Examining the unique impacts of Potentially Traumatic Experiences (PTE) and discrimination events on Post-Traumatic Stress Disorder (PTSD) and suicidal thoughts and behaviors among Multiracial/ethnic adults in the United States

Abstract

Background:

Suicide and PTSD are pressing public health issues in the US, with discrimination and potentially traumatic experiences (PTEs) influencing mental health. However, the unique effects of these factors on Multiracial/ethnic adults’ PTSD and suicidal thoughts/behaviors (STB) are not thoroughly researched.

Methods:

Using a cross-sectional design, an online survey was conducted (N = 1012) from October to December 2022. Multivariable logistic regression models analyzed relationships between PTEs, discriminatory events, and mental health outcomes, accounting for sociodemographics.

Results:

After adjusting for demographics, exposure to PTEs and discrimination correlated with heightened odds of PTSD and STB. Individual lifetime discrimination experiences and specific PTEs demonstrated varying associations with STB and PTSD. The study underscores discrimination’s relevance as a risk factor.

Limitations:

The study’s cross-sectional nature restricts causality or temporality interpretations. Moreover, the convenience sample of English-speaking online participants might not be reflective of all Multiracial/ethnic US adults.

Conclusions:

Findings underscore PTEs and discrimination’s interconnectedness in Multiracial/ethnic mental health outcomes. Discrimination might pose similar risks to PTEs. Acknowledging discrimination as potential precursors for PTSD and STB aids accurate diagnosis and effective treatment planning. Incorporating racial/ethnic discrimination and traumatic experiences into PTSD conceptualization and assessment is pivotal. This knowledge informs tailored interventions and mental health education for this population.

1. Introduction

Suicide is a leading cause of morbidity and mortality in the United States (US) and post-traumatic stress disorder (PTSD) is a condition that is estimated to impact 8 % of US adults in their lifetimes; data have shown concerning increases in disparities across social factors (Perry et al., 2022; Spoont and McClendon, 2020). Potentially traumatic experiences (PTE) are experiences established by the American Psychiatric Association’s Diagnostic Statistical Manual (DSM-5) as events that meet qualifying criteria for a diagnosis of PTSD, and include “exposure to actual or threatened death, serious injury, or sexual violence” through direct experience, witnessing, or learning of such an occurrence to close family or friends (American Psychiatric Association, 2013). Studies have demonstrated the impact of type of PTE on PTSD and suicidal thoughts and behaviors (STB) (Beristianos et al., 2016; McLaughlin et al., 2013). Exposure to discrimination has been identified as a risk factor for PTSD and STB among racial and ethnic minorities (Bird et al., 2021; Oh et al., 2019). DSM-5 does not include exposure to discriminatory events as a specified qualifying PTE for a diagnosis of PTSD.

Multiracial people identifying with two or more racial categories comprise 10 % of the U.S. population, increasing 276 % in the last decade, yet little is known about their health and wellbeing (U.S. Census Bureau, 2021). Multiracial individuals experience discrimination for their monoracial and multiracial group memberships from many sources including their own family and racial ingroup members (Johnston and Nadal, 2010). The aim of this study is to estimate the association of potentially traumatic experiences and discriminatory events with PTSD and STB among a sample of Multiracial/ethnic adults in the US.

2. Methods

A nonprobability-based convenience sample of English-speaking adults living in or from the United States that identify as Multiracial/ethnic was obtained through an online anonymous survey collected from October to December 2022. Respondents were recruited from multiple market research panels facilitated by Qualtrics and compensated up to $9.50. The study was approved by the Johns Hopkins University Institutional Review Board and informed consent was obtained from all participants. Statistical analyses were performed using STATA/SE 17.0. Multivariable logistic regressions were conducted to examine the association between PTEs and discriminatory events and mental health outcomes, controlling for age, gender, sexual orientation, educational attainment, and income.

2.1. Measures

Symptoms of post-traumatic stress disorder (PTSD) were assessed using both the Life Events Checklist for DSM-5 (LEC-5) and PTSD Checklist for DSM-5 (PCL-5); suicidal behaviors were established through five items from the National Survey on Drug Use and Health (NSDUH) (Gray et al., 2004; Substance Abuse and Mental Health Services Administration, 2022; Weathers et al., 2013). Exposure to discriminatory events was measured with the Perceived Discrimination Scale and the Racial and Ethnic Microaggressions Scale (REMS) (Kessler et al., 1999; Nadal, 2011; Williams et al., 1997). The survey collected demographic data on racial and ethnic identity, gender identity, sexual orientation, age, place of birth, educational attainment, and household income level. Potentially traumatic experiences (PTE), lifetime discrimination, and microaggressions were computed by calculating the number of different situations experienced. Everyday discrimination was computed by summing the total of the Likert scale responses for the Daily Discrimination subscale (Michaels et al., 2019). PTSD was established by endorsing exposure to at least one event on LEC-5 and PCL-5 score greater than or equal to 33.

2.2. Definition of Multiracial/ethnic

The term Multiracial/ethnic is used throughout the paper as an abbreviation for Multiracial and/or multiethnic. Established in 1997 and last updated in 2000 to allow the selection of more than one option, national standards for racial and ethnic data collection set by the federal government include five categories for race (American Indian or Alaska Native (AI/AN), Asian, Black or African American, Native Hawaiian or Other Pacific Islander, White, Other) and two categories for ethnicity (Hispanic or Latino, not Hispanic or Latino) (Office of Management and Budget, 1997). To the authors’ knowledge, most public health entities and scientific research studies do not incorporate Hispanic and Latino populations within their definition of Multiracial. As this study includes Hispanic and Latino populations as well as populations identifying as “Middle Eastern or North African,” this study refers to the sample population broadly as Multiracial/ethnic. Racial categories are socially constructed and have changed throughout history (Atkin et al., 2022; Braveman and Parker Dominguez, 2021). Scholars argue that these seven groups are distinct racial groups due to their uniquely racialized experiences, and this is reflected in the drafts for the updated 2030 census format, which no longer asks separately about Hispanic ethnicity but include all of seven groups in one question (Atkin et al., 2022). Please note that this approach to gathering racial/ethnic background does not fully or adequately capture the rich diversity of the study population, nor the language used by each individual participant to describe their background.

3. Results

Participant characteristics (N = 1012) are available in Table I. Adjusting for demographics, increased exposure to PTEs, everyday discrimination, and microaggressions was associated with 5–34 % higher odds of STB and PTSD. For unique PTEs, adjusted odds ranged from 1.76 (transportation accident) to 3.20 (unwanted/uncomfortable sexual experience) for suicidal ideation, 2.06 (unwanted/uncomfortable sexual experience) to 6.22 (serious injury, harm, or death you caused to someone else) for suicide attempt, and 2.09 (natural disaster) to 5.76 (sexual assault) for PTSD. Adjusted odds for unique experiences of lifetime discrimination ranged from 1.62 (fired) to 3.18 (denied or provided inferior medical care) for suicidal ideation, 1.95 (fired) to 3.47 (denied a scholarship) for suicide attempt, and 2.83 (prevented from renting/buying home in neighborhood) to 4.75 (denied or provided inferior medical care) for PTSD. Table II provides odds ratios, 95 % confidence intervals, and p-values for the demographic-adjusted associations between unique PTEs and discriminatory events on STB and PTSD, including everyday discrimination and microaggressions.

Table I.

Sample population, PTSD, suicidal ideation, suicide attempts^a.

	Total	Suicidal thoughts		Suicide attempt		PTSD
	% (n)*	% (n)*	p-Value	% (n)*	p-Value	% (n)*	p-Value
	N = 1012	N = 198		N = 60		N = 409
Racial and ethnic identities
White	55.0 % (557)	51.5 % (102)	0.20	45.0 % (27)	0.083	53.3 % (218)	0.36
Black	48.2 % (488)	51.5 % (102)	0.24	58.3 % (35)	0.092	54.0 % (221)	0.002
Hispanic or Latino	48.1 % (487)	50.5 % (100)	0.46	61.7 % (37)	0.031	50.1 % (205)	0.29
American Indian or Alaska Native	29.4 % (298)	27.8 % (55)	0.66	28.3 % (17)	0.93	30.8 % (126)	0.43
Asian	16.3 % (165)	17.7 % (35)	0.45	11.7 % (7)	0.32	13.9 % (57)	0.093
Native Hawaiian or Pacific Islander	8.5 % (86)	8.6 % (17)	0.99	8.3 % (5)	0.94	7.3 % (30)	0.27
Middle Eastern or North African	8.1 % (82)	9.6 % (19)	0.18	15.0 % (9)	0.017	7.8 % (32)	0.79
Other racial/ethnic identity	8.9 % (90)	10.1 % (20)	0.62	5.0 % (3)	0.26	10.0 % (41)	0.30
Birth year	1981.4 (14.4)	1986.9 (13.2)	<0.001	1988.9 (14.1)	<0.001	1985.8 (12.6)	<0.001
Educational attainment			<0.001		0.005		<0.001
High school graduate or less	20.1 % (202)	29.6 % (58)		36.2 % (21)		26.6 % (108)
Some college	42.2 % (425)	42.9 % (84)		36.2 % (21)		42.4 % (172)
College degree or higher	37.7 % (379)	27.6 % (54)		27.6 % (16)		31.0 % (126)
Household income			0.028		0.001		0.002
Less than $30 K	29.0 % (279)	35.6 % (67)		42.9 % (24)		35.0 % (135)
$30–60 K	28.4 % (273)	20.7 % (39)		12.5 % (7)		29.0 % (112)
60–90 K	16.8 % (161)	17.0 % (32)		7.1 % (4)		13.5 % (52)
Over 90 K	25.8 % (248)	26.6 % (50)		37.5 % (21)		22.5 % (87)
Sexual orientation			<0.001		0.019		<0.001
Straight	80.1 % (798)	63.4 % (123)		68.4 % (39)		70.0 % (283)
Gay or lesbian	6.2 % (62)	10.8 % (21)		14.0 % (8)		7.7 % (31)
Bisexual or something else	13.7 % (136)	25.8 % (50)		17.5 % (10)		22.3 % (90)
Gender Identity			0.006		0.091		<0.001
Male	30.1 % (303)	33.5 % (65)		42.9 % (24)		28.6 % (116)
Female	67.9 % (683)	62.4 % (121)		55.4 % (31)		67.2 % (273)
Transgender or gender expansive	2.0 % (20)	4.1 % (8)		1.8 % (1)		4.2 % (17)
Potentially traumatic experiences
Any exposure	8.2 (4.9)	10.5 (4.7)	<0.001	11.7 (5.3)	<0.001	10.7 (4.3)	<0.001
Personally experienced	4.0 (3.1)	5.3 (3.7)	<0.001	4.9 (4.6)	0.02	5.3 (3.3)	<0.001
Witnessed	2.9 (3.3)	3.9 (3.8)	<0.001	4.5 (4.4)	<0.001	4.0 (3.6)	<0.001
Prejudice events
Lifetime discrimination	3.6 (3.3)	5.1 (3.5)	<0.001	5.7 (3.7)	<0.001	5.2 (3.4)	<0.001
Everyday discrimination	15.4 (11.9)	21.6 (11.6)	<0.001	24.1 (12.9)	<0.001	20.8 (11.2)	<0.001
Microaggressions	25.4 (13.9)	31.7 (12.3)	<0.001	34.1 (13.3)	<0.001	31.3 (12.8)	<0.001

^aMean and SD provided for continuous variables.

Table II.

Potentially traumatic experiences and prejudice events, suicidal ideation, suicide attempt, and PTSD^a.

	Suicidal Thoughts			Suicide Attempt			PTSD
	OR	95 % CI	p-value	OR	95 % CI	p-value	OR	95 % CI	p-value
Total Potentially Traumatic Experiences (PTE)	1.14	[1.09, 1.18]	<0.001	1.17	[1.09, 1.25]	<0.001	1.23	[1.19, 1.27]	<0.001
Natural disaster	2.34	[1.52, 3.59]	<0.001	3.48	[1.44, 8.43]	0.006	2.09	[1.52, 2.87]	<0.001
Fire or explosion	2.03	[1.42, 2.89]	<0.001	2.44	[1.31, 4.57]	0.005	2.49	[1.87, 3.32]	<0.001
Transportation accident	1.76	[1.14, 2.71]	0.011	1.39	[0.67, 2.87]	0.378	2.17	[1.55, 3.05]	<0.001
Serious accident at work, home, or during recreational activity	1.81	[1.27, 2.59]	0.001	2.51	[1.31, 4.81]	0.006	2.56	[1.92, 3.42]	<0.001
Exposure to toxic substance	1.98	[1.37, 2.86]	<0.001	2.81	[1.54, 5.13]	0.001	3.06	[2.23, 4.20]	<0.001
Physical assault	2.63	[1.70, 4.07]	<0.001	1.47	[0.74, 2.92]	0.274	3.94	[2.81, 5.52]	<0.001
Assault with a weapon	2.40	[1.67, 3.44]	<0.001	3.27	[1.68, 6.37]	<0.001	3.46	[2.58, 4.64]	<0.001
Sexual assault	2.67	[1.81, 3.94]	<0.001	2.45	[1.25, 4.80]	0.009	5.76	[4.16, 7.97]	<0.001
Other unwanted or uncomfortable sexual experience	3.20	[2.11, 4.86]	<0.001	2.06	[1.04, 4.08]	0.037	5.24	[3.76, 7.30]	<0.001
Combat or exposure to a war zone	1.44	[1.00, 2.09]	0.053	4.52	[2.43, 8.39]	<0.001	2.77	[2.03, 3.76]	<0.001
Captivity	1.97	[1.31, 2.96]	0.001	4.12	[2.23, 7.61]	<0.001	4.07	[2.82, 5.90]	<0.001
Life-threatening illness or injury	2.18	[1.49, 3.20]	<0.001	1.56	[0.83, 2.93]	0.166	2.55	[1.88, 3.44]	<0.001
Severe human suffering	2.09	[1.46, 2.99]	<0.001	3.11	[1.70, 5.70]	<0.001	4.66	[3.40, 6.38]	<0.001
Sudden violent death	2.24	[1.56, 3.21]	<0.001	2.03	[1.10, 3.74]	0.023	3.45	[2.57, 4.64]	<0.001
Sudden accidental death	2.12	[1.49, 3.03]	<0.001	1.80	[0.99, 3.29]	0.055	2.97	[2.22, 3.98]	<0.001
Serious injury, harm or death you caused to someone else	2.18	[1.46, 3.26]	<0.001	6.22	[3.28,11.79]	<0.001	3.90	[2.73, 5.58]	<0.001
Any other very stressful event or experience	2.47	[1.66, 3.68]	<0.001	1.68	[0.87, 3.24]	0.123	3.21	[2.35, 4.39]	<0.001
Total PTEs witnessed	1.09	[1.03, 1.14]	0.001	1.11	[1.03, 1.20]	0.010	1.19	[1.14, 1.25]	<0.001
Total PTEs personally experienced	1.22	[1.15, 1.29]	<0.001	1.11	[1.02, 1.22]	0.018	1.29	[1.22, 1.36]	<0.001
Lifetime discrimination	1.21	[1.15, 1.28]	<0.001	1.23	[1.13, 1.35]	<0.001	1.34	[1.27, 1.41]	<0.001
Discouraged by a teacher or advisor from seeking higher education	1.94	[1.35, 2.77]	<0.001	3.34	[1.81, 6.16]	<0.001	3.43	[2.53, 4.66]	<0.001
Denied a scholarship	2.77	[1.87, 4.09]	<0.001	3.47	[1.88, 6.38]	<0.001	3.74	[2.66, 5.26]	<0.001
Not hired for a job	2.37	[1.64, 3.42]	<0.001	1.65	[0.90, 3.01]	0.107	3.02	[2.25, 4.07]	<0.001
Not given a promotion	2.18	[1.52, 3.12]	<0.001	2.21	[1.20, 4.07]	0.011	2.94	[2.19, 3.95]	<0.001
Fired	1.62	[1.13, 2.33]	0.009	1.95	[1.08, 3.54]	0.028	3.02	[2.22, 4.10]	<0.001
Prevented from renting/buying home in desired neighborhood	2.29	[1.59, 3.31]	<0.001	3.32	[1.81, 6.07]	<0.001	2.83	[2.07, 3.86]	<0.001
Prevented from remaining in a neighborhood because neighbors made life so uncomfortable	1.98	[1.34, 2.92]	0.001	2.59	[1.40, 4.79]	0.002	3.76	[2.66, 5.32]	<0.001
Hassled by the police	2.09	[1.45, 2.99]	<0.001	2.34	[1.24, 4.40]	0.009	3.15	[2.34, 4.24]	<0.001
Denied a bank loan	2.86	[1.96, 4.18]	<0.001	2.55	[1.39, 4.68]	0.003	3.47	[2.51, 4.80]	<0.001
Denied or provided inferior medical care	3.18	[2.19, 4.62]	<0.001	3.44	[1.87, 6.33]	<0.001	4.75	[3.42, 6.60]	<0.001
Denied or provided inferior service by a plumber, car mechanic, or other service	2.64	[1.80, 3.88]	<0.001	2.46	[1.32, 4.57]	0.005	2.99	[2.15, 4.16]	<0.001
Everyday discrimination	1.06	[1.04, 1.07]	<0.001	1.06	[1.03, 1.08]	<0.001	1.07	[1.05, 1.08]	<0.001
I am treated with less courtesy than other people are.	1.34	[1.20, 1.50]	<0.001	1.32	[1.10, 1.58]	0.002	1.44	[1.31, 1.57]	<0.001
I am treated with less respect than other people are.	1.32	[1.18, 1.47]	<0.001	1.29	[1.08, 1.54]	0.005	1.44	[1.31, 1.58]	<0.001
I receive poorer service than other people at restaurants or stores	1.36	[1.22, 1.53]	<0.001	1.46	[1.22, 1.74]	<0.001	1.45	[1.32, 1.60]	<0.001
People act as if they think I am not smart.	1.36	[1.22, 1.51]	<0.001	1.30	[1.10, 1.54]	0.002	1.40	[1.28, 1.53]	<0.001
People act as if they are afraid of me	1.32	[1.19, 1.46]	<0.001	1.48	[1.25, 1.76]	<0.001	1.36	[1.25, 1.49]	<0.001
People act as if they think I am dishonest.	1.35	[1.21, 1.50]	<0.001	1.38	[1.16, 1.63]	<0.001	1.45	[1.32, 1.59]	<0.001
People act as if they're better than I am.	1.38	[1.24, 1.54]	<0.001	1.18	[0.99, 1.41]	0.060	1.44	[1.32, 1.57]	<0.001
I am called names or insulted.	1.42	[1.27, 1.60]	<0.001	1.56	[1.30, 1.88]	<0.001	1.52	[1.37, 1.69]	<0.001
I am threatened or harassed.	1.44	[1.28, 1.62]	<0.001	1.47	[1.23, 1.75]	<0.001	1.60	[1.44, 1.79]	<0.001
Microaggressions	1.05	[1.03, 1.06]	<0.001	1.05	[1.03, 1.08]	<0.001	1.06	[1.05, 1.07]	<0.001
Assumptions of inferiority	1.19	[1.12, 1.27]	<0.001	1.20	[1.07, 1.34]	0.002	1.26	[1.20, 1.32]	<0.001
Second-class citizen & assumption of criminality	1.20	[1.12, 1.28]	<0.001	1.28	[1.13, 1.44]	<0.001	1.30	[1.23, 1.38]	<0.001
Microinvalidations	1.18	[1.11, 1.26]	<0.001	1.23	[1.08, 1.39]	0.001	1.25	[1.18, 1.31]	<0.001
Exoticization and assumptions of similarity	1.24	[1.16, 1.32]	<0.001	1.25	[1.10, 1.41]	<0.001	1.25	[1.19, 1.32]	<0.001
Environmental microaggressions	1.13	[1.04, 1.23]	0.003	1.19	[1.01, 1.39]	0.032	1.19	[1.11, 1.27]	<0.001
Workplace and school microaggressions	1.29	[1.18, 1.42]	<0.001	1.34	[1.14, 1.58]	<0.001	1.44	[1.33, 1.55]	<0.001

^aadjusted for age, gender, sexual orientation, educational attainment, and income.

4. Discussion

The findings from this study illuminate the significant links between exposure to PTEs and discriminatory events with outcomes of PTSD and STB within a sample of US multiracial/ethnic adults. Those with exposure to lifetime discrimination showed slightly greater odds of PTSD and STB compared to exposure to PTEs. While our sample size was not powered to detect significant differences between unique events in predicting outcomes, findings suggest that certain unique events may have greater odds of negative outcomes, warranting further research. For example, unique experiences of lifetime discrimination, such as being denied or provided inferior medical care, had similar magnitudes of association to STB and PTSD as unique PTEs, such as sexual assault. These findings add to those of Coimbra et al. (2022) identifying a connection between racial discrimination and STB and Bird et al. (2021) identifying a connection between discrimination and PTSD by demonstrating that racial discrimination is experienced by multiracial/ethnic people, and may pose a similar risk for STB and PTSD as traditionally recognized PTEs (Bird et al., 2021; Coimbra et al., 2022). Thus, our study suggests it is crucial to recognize exposure to discrimination as a risk factor for STB and PTSD and incorporate it in the assessment of PTSD and subsequent treatment planning. Failure to acknowledge discriminatory events as precursors to PTSD and STB may lead to underdiagnosing or misdiagnosing multiracial/ethnic and other racially marginalized individuals, which could have long term health and mortality implications.

4.1. Strengths/limitations

This study includes numerous strengths. Importantly, this study adds to the extant literature by examining trauma, discrimination, and suicidal ideation and attempts among multiracial/ethnic adults, an often-overlooked and understudied population in the U.S. despite growing evidence that this population experiences discrimination and a high burden of mental illness and STB (Franco et al., 2021). Also, this study utilized participatory action research that included multiracial/ethnic leadership and an advisory committee who guided the study, ensuring that it aligns with the lived experiences of multiracial/ethnic adults. Despite these strengths, this study is not without its limitations. The study’s cross-sectional design prohibits statements of causality or temporality of variables of interest. Further, the study included a convenience sample of English speakers recruited online and may not be representative of Multiracial/ethnic adults across the U.S.

4.2. Implications

It is important that PTEs may intersect with racism and discrimination. For example, on the Life Events Checklist for DSM-5 (LEC-5), there are items assessing whether someone has witnessed or experienced exposure to toxic substances, physical assault, or assault with a weapon. However, the assessment does not include contextual information that can intersect with racism. For example, “exposure to toxic substances” could result from the legacy of colonial violence against Indigenous peoples that has been linked to suicide-related outcomes among First Nations in Canada (Ansloos and Cooper, 2023). Additionally, it is well-documented that Black/African American people in the U.S. experience the highest burden of police violence, a known risk factor for suicidality, yet the LEC-5 item “physical assault with a weapon” does not provide this context if this is how an individual experienced assault (DeVylder et al., 2017). Therefore, the conceptualization and assessment of PTSD, as well as potential interventions, need to consider the additional stress and trauma that certain lifetime events may hold for Multiracial/ethnic people and monoracial people of color, and how the combination of traumatic events and racial/ethnic discrimination may increase risk for PTSD and suicidality.

Multiracial/ethnic people represent a growing and important sector of US society, and it is vital to understand strengths and potential ways to promote mental health among this population. For Multiracial/ethnic people, a better understanding of their multiple races/ethnicities, and how they understand and make sense of their identity has important implications for mental health education and intervention.

Abbreviations:

PTE

potentially traumatic experience

PTSD

post-traumatic stress disorder

STB

suicidal thoughts and behaviors

SI

suicidal ideation

SA

suicide attempt

OR

odds ratio

95 % CI

95 % Confidence Interval

Data availability statement

The participants of this study did not give written consent for their data to be shared publicly. Due to the sensitive nature of the research, supporting data are not available.