Black male college students who experience their first episode of psychosis (FEP) on campus often resist or reject counseling help, which can delay and reduce effective treatment for schizophrenia.

“For the most part, students of color have the same rates of mental illness as white students,” says Annelle Primm, MD, MPH, the senior medical advisor for the Steve Fund, an organization dedicated to the mental health and emotional well-being of students of color.

“But the biggest difference is that they’re much less likely to receive help. Many end up suffering in silence rather than interacting with a clinician who is not of their background, who might not understand them.”

A dearth of mental health professionals of color can present a barrier to care, but Dr. Primm notes that “counselors of any color or background can be helpful if they can communicate cultural humility.”

Pre-pandemic, students of color were less likely to seek mental health support, preferring to keep concerns to themselves. In one large study of over 40,000 students, 23% of Asian-American students, 26% of Black students, and 33% of Latinx students experiencing negative mental health outcomes sought treatment as compared to 46% of white students.1

In the case of Black men experiencing psychosis/FEP, gender, and general stigma around mental health in Black communities may also prevent them from seeking care.

“Traditionally, men tend to be less help-seeking than women,” says Steven M. Silverstein, PhD, a professor of psychiatry, neuroscience, and ophthalmology at the University of Rochester Medical Center. “But there is also a significant stigma about mental health in Black communities that make it less likely that people will seek services that could be helpful to them.”

Defining And Diagnosing The Problem

Schizophrenia often appears in men during their late teens to early 20s and in women from their 20s to early 30s. The disease alters a person’s ability to think clearly, manage emotions, make decisions and relate to others. People with the condition exhibit vivid hallucinations and delusions or false beliefs, appear emotionally flat or speak in a dull, disconnected manner (which may be confused with depression), and have cognitive issues or disordered thinking over at least six months.

While the diagnosis is extremely serious it is also very rare, affecting about 1% of US adults.2 And yet, astonishingly, Black men are four times more likely to be diagnosed with schizophrenia than their white male counterparts, often because clinicians tend to overemphasize psychotic symptoms in Black patients while overlooking symptoms of major depression or mood disorder.3

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“You need to do the work up very carefully and consider what else could be causing these symptoms and signs,” says Dr. Primm. “Just because someone might hear voices, or have a delusion, you need to consider whether that person might meet the criteria for a mood disorder or major depression before landing on the diagnosis of schizophrenia.”

Because schizophrenia is a diagnosis of exclusion, meaning that the final diagnosis is reached by a process of elimination, this is particularly important.

“Are they using drugs? Were the drugs laced with something stronger? Was there earlier trauma before they came to campus? Are we looking at recovering from a lost relationship like their first love? Are there pressures of emerging into adulthood?” asks Stacia’ Alexander, PhD, clinic director at Paul Quinn College, a historically black college in Dallas, Texas.

Racial factors must also be considered.

“When Black lives are wrapped up in the political climate or religiosity, an untrained person might not easily recognize paranoia or delusions connected to these factors,” says Alexander. “For example, when people in minority cultures start talking about demons and angels—customary in our culture—an unaware therapist might mistake a description of a spiritual encounter for a delusion or hallucination.”

Drug use—either recreational and/or used to self-medicate—must also be considered.

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“While controversial, many people believe that cannabis use can lead to a psychotic episode in a person who is vulnerable to psychosis but who would otherwise not have become psychotic without cannabis use,” says Silverstein.4

Although doctors don’t yet understand who is at highest risk for developing a psychotic episode after cannabis use, it is known that “cannabis use occurs at a high rate among people with a first episode of psychosis and this can interfere with the effects of treatments and increase the risk for relapse,” he adds.

What Happens When Psychosis Isn’t Treated?

Early and comprehensive treatment is the key to managing schizophrenia successfully.

“Data indicate that the longer a person goes with untreated psychosis, the poorer the long-term outcome will be, possibly due to non-reversible changes to the brain resulting from ongoing psychosis and/or its associated neurobiological mechanisms (i.e. neuroinflammation, which can lead to the death of brain cells),” says Silverstein.   “The earlier a person gets into treatment to have their psychotic symptoms reduced or eliminated, the more likely that person is to have a good long-term recovery.”

Also, the longer a person remains psychotic, the higher the risk for behavior that threatens themselves or others.

“Rates of suicide and other self-harm attempts or violence towards others are especially high in untreated FEP patients,” says Silverstein, who notes that this risk decreases greatly after treatment begins. Untreated psychosis also “increases the risk for behaviors that can lead to arrest and long-term legal complications, or even a fatal encounter with police.”

He noted that symptoms and behaviors can improve, or worsen, rapidly.

“To optimally deal with these issues, the preferred approach is to have a team of experts working closely together address the multiple needs, including treatment of psychosis, treatment of substance use, potential medical comorbidities (i.e., cardiovascular and metabolic issues), plans to return to school or work at the right pace and with adequate supports, and psychological support for patients and families, who can be traumatized by the recent experiences and unsure of the future,” he says.  “Recent data indicate that treatment provided by a team with expertise in these areas, that can also respond rapidly to changing needs, leads to significantly better outcomes.”

Barriers to Care

While early and comprehensive intervention is crucial in dealing with an FEP, young Black men may hesitate to seek or receive treatment.

“If you’re at a predominantly white institution and experiencing the first onset of mental illness, it could be especially difficult because you may just want to blend in, be part of the group and feel you belong,” says Dr. Primm. “Just being a student of color on some campuses might make a young man feel isolated or marginalized, so a student of color with schizophrenia might make them stand out more and become alienated.”

Students might also worry that classmates might see them “differently and discriminate against someone who they might think is experiencing a mental illness,” says Dr. Primm.

She also notes cases where Black people with a mental health problem fear that their unusual behavior might draw police or campus security, “where they are mistaken for a bad person rather than someone who needs medical attention.”

A recent study on factors that present barriers to care cite ”isolation, cultural mistrust, stigma, and a lack of diversity in the counseling staff” as major obstacles for Black students.4,5 The research found that “many college students do not understand the mental challenges they experience and might not understand the seriousness of their needs. Instead, they attribute their feeling to regular college life and do not seek treatment.”

Black students, who may experience racism along with a lack of social and academic support, might view mental illness as a “weakness, rather than a treatable condition” or “might try to address it alone or through prayer.”

The good news was that those who “received mental health education were more likely to seek treatment and said they would recommend professional help to others.”

The Role of Family

Families have a crucial role to play in dealing with schizophrenia since studies show that the lower level of family engagement, the poorer the outcome. Along with augmenting health histories to help practitioners understand what a patient was like growing up and to describe any notable changes in behavior, families can offer invaluable support.

“It’s important that families take the diagnosis seriously and not to dismiss symptoms,” says Dr. Primm. “They need to encourage and accompany their child to counseling appointments to be evaluated and treated as soon as possible.”

“What a student needs is unconditional love,” she says. “They need support, not criticism or harsh treatment.”

Family members can educate themselves about the signs and symptoms of psychosis and schizophrenia. NAMI (National Alliance for Mental Illness) offers useful information and family support through in-person and remote groups.

Some data indicate that Black youth are more likely than other groups to seek help from clergy than other young people. This suggests that churches could be good settings in which to provide education sessions about mental health, and treatment services, in addition to establishing links with hospitals and other agencies for when specialized services are required.6

First Episode of Psychosis Helpful Resources

Here, resources and information to help you get help for yourself or a loved one:

  • The Steve Fund is dedicated to the emotional health and well-being of young people of color. The group’s multicultural mental health experts work with many colleges and universities to provide on-campus programs and support.
  • The non-profit JED Foundation works to protect emotional health and prevents suicide for teens and young adults.
  • Students With Psychosis empowers student leaders to get involved in advocacy around issues of psychosis and mental health through community building and collaboration.
  • Black Men Heal provides access to limited but free mental health services.
  • Black Mental Health Alliance has a directory of Black psychiatrists across the US.
  • The Substance Abuse and Mental Health Services Administration (SAMSHA) has a comprehensive early serious mental illness treatment locator tool that can be used to find treatment centers you can use to be connected to treatment centers.

What Colleges Can Do

Reducing the stigma around mental health care can make seeking help less problematic for Black students. Many people with psychotic episodes will graduate from college but good treatment, support from the college or university’s behavioral health department, and lifestyle choices increase the likelihood that students who have experienced psychosis will stay in school.

As a clinic director at a historically Black college, Alexander has worked hard to make students aware and comfortable with counseling. Among the steps she has taken is to locate the counseling office down the hall from the cafeteria, so students pass the center several times a day. The clinic offers “walk-in” appointments and a “relaxation room.”

Pre-COVID, the center blanketed the campus with posters of famous Black performers who had to deal with mental health issues including Mariah Carey (alcoholism) and Beyonce (behavior disorder). After a few weeks, of the original 300 posters displayed only 7 remained.

“The students had taken them, a sign of a successful campaign,” says Alexander.

“Our message is simple: just because you’re successful doesn’t mean that you are immune to emotional challenges.”

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Last Updated: Oct 14, 2021