Psychosis Diagnosis 2.0

A new review links structural racism with psychosis risk, from psychotic experiences to schizophrenia

Researchers began with US-based literature focused on various social determinants, aka social and environmental conditions experienced across the lifespan, and along the way spotted a significant pattern that links racial disparities with psychotic disorders – including schizophrenia. Because racism is historically tied to US societal systems, the review concludes, structural racism appears to play a prominent role in psychosis risk factors for people of color and those from low socioeconomic backgrounds.

This conclusion was released during the American Psychiatric Association (APA) virtual meeting, with the review, titled From Womb to Neighborhood: A Racial Analysis of Social Determinants of Psychosis in the United States, published in the American Journal of Psychiatry.

However, of the 85,000 papers published in JAMA and the New England Journal of Medicine during the past 30 years and covering risk for psychosis, “only 15 include the word ‘racism’ anywhere in the text,” said review lead author Deidre M. Anglin, PhD, City College of New York, City University of New York, during an APA press session.

Following up on this finding, Dr. Anglin stated that structural racism’s role as a psychosis risk remains a sorely neglected issue in the United States. She added, “Our research indicates that we need to treat structural racism as a critical public health threat.”

A Trio of Concerns

While similar reviews exist, the work predominantly comes from European samples, which are not generalizable to the United States and the US vs. European environments have different socio-political histories, Dr. Anglin explained. She went on to note that structural racism forms a social hierarchy unique to the United States. Following through on that statement, the review authors selected three key areas to investigate – because they reflect social and environmental conditions that may affect psychosis risk through a common pathway shaped by structural racism.

The areas include the neighborhood environment, collective and individual exposure to trauma and stress, and prenatal and perinatal complications.

    • The study of neighborhood environments in the US pertains to disadvantages experienced by racially minoritized communities through inequitable access to healthcare, healthy foods, education, employment opportunities, and safe housing. Inequitable access produces cumulative stress and what Dr. Anglin suggests is increased risk for psychosis. “There’s a large body of research that speaks to how the neighborhood holds a lot of risk in terms of advantages versus disadvantages, and it gets preserved across generations. That is, I think, a critical piece in terms of thinking about mental health outcomes like psychosis,” Dr. Anglin said. She added, “Social environment, such as neighborhood disadvantage and discrimination, is critical to understanding risk for psychosis – maybe even more important than what genetic studies have shown us.”
    • Cumulative exposure to trauma and stress, at both collective and individual levels, is common among those with schizophrenia, with more than 85% of these people reporting at least one adverse childhood experience. In addition, rates of trauma and adversity are significantly higher in marginalized racial groups compared to white people and often associated with racism. Based on these known truths, review authors investigated a potential connection between trauma and increased risk of psychotic disorders. As Dr. Anglin explained, “A lot of studies show that among people experiencing psychosis, rates of trauma and adversity are significantly higher in marginalized racial groups compared to white people. And that cuts across various different kinds of trauma, from physical abuse, early childhood adversity, to discriminatory types of traumatic experiences.”
    • Multiple prenatal and perinatal complications, such as infections, maternal stress, an increase in maternal inflammation, and preterm deliveries as well as reduced fetal growth have been associated with increased risk for psychotic disorders. Bookending this statement is the fact that Black women in the US have a disproportionately increased risk for many obstetric complications compared to white women – although previous studies have neglected to consider racial disparities in birth complications. Dr. Anglin and her team investigated this previously ignored link and upon review, identified a connection between racial disparities in birth complications and increased risk of psychotic disorders.

As for how this review might lead the way forward, Dr. Anglin and her co-review authors write: “ While our review revealed that much of the work in this area has focused on Black and Latino populations, these social determinants are likely also relevant for Indigenous and Asian-descended populations; more research is needed in these populations.”

Furthermore, the review concludes, “More research studies that use both qualitative and quantitative methods will be necessary to fully understand the interplay between adversity, minority status, and other dynamic factors within US communities and how the unique experiences of these marginalized groups influence psychotic experiences, illness development, access to care, and ability to recover.”