking has really helped her feel more stable. However, she believes she wouldn’t have gotten the help she needed if she hadn’t insisted on a diagnosis. After reading more about the frequency of women with ADHD being misdiagnosed as bipolar, Katrina is convinced her diagnosis in 2013 should have been for ADHD.
“I had several people say, ‘They don’t think it’s ADHD,’ including three people working in psychiatry and therapy,” she said. “This is why I think if I hadn’t had the meltdown to get the diagnosis, I would have masked the issue better.”
Misogynoir in mental health
Dr. Nadia Richardson, PhD, a Black woman who lives with bipolar II disorder, wasn’t diagnosed until she reached her 40s. Though she doesn’t believe she was officially misdiagnosed because she is high-functioning and doesn’t experience long periods of mood changes, she was told by mental health professionals that much of her mental distress over the period of her life was due to transitional periods, depression, and anxiety.
It was only when Richardson consistently saw a team of mental health professionals after struggling at work that she was given a bipolar II diagnosis. Richardson’s journey inspired her to create No More Martyrs, a mental health awareness campaign committed to building a community of support for Black women with mental health concerns. One of Richardson’s primary concerns is how the misdiagnoses of Black women specifically can result in criminalization and lack of mental health care.
“[Misdiagnosis] happens depending on the type of practitioner [who] is doing the evaluation,” she said. “If someone who is not culturally responsive enough to understand how certain forms of mental distress might manifest in Black women and girls, then it can be demonized and criminalized or dismissed as either a personality flaw or anger.”
According to Richardson, some misdiagnoses of Black women seeking mental health care are due to implicit bias and racist stereotypes of the “angry Black woman.” For example, depression in Black women can be misconstrued as hyperirritability, a perception that can dangerously skew a medical practitioner’s diagnosis.
“The perception of hyper irritability in Black people is related to the stereotype of Black people with attitude, or the [stereotype of the] angry Black woman,” Richardson said. “But if you stop at the manifestation of the irritation, without asking more questions, then you’ll never really know what the real issue is.”
Reading Black women who are in mental distress as “angry” or “aggressive” might also result in police violence. According to a study by the Treatment Advocacy Center, untreated severe mental illnesses are involved in at least one in four and as many as half of all fatal police shootings. Consequently, for Black women, a racist misreading of their emotional distress could be a matter of life and death.
Sometimes, Richardson says, the “hyperirritability” identified in Black women by mental health practitioners is simply a response to the frustration of trying to access services and not being able to get the care they need. Having to navigate Medicare, Medicaid, or a lack of insurance can be complicated and incredibly stressful, even more so for someone trying to manage their mental health.
“It’s difficult, even if you’re mentally well, to go through your insurance and try to figure out how much your medication costs, and if it’s the right medication,” she said.
Black people being misdiagnosed or not diagnosed at all by medical professionals has a long history even beyond the mental health field. Black men who experience cultural mistrust or “healthy paranoia” tend to be overdiagnosed with schizophrenia, while Black and low-income mothers are several times more likely to suffer from postpartum depression but much less likely to get the treatment they need. Cargill noted there have also been many cases of underdiagnosing or lack of diagnosing of Black women, leading to untreated mental health conditions carrying risks of dangerous outcomes such as suicidal ideation or decline in their overall health.
“Black women tend to be overdiagnosed with more severe diagnoses due to implicit bias, lack of cultural awareness, and lack of trauma-informed care needed to treat generational and acute trauma that impacts Black women every day,” Cargill said. “This is particularly problematic when placing Black women on medications based on their overdiagnosis.”
Getting a diagnosis during COVID-19
For Katrina, the pandemic was a mixed bag. On the one hand, the onset of COVID-19 and lockdown heightened her level of sensitivity and struggle with feelings of failure, but she didn’t experience paralysis due to fear like most people did in the first few months of the pandemic.
“Even before the diagnosis, I was managing to catch up with my PhD writing, while most others experienced stagnation in their lives in the pandemic,” Katrina said.
The additional mental and emotional strain of the pandemic and the way it affected her may have made it easier for Katrina to get the diagnosis she needed. That doesn’t change the fact that the amount of distress she experienced in confirming what she suspected about her own mental health might have been avoided with culturally-sensitive mental health practitioners.
As with other areas of healthcare, the pandemic only magnified racial disparities faced by BIWOC in seeking comprehensive mental health treatment. In these conditions it’s even more essential to accurately assess and diagnose BIWOC’s mental health conditions both prior to and during the pandemic. Unable to wait for institutions to fill the gaps, some individuals and organizations have been developing mental health resources tailored to their communities’ needs, from understanding the trauma of Southeast Asian refugees to the religious and cultural concerns of Muslims and the struggles of Black immigrants. While these efforts are laudable, Cargill stressed that the effects of the pandemic mean that there’s an even greater industry-wide need for more trauma-informed care to help BIWOC manage their mental health.
“Women of color are more susceptible and at risk for psychological effects and physical symptoms of COVID-19,” Cargill said. “Due to the traumatic nature of the pandemic, culturally trauma-informed care is needed to assist women of color with navigating through compounded trauma they may be experiencing during these difficult, uncertain times.”
Seeking a specific diagnosis is daunting in itself, but during a global pandemic it can be even more challenging. Richardson says peer support among women managing mental health issues can be a powerful tool to navigate these difficult processes. Though mental health apps have been useful for some BIPOC who struggle to access traditional mental health care, these apps can also reproduce hierarchies of oppression.
In the end, however, ensuring providers are given training in cultural responsiveness and advocating for revisions to the Diagnostic and Statistical Manual of Mental Disorders will make an even greater positive impact on mental health care for BIWOC. In addition to pre-existing stressors that BIWOC navigate daily, the pressures created by the pandemic, extreme weather disasters, and white supremacist violence are taking a considerable toll on BIWOC’s mental health. It’s more vital than ever to prevent misdiagnosis of mental illnesses in the intersection of gender and race.
* Not her real name