June 30, 2020
By Dr. Oladunni Oluwoye and Dr. Deidre M. Anglin
Following the tragic killing of George Floyd in May, protests were held globally against the excessive use of force by police and entrenched systemic racism against Black people and people of colour. We asked Dr. Oluwoye of Washington State Center of Excellence in Early Psychosis and Dr Anglin of The City College and Graduate Center of the City University of New York, both early intervention researchers with expertise in racial health equity, to share with us the relationship between race and mental health in the USA and recommendations on how the global early intervention community can make progress towards addressing inequity in mental health research and practice.
There are now a multitude of calls and statements to end systemic racism in the U.S. and around the world. From the Ivory Towers of academia to CEOs to NASCAR (of all sports), it seems like almost every entity has woken up to an entrenched reality existential to the very fabric of the U.S. social hierarchical system. The public display of brutal police victimization, murder, and hate in the public execution of George Floyd finally has everyone aghast! The racism, discrimination, and violence that Black people have voiced for centuries are on display right before our very eyes and all this is on the backdrop of the COVID-19 pandemic which has highlighted the racial inequities that plague our health care systems.
Social determinants, which are inequities in social and environmental conditions experienced across the lifespan, disproportionately burden the health of the most marginalized and disadvantaged, which in a society built on systemic racism, includes Black people and other marginalized people of color. Adversity connected to racism such as exposure to police violence, racial trauma, and adverse childhood experiences have the power to subvert the healthy developmental trajectory. This impact can occur even before the baby is born, as it is known that racial disparities in obstetric complications that increase risk for psychosis are astonishing and linked to experiences of discrimination 1. From risk for illness, to premorbid functioning, to the development of illness, to access to care once ill, to the health system support given, to recovery; the social and environmental conditions we find ourselves trying to function within have the power to impact this health/illness trajectory at all points. The case of psychosis seems particularly vulnerable to the influence of such social determinants, as evidenced by numerous European studies and a small but growing number of U.S.-based studies.
Most young emerging adults are grappling with who they are and who they want to be, thinking about career choices, and planning for the future. Many are enjoying loving freely and with an extended sense of time. But the unjust and unequal social system of racism has significantly shaped these givens for a large proportion of people of color, modifying them in ways that increase exposure to negative social determinants of health. In an urban non-clinical undergraduate sample in the Northeastern U.S., we found that almost 75% reported being exposed to at least one traumatic event, almost 30% to 4 or more events,2 and 70 % reported experiencing racial discrimination in at least one domain, including in public on the street and at school3. These social and environmental stressors often connected to racism have real mental health consequences yet are not adequately incorporated in our models of early intervention.
The exposure to the aforementioned stressors (e.g., racial discrimination, trauma) are associated with higher levels of anxiety, depression, and psychotic experiences 3. Building on this and what we know about social determinants of health, is it really any surprise that prior to receiving any type of mental health services for the first episode of psychosis (FEP), Black people had poorer quality of life and more severe disorganized symptoms compared to White people, 4 and roughly 20% of Black families reported having contact with a mental health provider about FEP concerns prior to early intervention treatment. A recent study also showed that Black people were less likely to utilize mental health services prior to the first presentation of psychosis compared to White people 5. The experiences and interactions that many Black families endure along the pathway to receiving appropriate early intervention services are riddled by potholes, dead ends, and blockades that deter people along the way and unfortunately negatively impact service utilization (e.g., engagement) and clinical outcomes.
These experiences are not isolated to events prior to early intervention or coordinated specialty care programs, and as such, early intervention programs for FEP are not immune to the inequities that directly impact people of color, specifically Black people. Using data from a large randomized trial conducted in the U.S., we found that Black people, who were randomized to the condition that did not provide early intervention services (i.e., usual care/control), had more severe positive symptoms, disorganized thought, and uncontrolled hostility compared to White people after 2 years of treatment 6. These same disparities were not found in the treatment condition (NAVIGATE), which shows some promise for early intervention programs. We also found Black families in this study were less likely to be engaged in the family psychoeducation component of the early intervention program 6,and we know that among Black families, participation has a significant impact on their loved ones’ quality of life throughout treatment 7. So what do we know? We need to do better and we need to start doing better earlier. We need to start asking the question why? Why is it that Black families when seeking mental health care report more negative experiences? Why is it that clinicians frequently misdiagnose Black people with schizophrenia? Why is it that we do not see a high number of Black youth in early intervention services? Why is it hard to recruit Black people into research studies?
Dr. Berwick recently stated in JAMA, “Science and knowledge can guide action, they do not cause action.”8 The research and ideas stated in this piece represent the science and knowledge in early intervention and the pathway to getting there, as it pertains to early psychosis among people of color, and at this moment in time and moving forward there is no reason for inaction. If you are unsure of where to start after reading this piece, it should be to make tangible steps in your community, your organization, and your research to address these inequities, like those suggested by Dr. Anglin and colleagues in an article published early this year 9. Namely, lets strive for both cultural and structural competency and incentivize addressing the social disadvantages that increase risk for psychosis and thwart recovery.
1. Giscombé CL, Lobel M. Explaining Disproportionately High Rates of Adverse Birth Outcomes Among African Americans: The Impact of Stress, Racism, and Related Factors in Pregnancy. Psychological Bulletin. 2005;131(5):662-683. doi:10.1037/0033-2909.131.5.662
2. Anglin DM, Polanco-Roman L, Lui F. Ethnic Variation in Whether Dissociation Mediates the Relation Between Traumatic Life Events and Attenuated Positive Psychotic Symptoms. Journal of Trauma & Dissociation. 2015;16(1):68-85. doi:10.1080/15299732.2014.953283
3. Anglin DM, Lighty Q, Greenspoon M, Ellman LM. Racial discrimination is associated with distressing subthreshold positive psychotic symptoms among US urban ethnic minority young adults. Soc Psychiatry Psychiatr Epidemiol. 2014;49(10):1545-1555. doi:10.1007/s00127-014-0870-8
4. Nagendra A, Schooler NR, Kane JM, et al. Demographic, psychosocial, clinical, and neurocognitive baseline characteristics of Black Americans in the RAISE-ETP study. Schizophrenia research. Published online 2017.
5. Coleman KJ, Yarborough BJ, Beck A, et al. Patterns of Health Care Utilization Before First Episode Psychosis in Racial and Ethnic Groups. Ethnicity & Disease. 2019;29(4):609-616. doi:10.18865/ed.29.4.609
6. Oluwoye O, Stiles B, Monroe-DeVita M, et al. Racial-Ethnic Disparities in First-Episode Psychosis Treatment Outcomes From the RAISE-ETP Study. Psychiatric Services. 2018;69(11):1138-1145. doi:doi: 10.1176/appi.ps.201800067
7. Oluwoye O, Kriegel L, Alcover KC, Compton MT, Cabassa LJ, McDonell MG. The impact of early family contact on quality of life among non-Hispanic Blacks and Whites in the RAISE-ETP trial. Schizophrenia research. Published online January 2, 2020. doi:S0920-9964(19)30574-2 [pii]