In-depth analyses of racism and greater recruitment of Black practitioners needed to address inequities in mental health treatment for Black Americans

A series of literature reviews published online December 13 in The Lancet Psychiatry journal highlight the large body of evidence on the role played by racism in mental health disparities experienced by Black people living in the United States. 

Along with an essay from Black Americans that describes their lived experiences, the three new papers in the series include analysis of more than 50 years of literature on the effects of racism. The authors conclude that improving the mental well-being of Black Americans requires a community-centered and culturally informed approach that is inclusive, accessible and promotes empowerment and resilience in Black communities. The papers also highlight the urgent need for Black sociologists, anthropologists, scientists, physicians, clinicians, and citizens to be setting the priorities in mental health care based on lived experiences.

Led by a physician scientist at NYU Grossman School of Medicine, the authors call for a comprehensive analysis of the conditions and systems through which racism produces mental health issues, while highlighting the potential of community-driven action to reduce inequity.

“Our reviews highlight the impact of racism on mental health disparities, and emphasize the need to understand the roots of racial inequity to achieve racial justice in health care,” said series lead author Ayana Jordan, MD, PhD, the Barbara Wilson Associate Professor in the Department of Psychiatry, and co-lead for the community engagement pillar of the Institute for Excellence in Health Equity at NYU Langone Health.

Racism Shapes Black Mental Health

Due to centuries of racism, Black Americans have much greater exposure to risk factors for mental illness, says Dr. Jordan, including lower quality education, impoverished neighborhoods, high rates of homelessness, and exposure to violence with high rates of police brutality. Additionally, the mental health care system as it stands invalidates the experience of Black Americans, dismissing their cultural backgrounds.

Due to inequitable systems that are not culturally informed, Black people are less likely to seek mental health care when compared to White Americans. Further, Black people have historically been excluded from medical research, and Black scientists make up less than 1 % of researchers receiving independent research funding from the US National Institutes of Health.

Centuries of dehumanization have led to underestimation, misdiagnosis, and inadequate treatment of mental illness among Black Americans, says Jordan, who is also an associate professor in the NYU Langone Department of Population Health. The authors argue that the definitions and framing of mental health, mental illness, and the prescriptions for diagnosing, treating, and maintaining wellness have all been grounded in whiteness and myths of white supremacy. They point out that explanations for the differences in rates of mental illness and substance use disorders between racial and ethnic groups have often been incorrectly seen as evidence of biological or cultural distinctions, and are missing explanations of systemic, avoidable, and unjust policies.

To address these challenges, Jordan and colleagues are calling for a comprehensive analysis of the conditions and systems that produce mental illness and compromise mental health. They say this work must go beyond traditional views of individualized mental illness classifications to focus on collective efforts to combat racism and establish equitable systems that promote Black mental health.

Further, the new articles highlight the value of community-based participatory research (CBPR) conducted by Black scientists, Black leaders, and community members to improve the mental well-being of Black Americans. CBPR involves active participation and input from community members throughout the research process, giving communities a voice as they work with researchers toward long-lasting and culturally appropriate solutions.

In addition, the work looks at the effect of racism on epidemiology, the scientific discipline that estimates the burden of mental illness in populations. Effective sampling and minimizing bias are essential, particularly when the estimates are being used to determine policy. Thus, the methods of collecting, using, and analyzing epidemiological data are critical to the ways in which the intersection of race and mental illness is understood.

The researchers point out that explanations for the differences in rates of mental illness and substance use disorders between racial and ethnic groups are missing explanations of the systemic unjust policies underlying the inequities. For example, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which has long been the classification system to understand mental illness, does not fully capture the experience of being racialized as Black, Jordan notes. Instead of understanding the effects of racism, the DSM-5 locates the problems of mental illness in the bodies and behaviors of individuals and categorizes differences by race—perpetuating systemic biases.

The series authors are calling for a large-scale study that identifies publicly available datasets on political districting, economic factors, environmental exposures to racism, and individual-level data related to emotional wellbeing, standardizes them for analysis, and analyzes the data for impact on emotional wellbeing. This could serve as the basis for a risk index that quantifies different exposures to racism and their potential impact on emotional wellbeing.

This integrated analysis can inform policies by capturing the dramatic impact of inequities on Black mental health in terms of civilian deaths from police, the percentage of those where substance use and mental illness were involved in deaths, the lack of access to treatment, the likelihood of incarceration, and the way Black people are portrayed in the media.

Articles for this review were identified through searches of PubMed and Google Scholar for work published from January, 1969 to October, 2023, by use of the terms “racism”, “racial inequalities”, “mental health”, “Black people”, “minority”, and “public policy”.

Along with Dr. Jordan, authors of review series were Mindy Fullilove, MD, of The New School; Ebony Dix, MD, of Yale University School of Medicine; Sidney Hankerson, MD, of the Icahn School of Medicine at Mount Sinai; Jonathan Lassiter, PhD, of Cooper Medical School at Rowan University, Alfiee Breland-Noble, PhD, of the African American Knowledge Optimized for Mindfully-Health Adolescents (AAKOMA) Project, Frederick Streets, DSW, of Yale Divinity School; and Chyrell Bellamy, PhD, Richard Youins, and Kimberly Guy of the Program for Recovery and Community Health at Yale University School of Medicine.

The series was funded by NYU Grossman School of Medicine Department of Psychiatry, the Yale Department of Psychiatry, and the Yale School of Medicine, as well as by grant 5H79TI081358-04 from the Substance Abuse and Mental Health Services Administration (SAMHSA) in the U.S. Department of Health and Human Services, grant 5R01AA028778-04 from the National Institute on Alcohol Abuse and Alcoholism (NIAAA), and grant 1R01DA057651-01 from the National Institute on Drug Abuse (NIDA). NIAAA and NIDA are part of the National Institutes of Health.