Fragmented Realities: Structural Racism and Racial Disparities in Psychosis

By Lauren DeSouza- Master of Public Health, Simon Fraser Public Research University – Canada
https://empathymh.org/our-team/
Staff Research and Content Writer

In the US and around the world, immigrants and people of color experience symptoms of psychosis at much higher rates than White people. Black people in the United States experience psychotic symptoms— ranging from hallucinations, visions, voices, and paranoia— at roughly twice the rate of White people.

There is established literature on the racial gaps in psychosis rates in Europe and other parts of the world, but it is a lagging field of research in the US. While European countries have long recognized that inequitable socioeconomic systems increase the risk of psychosis among disadvantaged populations, the US has focused solely on the biomedical model of mental health, focusing on individual-level risks of psychosis and ignoring the social and environmental risks.

In recent years, US researchers have begun paying more attention to the link between minority status and the incidence of psychosis. Recent attention to this phenomenon is highlighted by a recent New York Times article and various research studies, which confirm earlier findings that Black and other minority individuals experience higher levels of psychosis than White individuals. These studies also explore the

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socioeconomic factors contributing to these disparities.

This article examines the research on racial disparities in psychosis among Black and other minority populations in the U.S., highlighting key findings and gaps in the literature.

What is psychosis?

Psychosis refers to conditions that affect someone’s mind that cause them to lose contact with reality. During a psychotic episode, a person’s thoughts and perceptions are altered, and they often struggle to recognize what is real and what is not. People with psychosis may experience delusions and hallucinations, such as believing that there are people out to get them or seeing and hearing things that others do not.

In some cases, psychosis can be a symptom of a mental illness such as schizophrenia, bipolar disorder, or depression. However, a person can experience psychosis without ever being diagnosed with a mental illness. As recent research on co-morbid psychosis suggests, Black people experience psychosis at higher rates than White people. Still, they are less likely than White people to be diagnosed with a co-morbid mental illness.

Racial differences in psychosis rates in the US

Racism is a fundamental cause of health inequity in the US. While the statistics on racial differences in psychosis rates remain inconclusive, researchers generally conclude that Black people are approximately twice as likely to experience psychosis compared to White people (a ratio of 1.9:1).

In the recent study by Mariam Sankoh and colleagues, Black participants were 86% more likely and Hispanic participants were 96% more likely to report experiencing psychosis compared to White participants. Other research has found that the prevalence of psychotic episodes was 15.3% among Black people compared to 9.7% among White people.

Why do Black people experience higher rates of psychosis?

Deidre Anglin and Els van der Ven are researchers who are pioneering research in the under-studied field of the social determinants of psychosis in the US. In their 2021 study on the topic, they proposed three key domains that could account for higher rates of psychosis among Black and Hispanic/Latino people in the United States: neighborhood factors, cumulative trauma and stress, and pre- and perinatal complications.

The authors explain that these domains share a common denominator of structural racism. Black and Hispanic people in the United States suffer disproportionately from risk factors within these domains, primarily due to racial discrimination and socioeconomic disadvantage. The authors describe evidence showing that Black and Latino people in the United States suffer disproportionately from risk factors within these three key areas, in large part as a result of racial discrimination and social disadvantage. These domains encompass social and environmental risk factors that cause cumulative stress, perinatal complications, and altered neurobiology, mechanisms that may cause or increase the risk of psychosis.

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Neighborhood factors

Neighborhood factors encompass various social, economic, and political conditions, including urbanicity, ethnic density, perceived neighborhood disorder (e.g., vandalism and other signals of loss of social control), residential stability, and access to resources, opportunities, and services. Adverse neighborhood conditions and a lack of neighborhood stability and social capital contribute to higher cumulative stress, which is a risk factor for psychosis.

Structural racism perpetuates disadvantages for racial minorities through formal and informal generational segregation and discrimination. This discrimination includes underfunding or defunding essential services, failing to meet community members’ basic needs, and stifling opportunities for growth and development. The legacy of slavery and Jim Crow laws places Black communities as the most disadvantaged neighbourhoods.

There is an observable relationship between social class and mental health disorders, wherein individuals of the lowest socioeconomic classes experience disproportionately high rates of psychotic disorders. People of color, especially Black people in the US, are more likely to fall under the lower socioeconomic classes and, thus, experience higher levels of psychotic disorders such as schizophrenia.

Several neighborhood-level factors have been linked to psychosis. For example:

Growing up in an urban community with stressful racial dynamics increases the risk of psychosis.
Insecurity from fear of being pushed out of one’s neighborhood (i.e., gentrification) or perceived reductions in social or community networks is associated with greater odds of having experienced a psychotic episode.
Neighborhood-level residential instability or housing insecurity, as measured by the percentage of people who lived in multiple homes within 1 year, predicts earlier psychosis onset.

Cumulative trauma and stress

Rates of traumatic experiences are significantly higher for marginalized racial groups compared to White people. Traumatic experiences may include physical and sexual abuse, family separation, domestic violence, gun violence, and violence at the hands of police or other law enforcement. Racial and ethnic minorities report higher levels of adverse childhood experiences, in particular maltreatment and exposure to violence, compared to White people. These traumatic experiences, especially during childhood, have been found to increase the risk of psychosis.

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In Daniel Bergner’s New York Times piece, he interviews Earl Miller, who has been experiencing psychotic episodes since age 13. Miller was abused by his mother and landed in foster care, where he continued to experience bullying in foster care and eventually racially motivated aggression in psychiatric facilities. He has also experienced trauma at the hands of the police. The accusation of these traumatic experiences has worsened his psychosis symptoms, which likely began as a result of his adverse childhood experiences.

Previous research has found that experiencing more than one trauma was associated with psychosis. The literature suggests a dose-response pattern, wherein more frequent trauma or stressors are associated with more frequent symptoms of psychosis. Disadvantaged racial minorities tend to have experiences of collective historical or generational racial trauma, which increases their potential for chronic stress and builds upon any individual-level traumatic events they experience to increase their risk of psychosis.

Perinatal complications

Obstetric complications ranging from infections, inflammation, maternal stress, and hypoxia have been linked to an increased prevalence of psychotic disorders in the US. It is well-known that Black women in the United States are at substantially increased risk for many obstetric complications, though the mechanisms behind this increased risk are complex. Racial disparities in maternal health persist even among Black women of higher socioeconomic status and are independent of access to prenatal care. Recent research suggests that Black women may experience more lifetime stress, leading to increased inflammation, lower cortisol, and other stress-related pregnancy conditions that lead to poor birth outcomes and subsequent risk for psychotic disorders in adulthood.

In the case of Earl Miller, mental illness seems to run in his family. His mother struggles with bipolar disorder, his father with alcoholism, and now his son appears to be dealing with symptoms of psychosis. Bergner quotes Miller as saying, “ I wonder how much of what looks like genetic predisposition is really generations of trauma.”

While there are genetic components to psychosis, researchers in this field warn that genetics are not the only factor at play and should not be the main focus of the story. As detailed above, complex social and environmental systems predispose people of color, especially Black people, to conditions that increase their risk of psychosis, and this risk can continue to manifest across generations.

How Can We Address Racial Disparities in Psychosis Prevalence?

As the factors outlined above suggest, the prevalence of psychosis is complex and multifaceted, rooted in historical and generational legacies of structural racism and racial violence. Addressing racial disparities in psychosis requires moving beyond an individual-focused biomedical model and acknowledging the broader social, economic, and historical forces at play.

Researchers and policymakers must prioritize a more context-based approach to mental health care that integrates social determinants of health. This includes:

Reforming mental health care systems to integrate the social determinants of psychosis.
Investing in early intervention and community-based support for Black people and those in other minorities struggling with symptoms of psychosis.
Prioritizing policies that expand affordable housing, economic opportunities, and social services in historically marginalized communities.
Confronting structural racism in health and social policy.
Expanding research on social determinants of psychosis.

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Reducing racial disparities in psychosis prevalence demands a shift in how the US approaches mental health care and policy. By challenging the systemic barriers that place Black and other minority populations at greater risk, we can work toward a more equitable and just mental health system—one that acknowledges and addresses the realities of structural oppression rather than pathologizing its effects.

Key Points

Black Americans experience psychosis at significantly higher rates than White Americans.
Social and environmental disparities, underpinned by structural racism, can partly explain why Black Americans and other racial minorities experience more psychosis and psychotic episodes than White Americans. These factors include but are not limited to neighborhood factors, cumulative stress and trauma, and perinatal complications.
The US views psychosis and other mental illnesses through a biomedical model that places focus on the individual and neglects the social and environmental context of disease.
To address racial disparities in psychotic experiences, we must continue researching the social determinants of psychosis, improve health equity for Black communities, and, most importantly, work to dismantle systemic racism.

References

Anglin, D. M., Ereshefsky, S., Klaunig, M. J., Bridgwater, M. A., Niendam, T. A., Ellman, L. M., DeVylder, J., Thayer, G., Bolden, K., Musket, C. W., Grattan, R. E., Lincoln, S. H., Schiffman, J., Lipner, E., Bachman, P., Corcoran, C. M., Mota, N. B., & van der Ven, E. (2021). From womb to neighborhood: A racial analysis of social determinants of psychosis in the United States. American Journal of Psychiatry, 178(7), 599–610. https://doi.org/10.1176/appi.ajp.2020.20071091

Bergner, D. (2024, December 3). America’s hidden racial divide: A mysterious gap in psychosis rates. The New York Times Magazine. https://www.nytimes.com/2024/12/03/magazine/psychosis-schizophrenia-risk-race.html

National Institute of Mental Health. (n.d.). Understanding psychosis. U.S. Department of Health and Human Services, National Institutes of Health. https://www.nimh.nih.gov/health/publications/understanding-psychosis

Sankoh, M., Clifford, J., Peterson, R. E., & Prom-Wormley, E. (2024). Racial and ethnic differences in comorbid psychosis: A population-based study. Frontiers in Psychiatry, 15, 1280253. https://doi.org/10.3389/fpsyt.2024.1280253

van der Ven, E., Olino, T. M., Diehl, K., Nuñez, S. M., Thayer, G., Bridgwater, M. A., Ereshefsky, S., Musket, C., Lincoln, S. H., Rogers, R. T., Klaunig, M. J., Soohoo, E., DeVylder, J. E., Grattan, R. E., Schiffman, J., Ellman, L. M., Niendam, T. A., & Anglin, D. M. (2024). Ethnoracial risk variation across the psychosis continuum in the US: A systematic review and meta-analysis. JAMA Psychiatry, 81(5), 447–455. https://doi.org/10.1001/jamapsychiatry.2023.5497