Margarita Alegría, Ph.D.
Chief, Disparities Research Unit, Department of Medicine, Massachusetts General Hospital, Mongan Institute
Professor, Departments of Medicine & Psychiatry, Harvard Medical School
There has been tremendous attention brought to mental health as part of the coronavirus pandemic. The good news is that there is now almost universal recognition that when our mental health is precarious, costs are immeasurable. What has become more apparent is how this cost is much higher for people of color. But why is their burden of mental illness so much greater? What can help shed light on how mental illness impacts racial and ethnic minorities so adversely and profoundly, even when they have lower or similar prevalence rates of mental health disorders when compared to White people1?
Let me offer some things to consider, some food for thought. First, we need to pivot from attributing these differences in mental health burden to the individual and recognize how they can be best understood by structural inequities attributed to policy, law, governance, and culture. They include, for example, U.S. immigration policies, voting ID laws, housing segregation regulations, drug sentencing laws, among others. They steer people of color to a plethora of unfair experiences, differences in opportunity and limitations toward accessing the beneficial social determinants of health. Together, structural inequities negatively influence the ability to recover from health problems, including mental health issues.
There is strong evidence that chronic exposures to early stressors influence brain development. For example, the harmful impact of structural inequities can be represented by differential exposure to traumatic and chronic stressors impacting child development2. Clearly, the environmental context matters, as we see from national surveys that show 61% of Black children have experienced at least one adverse childhood event compared with 40% of White non-Hispanic children. And although we have paid attention to the role of families in these negative outcomes, we have been ignoring the influence of institutions, including schools, criminal justice systems, and governments, along with their decision-makers. These are the prominent factors that influence (or determine) whether people live in socioeconomic advantage versus disadvantage, threat versus nurturance and support, or opportunity versus hopelessness.
Structural inequities are insufficiently addressed by academic researchers and in policy discussions of mental health among populations of color. Yet, they are the root causes of disparities in mental health. Take for example employment in the food and retailer industry, where women of color have the highest rates of work schedule unpredictability3; even higher than others within the same company, at the same rank. Daniel Schneider, Ph.D., assistant professor at the Department of Sociology, University of California, Berkeley, and Kristen Harknett, Ph.D., associate professor of Social Behavioral Sciences at the University of California, San Francisco, have shown how work unpredictability and instability, both in terms of hours and schedules, impact these women in their ability to make child-care arrangements4, and how it generates work-life conflicts in the family life5. All this instability translates to greater risk for behavioral problems in their children6, and anxiety and depression in themselves.
Or take for example, bail setting, sentencing laws, and racial profiling for people of color, which disregard a person’s available resources to defend oneself, and create rampant distrust and perpetual anxiety7. For Black youth, feelings of constant discrimination and a sense of unfairness, in combination with a lack of mental health treatment, may lead to losing hope that may even lead to suicide8,9.
We need to change the narrative to focus on how our institutions magnify the harms from mental illness rather than minimize them and promote well-being. It’s time to act on these structural inequities!
- Alvarez, K., Fillbrunn, M., Green, J. G., Jackson, J. S., Kessler, R. C., McLaughlin, K. A., Sadikova, E., Sampson, N. A., & Alegría, M. (2019). Race/ethnicity, nativity, and lifetime risk of mental disorders in US adults.Social psychiatry and psychiatric epidemiology, 54(5): 553-565. https://doi.org/10.1007/s00127-018-1644-5
- Sacks, V., Murphey, D. (2018). The prevalence of adverse childhood experiences, nationally, by state, and by race or ethnicityChild Trends.
- Storer, A., Schneider, D., & Harknett, K. (2019). What Explains Race/Ethnic Inequality in Job Quality in the Service Sector?Washington Center for Equitable Growth.
- Schneider, D., & Harknett, K. (2019). It’s About Time: How Work Schedule Instability Matters for Workers, Families, and Racial Inequality. The Shift Project.
- Schneider, D., & Harknett, K. (2019) Consequences of Routine Work-Schedule Instability for Worker Health and Well-Being. American Sociological Review, 84(1): 82-114. https://doi.org/10.1177/0003122418823184
- Schneider, D., & Harknett, K. (2019). Parental Exposure to Routine Work Schedule Uncertainty and Child Behavior. Washington Center for Equitable Growth.
- Davis, R. A., Savannah, S., Yañez, E., Fields-Johnson, D., Nelson, B., Parks, L. F., Do, R., Macaysa, A., & Rivas, R. (2016). Countering the Production of Health Inequities. Prevention Institute.
- Dennis, K. N. (2019). The complexities of black youth suicide. Scholars Strategy Network
- Lindsey, M. A.; Sheftall, A. H; Xiao, Y., & Joe, S. (Epub, 2019). Trends of suicidal behaviors among high school students in the United States, 1991-2017.Pediatrics, 144(5). https://doi.org/0.1542/peds.2019-1187
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