Review Examines How Racism May Increase Psychosis Risk

Racism has contributed to the disproportionate exposure to psychosis risk factors among racially minoritized groups, concluded the authors of a comprehensive review in AJP in Advance.

“We know that a person’s social environment is an important risk factor for psychosis, but most of the work in this area has come from European countries,” said lead study author Deidre M. Anglin, Ph.D., an associate professor of psychology at the City College of New York, during a press conference to discuss the paper at APA’s online Annual Meeting. Such studies likely fail to capture the experience of minority groups living in the United States.

“U.S. neighborhoods have evolved to systematically and generationally perpetuate disadvantage for racially minoritized communities through both formal and informal generational segregation and discrimination,” Anglin and colleagues wrote. A lack of access to healthy foods, safe water and housing, health care, employment opportunities, and more increases stress, the authors noted, which in turn increases the risk of psychosis.

In addition, people in disadvantaged neighborhoods are also disproportionately exposed to trauma such as gun violence and police victimization. Such violence creates a collective trauma that impacts everyone in a community.

“In America, where you start in life is a strong predictor of where you will finish,” Anglin said. Cumulative stressors build up in a community over generations, which may increase the psychosis risk with each new generation.

As evidence, the authors pointed to several studies showing that Black and Latinx women in the United States are at substantially increased risk for many obstetric complications, including preterm births and low-weight babies—both of which are known to be associated with psychosis. They also highlighted data that suggest that racial discrimination drives some of these obstetric risks. “People may assume the pregnancy risks among minorities are a product of socioeconomic status,” Anglin said. But she pointed out data showing that Latinx women have higher rates of pregnancy complications the longer they have been in the United States, which suggests exposure to discrimination may be involved.

“We think of trauma as a specific event or a personal loss, not some pervading psychological issue,” said AJP Editor in Chief Ned Kalin, M.D. Kalin praised the paper by Anglin and colleagues as a call to action for psychiatrists to address individual and structural racism to improve the mental health of minority populations.

Study co-author Lauren Ellman, Ph.D., an associate professor of psychology at Temple University, noted during the press conference that the idea of transgenerational risk for mental disorders is not new. She cited the groundbreaking research of Rachel Yehuda, Ph.D., at the Icahn School of Medicine at Mount Sinai. She demonstrated that the children and even grandchildren of Holocaust survivors display biological markers of posttraumatic stress disorder.

“Overall, this research indicates that we need to acknowledge and treat structural racism as it is: a critical public health threat,” Anglin said.

The authors said this comprehensive review points to several goals for the future. First, researchers need to develop more objective measurements of neighborhood health. Ellman noted that the research done by the obstetrics community was robust with findings linking racism or trauma to biological changes, such as birth complications and increased levels of stress hormones during pregnancy. Some of the neighborhood-level studies did as well, such as a recent study that found Black youth who experienced racial discrimination between the ages of 10 and 15 years had advanced cellular aging a decade later. By and large, however, conditions like stress, anxiety, and trauma are assessed with scales that involve participants’ subjective responses.

The authors called on federal funding to support research that provides reliable and up-to-date estimates of psychosis prevalence across different racial and ethnic groups. Expanding the training of leaders in mental health care to understand how discrimination and racial trauma increase the risk of psychosis is also important, Anglin said.

“This is more than just attending a diversity workshop,” she explained. “Training efforts need to be continual and sustained so mental health professionals can develop structural competency.” She recommended that all psychiatrists complete their training with the ability to make use of the DSM-5 cultural formulation interview in everyday practice.

“This study reinforces that we need to dismantle structural racism,” Anglin said. “It may seem unrealistic or idealistic, but if we can start chipping away at some of these specific barriers we identified, it would start to make a difference.” ■