Psychotic Disorders and Structural Racism: On Considering Complexity

After the death of George Floyd and amid the glaring racial inequities of the COVID-19 pandemic, the United States entered into a “racial reckoning” in which the health impacts of structural racism became more obvious to a wider segment of the population than ever before.¹ This reckoning led the fields of medicine and public health to call for greater emphasis on examining the detrimental health effects of structural racism. For example, a PubMed search of the term “structural racism” found a 354% increase in journal references between 2019 and 2021. In a policy statement issued in October 2020, the American Public Health Association officially declared that structural racism is a public health crisis, and in April 2021, the Centers for Disease Control and Prevention followed suit in declaring racism a “serious public health threat.”^2,3 Yet, with all this renewed attention and focus, the precise mechanisms by which structural racism drives health inequities and health outcomes largely remain unclear.

STRUCTURAL RACISM AND MENTAL HEALTH

Nowhere is the impact of structural racism more directly relevant than in considering mental health problems, which are filtered directly through the cultural lens of society in ways that can exacerbate its effects. Because they are so highly stigmatized, psychotic disorders are particularly sensitive to “racial and political currents” that underlie the evaluation, diagnosis, and management of these conditions.⁴ In this issue of AJPH, Misra et al. (p. 624) seek to clarify these difficult associations and draw more direct lines from the role of structural racism to inequitable outcomes of psychotic disorders in current practice. This is a highly complex task because the etiology of inequities in psychotic disorders is complicated, multifaceted, and steeped in historical injustice, discrimination, and racism.⁵

This work is highly personal to me. As a Black psychiatrist whose clinical practice is focused on providing mental health services to young people experiencing early psychotic illnesses, I have watched the detrimental impacts of structural racism on psychotic disorders play out in real time at the individual level. In my clinical experience, I have witnessed my Black patients who were hospitalized for stabilization during a mental health crisis removed from their second-generation antipsychotic medications and switched to high doses of haloperidol, a first-generation antipsychotic medication that was specifically associated (via print advertisements from pharmaceutical companies to prescribers) with images of aggressive and hostile Black men in the 1960s.^5,6 I have directly observed psychiatrists and other mental health providers misinterpret adaptive suspicious behaviors and symptoms of distress in Black patients as paranoid delusions, leading to misdiagnoses of psychotic illness. I have noticed, consistent with the research literature, that Black patients in emergency settings are more likely than White patients to be placed in seclusion and restraints.⁷

My clinical experience has taught me that explanations for the cause of inequities in psychotic disorders, a condition that has historically been racialized and stigmatized, are extremely complex, as are the mechanisms by which structural racism interacts with these outcomes. The prevailing theory for the development of psychosis risk is the vulnerability-stress model, which hypothesizes that the interaction between biological vulnerability and environmental stressors leads to the development of psychotic symptoms.⁴ This theory helps to explain how the environmental stressor of structural racism can interact with biological risk to increase the likelihood of developing psychotic illness. Similarly, the social defeat hypothesis incorporates the role of oppression and minoritized status as a driver of psychotic illness (via increased dopaminergic activity).⁴ Structural racism, as a tool used to oppress racially minoritized groups, must be conceptualized as a system based on the belief that human hierarchies exist in our society.⁸ Unfortunately, both people with psychotic illnesses and people from racially minoritized groups (Black people in particular) are at the highest risk to be oppressed and forced to the bottom of the social hierarchy.

CONNECTING STRUCTURAL RACISM AND PSYCHOSIS

Misra et al. specifically highlight the role of racialized policing and economic exploitation as the most salient contributors to inequities in outcomes. Although these particular examples of structural racism are a reasonable starting point for further research and exploration, they do not encompass the entirety of the impact of structural racism on outcomes associated with psychotic illnesses. Even when considering these examples, there are multiple layers of complexity that must be explored. For example, the War on Drugs (which encompasses both racialized policing and additional structurally racist policies) is a salient example of how stigmatized negative beliefs about certain populations (e.g., Black people who use crack cocaine) led to inequitable policies such as the Anti-Drug Abuse Act of 1986, which mandated a 100:1 jail sentencing disparity in which 1 gram of crack cocaine carried the same jail sentence as 100 grams of powder cocaine. Similarly, cannabis is associated with an increased risk of psychosis,⁹ and the racialized criminalization of cannabis use has led to high rates of people with psychotic disorders being incarcerated instead of receiving mental health treatment.¹⁰ Evaluation of structural racism as it relates to cannabis policy then becomes a highly complicated endeavor, because antiracist policies legalizing cannabis use could increase the risk or prevalence of psychotic illness but must be weighed against the significant psychological damage of inequitable rates of incarceration of Black people, despite their use of cannabis at rates similar to or lower than those of White people.

Misra et al. attempt to create distance between the concept of provider bias in diagnosis and assessment from the consideration of a structural racism framework. However, it is worth noting that provider bias is yet another manifestation of structural racism. The structural level of discrimination within the health care system has effectively penetrated all other levels, including institutions (such as the institution of psychiatry) and individuals.⁵ The history of the reconceptualization of schizophrenia from a psychotic illness affecting docile White women who did not meet gendered, patriarchal expectations for their roles in society to an illness centrally defined as one in which Black men were hostile, aggressive, and “delusional” for seeking to assert their civil rights and rejecting notions of White superiority is well documented.⁵ However, one cannot overstate the impact that this reconceptualization, codified into various editions of the Diagnostic and Statistical Manual of Mental Disorders,¹¹ has had on the modern conceptualization of schizophrenia and other psychotic disorders. Thus, the bias that clinicians bring to their assessment, including misdiagnosis and overdiagnosis, is the foundation for inequities through racialized perceptions of the very definitions of what psychosis is and how it presents in different populations. Structural racism, enacted through mental health providers’ clinical decision-making, is the reason for the increase in involuntary hospitalizations of Black people starting in the 1960s and for the association of aggressiveness and hostility with both Black people and people with psychotic disorders, despite evidence that people with psychosis are more likely to be victims than perpetrators of violent crimes.¹²

CONSIDERING COMPLEXITY

Connecting the inequities associated with psychotic disorders in the diagnosis and outcomes of Black Americans is indeed a complex undertaking. A host of health outcomes are directly impacted by structural racism, and psychotic disorders in particular, which represent a complicated intersection of genetic and environmental factors. The task for public health providers is to begin to educate themselves on this complexity by actively learning the history of structural racism in psychiatry (a history that has been intentionally suppressed) and, armed with this information, conduct more thoughtful and nuanced research. This renewed commitment could lead to policies and interventions that account for the complexity and could intentionally seek to eliminate racial inequities associated with psychotic disorders.