On Structural Racism and Mental Illness

“Barbara” is a 64-year-old Black woman who is an adjunct professor and lives in a large city in the northeastern United States. She has a personal and family history of depression and posttraumatic stress disorder (PTSD). Barbara’s mother was diagnosed with depression and had multiple depressive episodes during Barbara’s childhood but never sought treatment. “The only thing psychiatrists do for us [Black people] is lock us up in the hospital. I’ll handle this by myself,” Barbara remembers her mother saying.

Barbara’s father was born in a town in the deep South. On two occasions, he woke up to see a cross burning in his front yard. His family migrated to a large northern, urban city shortly after Emmett Till was murdered in 1955 in Mississippi because his mother was terrified that her son’s life would be in danger as he got older. In 1974, he was arrested when Barbara was an adolescent and sentenced to 15 years in prison for possession of marijuana. Although this was his first criminal offense, he was incarcerated for eight years of his 15-year sentence.

The case of Barbara illustrates how historically rooted racist societal structures and the experience of trauma influence the presentation of depression among African Americans across generations, said Sidney Hankerson, M.D., an associate professor of psychiatry at the Icahn School of Medicine at Mount Sinai, and colleagues in a paper in a special edition of The American Journal of Psychiatry (AJP) on structural racism and mental illness. The paper is titled “The Intergenerational Impact of Structural Racism and Cumulative Trauma on Depression.”

“To this day, Barbara experiences recurrent depressive episodes and PTSD symptoms, most notably hypervigilance,” the authors wrote. “Her symptoms are exacerbated by present-day events, such as the murder of George Floyd in 2020, that remind her of the historical traumatic events to which her family was exposed.”

David Hathcox

At a press conference at APA’s Annual Meeting announcing the special edition, Hankerson joined other special edition authors, AJP Editor-in-Chief Ned Kalin, M.D., and Crystal Barksdale, Ph.D., M.P.H. Barksdale is the program chief of the Minority Mental Health Research Program in the Office for Disparities Research and Workforce Diversity at the National Institute of Mental Health, who provided editorial consultation for the issue.

In the paper introducing the issue, “Innovative Directions to Advance Mental Health Disparities Research,” Barksdale and co-authors Eliseo Pérez-Stable, M.D., and Joshua Gordon, M.D., Ph.D., wrote: “The articles in this issue capture the evolving, yet overdue, shift in mental health and the broader biomedical research fields that acknowledges the role of social and structural determinants of health (particularly structural racism and discrimination) in the cause and perpetuation of disparities and inequities and the goal to adopt multilevel, structural intervention and research approaches to achieve desired mental health and health care disparities reductions.”

Other articles in the special edition include the following:

• “A New Agenda for Optimizing Investments in Community Mental Health and Reducing Disparities,” by Margarita Alegria, Ph.D., Jenny Zhen-Duan, Ph.D., Isabel O’Malley, B.A., and Karissa DiMarzio, M.S. The authors wrote that health care systems and mental health professionals need to re-imagine how mental health services are delivered to marginalized communities in order to provide more community-based interventions of care. This involves establishing multisector partnerships to address the social and psychological needs that can be addressed at the community level rather than the clinical level. This requires a shift in training, delivery systems, and reimbursement models. The authors describe the scientific evidence justifying these programs and elaborate on opportunities to target investments in community mental health that can reduce disparities and improve well-being for all.

• “Perspectives from the National Institutes of Health on Multi-Dimensional Mental Health Disparities Research: A Framework for Advancing the Field,” by Crystal Barksdale, Ph.D., M.P.H., and Jennifer Alvidrez, Ph.D. The authors offer a research framework, adapted from the National Institute on Minority Health and Health Disparities Research Framework, that provides examples of determinants that may cause or sustain mental health disparities and that can serve as intervention targets to reduce those disparities. They also discuss different types of mental health disparities research to highlight the need for more research testing and implementing interventions that directly modify social determinants of health and promote mental health equity.

• “Structural Racism and Youth Suicide Prevention: A Conceptual Framework and Illustration Across Systems,” by Kiara Alvarez, Ph.D., Lilian Polanco-Roman, Ph.D., Aaron Breslow, Ph.D., and Sherry Molock, Ph.D. The authors propose the Structural Racism and Suicide Prevention Systems Framework and illustrate pathways through which structural racism impacts suicide prevention and intervention for youth of color in the United States. The authors then propose recommendations to address structural racism in suicide prevention, including macro-level interventions to improve societal conditions, research strategies to inform structural solutions, training approaches to address institutional racism, and clinical approaches to address the impact of racism and racial trauma on youth and families.

In an editor’s note, Kalin wrote: “There is no question that there are huge inequities in the delivery of mental health care that are related to systemic factors, and there is also no question that structural racism is a major determinant of these inequities. Individuals of color and other minoritized groups disproportionately face interpersonal, societal, and environmental stressors that increase their risk to develop psychiatric disorders, and these factors also impede access to mental health care. The impact of structural racism on mental well-being and mental illness cannot be overstated. As a field we need to commit to taking action to enforce changes at multiple levels, individual and societal, with the goal of eliminating mental health disparities.” ■