Improving the mental health and wellness of Black Americans requires acknowledging and confronting systemic racism underlying the US political, social, and healthcare systems that create and maintain racial inequality in every aspect of life for Black people in the USA.
The new Series of three papers on Black mental health in the USA, plus an essay from Black Americans with lived experience, published inThe Lancet Psychiatry journal, outlines the overwhelming evidence for the role racism plays in producing, maintaining, and amplifying mental health disparities for Black Americans. Against this background, the authors call for a comprehensive analysis of the conditions and systems in which racism can produce mental health issues while highlighting the potential of community-driven action to reduce inequitable mental health care and outcomes among Black Americans.
"There is a tremendous need for systemic change in how Black Americans are able to seek out and receive mental health care. Our research demonstrates how community-centered and culturally sensitive mental health care that actively includes Black people and Black scientists can reduce discrimination and create more equitable mental health outcomes," says Series lead author Associate Professor Ayana Jordan at NYU Grossman School of Medicine, New York, USA. "We hope that our findings have far-reaching impacts toward creating an anti-racist society and a mental health care system that tailors services to the unique needs of not only the individual but for the ethnically diverse groups of Black Americans." [1]
How racism shapes Black mental health in the USA
Centuries of systemic racism have created vast disparities in mental care for Black people in the USA leading to unfavourable health outcomes and increased illness. Due to racism, Black Americans are exposed to several risk factors for mental illness, including lower-quality education, impoverished neighbourhoods with high rates of homelessness, and exposure to violence with high rates of police brutality. Additionally, due to a mental health care system that has invalidated the experience of Black Americans, by dismissing or not incorporating the cultural backgrounds of Black Americans, Black people are less likely to seek mental health care compared to White Americans. There is also a structural reason for worse healthcare: Black people have historically been excluded from much medical research, and Black scientists make up less than 1% of researchers receiving independent research funding from the US National Institutes of Health, further hampering mental health equity efforts.
The Series underscores the need to directly address racism as a root cause of poor mental health, in order to eradicate these racial inequities in health.
"Centuries of dehumanisation and oppression—from European imperialism and enslavement to the myth of Black inferiority and biological racial classification—have evolved into present-day racism (structural, institutional, and individual) that perpetuates disparities, leading to the underestimation, misdiagnosis, and inadequate treatment of mental illness among Black Americans," says Series co-author Professor Helena Hansen from the University of California Los Angeles (USA). [1]
Racist roots of mental health care
The authors argue that the definitions and framing of mental health, mental illness, and the processes and prescriptions for diagnosing, treating, and maintaining wellness have all been grounded in whiteness and myths of white supremacy.
They point out that explanations for the differences in rates of mental illness and substance use disorders between racial and ethnic groups have often been incorrectly seen as evidence of biological or cultural distinctions, and are missing explanations of the systemic, avoidable, and unjust social and economic policies and practices underlying the inequities.
For example, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which has long been the classification system to understand mental illness, does not fully capture the experience of being racialized as Black. Instead of understanding the effects of racism, the DSM-5 locates the problems of mental illness in the bodies and behaviours of individuals and categorises differences by race—perpetuating systemic biases.
Likewise, the Series notes that common epidemiological surveys have pathologised Black behaviour, wrapping up racist beliefs in the mantle of scientific certainty and big data. For instance, the 1971 National Survey of Drug Use and Health (NSDUH), which indirectly informed how race and ethnicity are used in Federal legislation, found that Black populations had higher rates of illicit drug use than White populations. However, the survey oversampled individuals from low-income communities where Black people are more likely to live, and likely reflected socioeconomic disparities rather than ethnicity. In 2019, the NSDUH reported that the prevalence of major depressive episodes was higher among White populations but was based on a sample of Black adults that was not representative of the USA as a whole [2].
In contrast, the National Survey of American Life (NSAL) captured a more nationally representative and ethnically diverse sample of Black people and includes community-level data on the social conditions that contribute to racial differences in the prevalence of mental disorders, finding that 12-month major depressive disorder estimates were similar between White and Black populations [3].
To address these challenges, the authors call for a comprehensive analysis of the conditions and systems that produce mental illness and compromise mental health. "A reckoning with this history is crucial to reform the meanings and values that we assign to race and the ways race is weaponized in the formation of health policy and practice," says Series co-author Courtney Cogburn at Columbia University School of Social Work (USA). "We must go beyond traditional views of individualised mental illness classifications to focus on collective efforts to combat racism and establish equitable systems that promote Black mental health and dismantle systemic racism." [1]
According to co-author Associate Professor Nii Addy from Yale University School of Medicine (USA), "This demands a comprehensive, culturally sensitive approach to mental health care that is inclusive, accessible, and seeks to empower Black communities and foster resilience." [1]
Transitioning from surviving to thriving
Throughout history, Black people living in the USA have relied on different systems of collective resistance and community support to manage various threats to their survival and well-being, from forced enslavement and violence during the civil rights movement in the 1960s, to the war on drugs and mass incarceration.
"Black communities have their own distinctive challenges and mental health needs that aren't understood or captured by current systems or mainstream services, as well as valuable and unique ways of addressing them", says Series author Professor Mindy Fullilove from The New School, New York (USA). "While treatment of mental illness is often the key focus of intervention, Black Americans have survived and thrived through community and collective action. These systems have continued to support Black people in their efforts to promote mental health, throw off oppression, protect self-esteem, and support morale." [1]
A successful and sustainable transition to effective mental health care for Black Americans requires commitment from individuals, communities, institutions, and society as a whole to combat racism, create opportunities, and promote social and economic justice. The authors highlight how drawing on the centuries of experience and resilience among Black communities (see figure in paper 2, page 67) can support the steps necessary to improve mental health care for Black Americans.
"Black communities can help themselves through their own agency as they have done throughout history by nurturing a sense of spirit, developing a sense of nation and unity, organising for change, and giving back and achieving on behalf of the larger community," says co-author Dr Sidney Hankerson from Icahn School of Medicine at Mount Sinai, USA. "Black elders exemplify this dedication, passing on a legacy of resilience and inspiring future generations to drive societal and political change for a better future." [1]
It takes a community to improve Black mental health
A key takeaway from the Series is the value of community-based participatory research (CBPR) conducted by Black scientists, Black leaders, and community members to improve the mental well-being of Black Americans. CBPR involves active participation and input from community members throughout the research process, giving communities a voice and empowering them to work with researchers for long-lasting and culturally appropriate solutions.
"This inclusive and culturally sensitive approach can contribute to providing mental health services to the Black community in a way that acknowledges and addresses their painful history of abuse in the name of research, that has led to a legacy of suspicion, mistrust, fear and anger towards mental health research and treatment," explains Associate Prof Jordan. [1]
She continues, "With such low representation of Black people in research, we have failed to capture what the experience of mental ill health is like for this community. When you give community members a voice, you prioritize the issues the community has and better reflect their needs." [1]
The authors highlight examples of CBPR initiatives that have been shown to improve Black mental health through collaboration, empowerment, and cultural sensitivity. For example, the AAKOMA (African American Knowledge Optimized for Mindfully-Health Adolescents) empowers individuals and strengthens communities to support the mental health needs of young people of colour, alongside generating the culturally relevant and community-partnered evidence to influence federal and state agencies and policymakers to reduce mental health disparities [3].
Another CBPR peer support program, set up to reduce recidivism in Black people with severe mental illness and substance abuse disorders coming out of prison, halved rates of recidivism compared with the general US prison population (22% vs. 43%) [5].
The Series notes that faith-based health outreach in the Black Church has been particularly successful in targeting stigmatising issues such as depression among Black men and HIV care. One programme known as the Addiction Treatment in the Black Community (ATBC) project combines computer-based cognitive behaviour treatment with a spiritual component provided by church-based health advisors, and has been shown to be an acceptable culturally informed treatment modality for Black adults with alcohol and other substance use disorders [6].
"These real-world examples demonstrate that community-based initiatives have great potential for promoting health equity and addressing the mental health of Black America," says Dr Alfiee Breeland-Noble, founder of the mental health nonprofit, The AAKOMA Project, Virginia, USA.[1]
An accompanying essay from Black Americans with lived experience adds further weight to these findings, highlighting the importance of understanding their real-world insight into the mental health system to help reimagine holistic care for Black people and to build trust and genuine engagement.
"Mental health care needs to be revamped, or care needs to be developed outside the traditional system in community centres, churches, and other places of trust," writes Kimberly Guy from Yale School of Medicine, USA. "What's more, we need a mental health system that sees people as whole people, as human, as full Black people with the capacity to thrive."
Ultimately, the Series solidifies the need for Black sociologists, anthropologists, scientists, researchers, physicians, clinicians, and citizen experts to set the priorities and provide perspectives at all levels.
"With Black people setting the agenda, it's more likely that the critical questions which are salient for Black and racially diverse communities, will be raised and addressed," says Dr Breeland-Noble. "We hope that this Series will galvanise deliberate action to support and fund Black scientists, who are more likely to conduct research and find solutions to problems that adversely impact Black people and contribute to the broader fight against racism at a systemic level." [1]
