Meeting patients where they are: Improving bipolar I disorder care for Black Americans

As a psychiatric provider working with people from all walks of life, I’ve seen how serious mental health conditions, particularly bipolar I disorder (BD-I), can present differently depending on who is sitting across from you. In the Black community, variations in presentation, expression, and timing often lead to delayed or missed diagnoses, complicating the treatment journey before it even begins.

Cultural context matters. The way people describe their symptoms, when they seek care, and how they respond to treatment are shaped by lived experiences, which can include influences from history, family, faith, and systemic inequities. Yet, our mental health system has not always accounted for these nuances. To improve outcomes, we need to slow down, ask better questions, and build trust that empowers patients.

“What happens in this house stays in this house.”

If you're from the Black community, you’ve probably heard the phrase, “What happens in this house stays in this house.” Passed through generations, this principle reflects a cultural norm meant to protect families. However, relative to mental health it can delay recognition of a potential issue and initiation of care. In my clinical experience, perceived stigma or beliefs related to family privacy and individual fortitude can make it hard for patients and their families to speak openly about symptoms, even with one another. As a result, clinicians may only become aware of a person’s symptoms after significant escalation, such as during psychosis or severe behavioural change. By then, the presentation may be so acute that it’s misidentified as schizophrenia or another serious psychotic disorder, rather than accurately diagnosed as a mood disorder like BD-I.

Research supports this pattern: Black Americans are more likely to be misdiagnosed with schizophrenia, underscoring persistent racial disparities in how psychosis and mood disorders are assessed and identified. This trend is driven by misinterpretation of culturally influenced expressions of symptoms and limited training on how BD-I presents in Black patients. Delays in seeking care – often shaped by stigma, trauma, and mistrust – can lead individuals to present only once symptoms have escalated. These barriers are not due to a lack of concern, but rather a protective response to long-standing inequities in the healthcare system. As providers, we have a responsibility to understand that context and respond with empathy.

The importance of listening in clinical encounters

A key part of providing care for Black Americans lies in how clinicians approach the diagnostic process. There are many demands on providers’ time and attention, leading to a reliance on symptom checkers and other more surface-level assessments. But for conditions like BD-I with known heterogeneity, particularly in Black patients, this approach can lead to misdiagnosis and missed opportunities for care. A patient-centric mindset that includes in-depth conversation alongside clinical tools can lead to a more nuanced understanding of what a person may be experiencing.

My approach is to hold off on drawing clinical conclusions until I’ve had a chance to truly listen. Every patient is on their own journey, and it’s my job to join them. I ask when symptoms began, how they’ve changed, and what the experience has been like – to collect data and to understand their story. I don’t diagnose based on a form; I diagnose based on the person and their comprehensive health and life history, because if we’re not listening closely, we risk misunderstanding.

This approach isn't radical – it’s human. But it requires clinicians to pause, listen, and build trust, which unfortunately doesn’t always feature in exam room conversations. When we don't engage and connect with patients, it can translate into how people experience their involvement with healthcare.

A 2022 survey found that 55% of Black adults reported having at least one negative experience with a healthcare provider, such as feeling the need to speak up to receive proper care or being treated with less respect than other patients. For example, when Black patients present with symptoms commonly associated with BD-I, such as elevated energy, irritability, or mood swings, these behaviours are too often interpreted through the lens of bias. Instead of being recognised as signs of BD-I, they may be misread as anger, aggression, or instability. As a result, providers may pursue an inaccurate diagnosis, delaying appropriate treatment and further undermining the patient’s trust.

Navigating mistrust and meeting patients where they are

The historical and at times deeply personal mistrust held by the Black community in relation to healthcare is driven by generations of mistreatment, exclusion from research, and inequitable access to care. It’s valuable for mental health clinicians to recognise that the downstream implications of this history – scepticism towards receiving a diagnosis, reluctance to start medication, or disengagement from care – are not overt signs of resistance, but honest reflections of past experiences and a desire to stay safe in a system that hasn’t always earned trust.

That mistrust can be even more pronounced when providers don’t reflect the patient’s background or lived experience. An October 2020 poll indicated that 70% of Black Americans believed people seeking care are treated unfairly based on race or ethnicity. In light of that reality, how we communicate as clinicians matters. Building trust requires more than medical expertise, but also empathy, cultural humility, and a willingness to meet patients where they are.

My patients’ beliefs offer important insights into treatment conversations. Using motivational interviewing, a patient-centred technique that helps people explore and resolve ambivalence, clinicians can pose questions like: ‘You’ve said you don’t want to take medication, but you also want to feel better, so what would you like us to do together to get there?’ This approach allows the patient to take an active role in their care and helps identify shared goals. When patients feel heard and supported, they’re more likely to engage in care and that’s where meaningful progress can start.

Rethinking treatment together

Cultural competence must become a foundational part of clinical education at every level. Whether physicians, nurse practitioners, physician assistants or therapists, all providers pass through some form of hands-on learning. These are crucial opportunities to teach diagnostic skills while instilling cultural awareness and sensitivity. Equally important is increasing the number of clinicians who reflect the communities they serve. Representation matters for building trust and bringing lived experience and cultural insight to the clinical encounter. As clinicians, we can then pass that knowledge on to help future providers recognise bias, be familiar with cultural context, and approach each patient with the understanding they deserve.

Meeting patients where they are includes reaching beyond the four walls of the clinic and connecting in spaces they trust: churches, schools, community events, and social media. It also means speaking in ways that feel familiar and relevant. We have to communicate so that patients see themselves reflected in the conversation. When that happens, engagement and healing can begin.

There’s no single solution, but there are clear starting points. Listen more – think about what patients and their loved ones are saying, and equally what they may not be overtly saying, but that may provide context clues. Be aware of, in order to minimise, where bias arises. Ask better questions. And never assume you understand someone’s story until you’ve taken the time to truly hear it. While these recommendations won’t undo collective or generational trauma, if they help one more provider help one more patient, then we can embrace that as progress while continuing to push for better.

About the author

Kevin Williams, MS, MPAS, PA-C, is CEO and lead clinician at OnPoint Behavioral Health. He is a physician associate who specialises in psychiatry and has a mission to provide care that is experienced, holistic, and compassionate. He holds two Master’s degrees in Interdisciplinary Medical Sciences and Physician Assistant Studies from the University of South Florida and South University, respectively. He has gained experience treating children, adolescents, and adults for the past nine years in the areas of inpatient, outpatient, and long-term care. Williams has eight years of experience teaching as an adjunct professor at several institutions around the country and also has over 10 years in executive leadership experience, maintaining a passion for educating others to lead with effective influence. He has participated in mission work abroad and has enjoyed volunteering in several organisations in the Tampa Bay community. He enjoys spending time with his family, along with his hobbies of aviation and travelling abroad.