Racism in Swedish psychiatry - a vast problem surrounded by silence

Theme: Education

 

In order to work as a psychiatrist it is important to know about diagnostics, symptomatology, neurobiology and pharmacology, which is why these subjects are mandatory, as they should be. But the student of psychiatry is taught nothing about the power structures that a psychiatrist will have to work within, and how these affect epidemiology and even the psychiatrist's own assessments. It is about time that racism was put on the psychiatric curriculum.



Racial stereotypes were not something I learned about in medical school, either during AT (general internship) or ST (residency). Neither did I learn about the significance and impact of race when studying in Swedish elementary school and high school. All I learned concerning race was that talking about it was ugly and wrong, since Sweden, unlike the USA, did not have any racism.


During my time at medical school, lectures were given in the Retzius lecture hall at my university, Karolinska Institutet. The lecture hall was named after the race biologist Gustaf Retzius who, in the 19th century, dug up graves all over the world to collect skulls and measure them. He then claimed that his findings proved that the nordic race was the purest and most civilized of all races. Using this so-called science, he laid the foundations for a "scientific" form of racism that still permeates society today.


When I first started working as a junior doctor in psychiatry in 2015, I quickly noticed a severe over-representation of BIPOC (black, indigenous and people of colour) patients in the psychotic disorder and intensive psychiatric care units. I also noticed that they received involuntary care and restraint to a much higher extent than their white counterparts, and that they were treated more harshly by the staff. But at that time I lacked the words and context to understand exactly what I was seeing.


Trasnaprant about racism. Image by Unsplash.
Transparant about racism. Image by Unsplash.

Then, in 2020, the Black Lives Matter movement was growing rapidly due to the murder of George Floyd. Its waves reached all the way to Sweden and finally a discussion about race took place in Swedish institutions and media. I was provided, for the first time, with words for the patterns I had noticed, not only in health care but in society as a whole. With this, I, a swedish-born white woman, was also able to identify my own part in racist structures, and understand how racism affected my own assessments and decisions. I became aware of how seldom I had diagnosed a black patient with depression, how I was more likely to ask for a drug screening before meeting my BIPOC patients, and also more likely to believe that a BIPOC patient was exaggerating their symptoms.


I started to search the web for research, and found a lot of international studies on racism in psychiatry. For example, I found out that bipolar patients of African descent are more likely to be misdiagnosed with schizophrenia than patients of non-African descent. They are also more likely to be under-represented in clinical psychiatric research. A Swedish study from 2020 showed that foreign-born citizens were more likely to receive involuntary care, and this was especially obvious for people from sub-Saharan Africa. Another Swedish study indicated an increased risk of post-partum suicide for mothers born in low-income countries. A British study found that patients with psychotic disorder were three times more likely to receive involuntary care if they had Caribbean or African descent, compared to the reference group of white patients with British descent. British people with Caribbean and African descent were also more likely to have been taken to psychiatric care by police, but less likely to come in contact with psychiatry through their GP, as compared to the reference group.


A meta analysis from 2021 found that the most significant risk factors for developing a psychotic disorder were racism (OR = 3.90), migration (OR = 2.22), and childhood trauma (OR = 2.81).


My own newly discovered prejudices were in line with the findings of a 2021 study which showed that 294 medical students and psychiatrists were more likely to pair faces of black individuals with words connected to psychotic disorders, non-compliance and anti-psychotic medication than they were for white faces.


Presented here is only a small selection of the available research on racism in psychiatry, but I hope it has been enough to highlight the immense impact that racism has had and continues to have on the psychiatry field. In order to become better doctors we need to learn about these patterns as well as our own prejudices and how it affects our work.