Moving Beyond Healthcare

American medical and mental health practice have propagated race-based disparities since their inception. As a prime example, nineteenth century medical literature suggested that enslavement of Black Americans would protect them from severe mental illness. Propaganda during the Antebellum period intentionally overestimated the prevalence of mental illness among Black Americans in free states to dissuade abolitionist and emancipation movements. As a result, resources from local and state governments and philanthropic support waned considerably. In a recent  review article, we detail the foundation of inequity in mental health policy in the US. We document the history of discrimination and the incremental changes in federal legislation which followed with the goal of informing a modern-day, antiracist approach to policy making.

The mental health services landscape developed as segregated and inadequate for Black Americans during and after Reconstruction. “Separate but equal” policies in education, housing, and healthcare for Black Americans created programs that were inaccessible and low quality. Interwoven with the mental health reforms of the mid-twentieth century were advancements in civil rights and civil liberties. Mental health reforms and civil rights legislation inched the mental health system in the uS closer to equity for Black Americans, yet significant disparities and struggles persist. Today, inequity manifests individually and systemically: the convergence of racism, mental health crises, and police use of deadly force that led to the death of Daniel Prude in Rochester, NY; the growing rates of suicide among Black youth; racial disparities in the overdiagnosis of schizophrenia in Black patients; and unequal access to insurance and differential access to minimally adequate care.

The sociopolitical determinants of mental health – economic, neighborhood and community contexts, environmental events, and sociocultural organization, including systemic racism – intersect with race and ethnicity. Certain social phenomena disproportionately affect the health of Black Americans. Research shows police killings of unarmed Black people are detrimental to the mental health of Black Americans in states where they occurred. Disparities in morbidity and mortality and their connection to poor mental health are clearly apparent in the Covid-19 pandemic. A recent study of more than 61 million patients in the US showed that people with a recent diagnosis of a mental illness were significantly more vulnerable to Covid-19. Those with depression or schizophrenia had more than seven times the odds of being infected with SARS-CoV-2 than people without mental illness. Hospitalization and death rates were nearly twice that of people without mental illness. The racial disparity was notable for Black Americans who had more than threefold greater odds of infection than whites.

Since history informs us that piecemeal policies fail communities of color, we should create comprehensive policy environments that promote mental wellness and recovery for Black Americans to bridge equity gaps.

Social and economic policies that negatively affect minority communities contribute to disparities in mental health. Since racism is a fundamental cause of adverse health outcomes, dismantling policies that support racism is a critical step toward improving population mental health. This process begins by transforming our perception of mental illness to recognize that reforms outside of healthcare are essential to ensure the wellbeing of Black communities. While equitable mental health services are critical, and the elimination of health coverage gaps through Medicaid expansion is an ideal, equally important are reforms in the criminal-legal system and in education, housing, and nutrition access.

To prevent the mental health sequela of trauma, criminal-legal policies should target mandates for antiracism training for local police, state court officials, and judicial leaders, as well as transparency in police oversight and accountability in cases of human rights abuses. To decriminalize mental illness in persons of color, nonviolent offenses and penalties commonly associated with mental health and substance use disorders should be reclassified as lessor offenses so needed care can be provided in community settings. To protect Black youth from the impact of adverse childhood experiences, improvements in education access and enhanced resources for public schools may nurture resilience. To sustain connectedness for Black communities, reducing economic vulnerability through employment training, enhanced unemployment assistance, nutrition assistance programs, and access to safe, affordable housing may promote collective efficacy.

Since history informs us that piecemeal policies fail communities of color, we should create comprehensive policy environments that promote mental wellness and recovery for Black Americans to bridge equity gaps.

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