Racism and mental health
Authors: David R. Williams, Onisha S. Etkins
Journal: World Psychiatry (2021)

The COVID-19 pandemic, with its striking inequities in mortality rates between Whites and stigmatized racial/ethnic groups in the US and UK, and the recent global protests about police violence have raised questions about and increased interest in the potential impacts of racism on health and particularly on mental health. Racism is an organized societal system in which the dominant White group categorizes individuals into "races" and devalues, disempowers, and differentially allocates resources to ethnic groups considered to be inferior1. The ideology of inferiority permeates societal systems and institutions ensuring that racism is not limited to individual beliefs and behaviors1. Racism operates through institutional, interpersonal and cultural pathways. Here we provide a brief overview of these levels of racism and how they can adversely affect mental health. Institutional or structural racism can be defined as racial discrimination that is embedded in institutional structures and poli­cies1. Examples of institutional racism include residential segregation, racialized immigration policy, and racialized incarceration. For example, in the US, residential segregation, the physical separation of races by enforced residence in particular places, is a central determinant of racial inequities in health. Residing in areas with concentrated poverty and social disadvantage can adversely affect mental health by leading to high levels of exposure to stressors (psychosocial, physical and chemical) and reduced access to opportunities and resources, including schooling, employment, and health services. Empirical analyses reveal that eliminating residential segregation in the US would erase racial differences in income, education and unemployment, and reduce racial differences in single motherhood by two thirds1. Immigration policies often reproduce ideologies of belonging and othering that are patterned by race/ethnicity and can adversely affect racialized immigrant groups. Research documents that exclusionary immigration policies with restrictions on rights and aggressive anti-immigrant policy enforcement have negative effects on mental health2. Racialized incarceration also has mental health consequences. The US have the largest incarcerated population globally, with an overrepresentation of Blacks and Latinos3. This has facilitated a historic shift from mental illness being treated in hospitals to being treated in carceral systems, which has led to jails and prisons in the US becoming the largest providers of mental health care. A national study in the US found that prior arrest history was associated with the prevalence of major depressive disorder among African Americans and Caribbean Blacks4. In addition, other US research reveals that aggressive policing, such as the killing of unarmed African Americans, leads to declining mental health for the entire Black population in the state in which the incident occurs1. Self-reported interpersonal discrimination is the most studied domain of racism in the mental health literature. A review of literature reviews and meta-analyses published between 2013 and 2019 on discrimination and health identified eight reviews focused on mental health5. Although most studies came from the US, there were studies from some 20 countries. This body of research indicates that discrimination was positively associated with increased risk of major mental disorders and inversely related to positive mental health outcomes such as life satisfaction and self-esteem. The accumulation of experiences of discrimination over time was associated with increasing risk of mental health problems. Exposure to discrimination was also associated with adverse changes in personality over time, such as increases in neuroticism. Although the majority of studies have been cross-sectional, a growing number of prospective studies link discrimination to mental health risk. Some studies have also documented that the association between discrimination and mental health is robust to adjustment for potential psychological confounders such as neuroticism6. In addition, racial discrimination is also linked to worse mental health and increase in risky behavior for children and adolescents7. In addition to direct exposure to racial discrimination, vicarious exposure, through parental or caregiver experiences of discrimination, is also associated with worse mental health outcomes8. Cultural racism refers to the racist ideologies that are present in the media, stereotypes, and norms of society that undergird institutional and interpersonal racism1. It can affect mental health in multiple ways. First, cultural racism can initiate and sustain policies that create conditions which are harmful to mental health, such as housing decisions to maintain residential segregation which facilitates increased exposure to traumatic experiences and a broad range of physical and social stressors. Second, some members of stigmatized racial groups internalize the negative racial stereotypes of the culture, which in turn can lead to increased psychological distress and substance use. Third, cultural racism can also trigger stereotype threat – expectations and anxieties activated by a stigmatized group when negative stereotypes about their group are made salient. Research reveals that stereotype threat can lead to increased anxiety, reduced self-regulation, and impaired decision making, which can also affect patient-provider communication and adherence to medical advice1. Furthermore, cultural racism can lead to individual-level unconscious bias in clinicians that can trigger discrimination adversely affecting the quality of clinical care. For example, research has documented racial differences in the application of psychiatric diagnostic criteria, so that Latinos are diagnosed with anxiety disorders more frequently than White people reporting the same symptoms4. Similarly, clinicians exposed to the same symptoms are more likely to diagnose African Americans with psychotic disorders than mood disorders compared to Whites4. Future research is needed to better understand the intersection of racial discrimination with other forms of group discrimination (e.g., gender-related) and identify how multiple forms of discrimination may impact mental health. Emerging evidence indicates that multiple forms of discrimination, such as racism and heterosexism, are associated with increased risk of mental health problems9. Additionally, our current understanding is limited about the potential intergenerational impacts of racism and their related epigenetic effects, with emerging evidence suggesting that these processes are likely to be operative1. Research on racism and mental health, to date, has focused more on documenting that racism matters than on identifying interventions to minimize the adverse effects of exposure to racism and reduce the occurrence of racism in the first place. Some evidence suggests that psychosocial resources such as social ties and religious involvement can reduce some of the negative effects of discrimination on mental health6. However, effectively addressing the multifactorial impacts of racism on mental health will require multilevel societal interventions that seek to build racial equity into homes, schools, neighborhoods and workplaces to minimize current racial economic gaps and improve socioeconomic and living conditions for the disadvantaged. Interventions around resiliency and cultural/structural competency in the medical field have shown some promise, but more concerted attention is needed to address the multiple and interconnected systems through which racism operates1, 3. Diversifying the mental health workforce in terms of including underrepresented racial/ethnic groups and professional experience (e.g., medicine, social work, religion) is also a necessary step towards addressing inequities in mental health care3. Comprehensive, coordinated, strategic initiatives are needed both within and outside of psychiatry and medicine to better understand, prevent and effectively intervene on the effects of racism on mental health.