HSBXXX10.1177/0022146518814251Journal of Health and Social BehaviorWilliams 814251research-article2018

2017 Leonard I. Pearlin Award Paper

Journal of Health and Social Behavior 2018, Vol. 59(4) 466 –485 and the Mental Health © American Sociological Association 2018 DOI:https://doi.org/10.1177/0022146518814251 10.1177/0022146518814251 of Populations of Color: jhsb.sagepub.com Advancing Our Understanding of Race-related Stressors

David R. Williams1,2,3

Abstract This article provides an overview of research on race-related stressors that can affect the mental health of socially disadvantaged racial and ethnic populations. It begins by reviewing the research on self-reported and mental health. Although discrimination is the most studied aspect of racism, racism can also affect mental health through structural/institutional mechanisms and racism that is deeply embedded in the larger culture. Key priorities for research include more systematic attention to stress proliferation processes due to institutional racism, the assessment of stressful experiences linked to natural or manmade environmental crises, documenting and understanding the health effects of hostility against immigrants and people of color, cataloguing and quantifying protective resources, and enhancing our understanding of the complex association between physical and mental health.

Keywords mental disorders, mental health, race, racial discrimination, racism, stress

There is considerable complexity in the association than whites (Miranda et al. 2008). However, when between race and mental health. The patterning of blacks and Latinos experience mental illness, their racial differences in mental health appears to vary episodes tend to be more severe, persist for longer by indicator of mental health status. For several periods of time, and are more debilitating than for decades, research has shown that while blacks (or any other race or ethnic group (Breslau et al. 2005). ) often have higher rates of psy- For example, in the National Study of American chological distress than whites, some studies also Life (NSAL), African Americans and Caribbean find that whites have elevated levels of depressive and anxiety symptoms compared to blacks 1Department of Social and Behavioral Sciences, Harvard (Dohrenwend and Dohrenwend 1969; Vega and T.H. Chan School of Public Health, Boston, MA, USA Rumbaut 1991). Blacks tend to report lower levels 2 Department of African and African American Studies of psychological well-being on cognitively focused and of Sociology, Harvard University, Cambridge, MA, measures such as life satisfaction and happiness USA (Hughes and Thomas 1998) but also report higher 3Department of Psychiatry and Mental Health, levels of flourishing than whites (Keyes 2007). University of Cape Town, Cape Town, South Africa Flourishing refers to the absence of mental disor- Corresponding Author: ders and the presence of high levels of psychologi- David R. Williams, Department of Social and Behavioral cal well-being. With regard to defined psychiatric Sciences, Harvard T.H. Chan School of Public Health, disorders, Hispanics (or Latinos; with the exception 677 Huntington Avenue, 6th Floor, Boston, MA 02115, of Puerto Ricans), blacks, and Asians all have lower USA. rates of lifetime and past year psychiatric disorders E-mail: [email protected] Williams 467

Blacks had lower current and lifetime rates of major buttressing the structure of racism is an ideology depression than whites (Williams et al. 2007). that is deeply embedded in the culture of the society However, once depressed, both black groups were that provides the rationale for the ranking of groups. more likely than whites to be chronically or persis- This leads to the development of negative attitudes tently depressed, have more severe symptoms and and beliefs toward racial outgroups (prejudice and higher levels of impairment, and not receive stereotypes) and differential treatment (discrimina- treatment. tion) of these groups by both individuals and social We do not currently have a clear sense of either institutions. There is a large body of high-quality the determinants of the levels of mental health sta- scientific evidence that documents the persistence tus for the major racial-ethnic groups in the United of racial discrimination in employment, housing, States or the patterning of the various indicators of banking and other commercial transactions, and a mental health status for all of these minority popu- broad range of domains of life (Pager and Shepherd lations. However, there is broad agreement that 2008). social contextual factors that reflect exposure to Targets of discrimination are aware of at least chronic and acute stressors linked to the living and some of these incidents of bias, and they are often working conditions of these populations play a role experienced as stressors that can adversely affect in shaping their mental health risk (Pearlin et al. mental and physical health. Historically, such 2005; Turner 2013; Vega and Rumbaut 1991). experiences had not been included in the typical Historically, the assessment of stressful life experi- scales used to assess acute and chronic stress. ences was heavily driven by the stressors experi- Considerable evidence now suggests that these enced by middle-class white males. There has been experiences are commonplace in contemporary enormous scientific interest and effort in recent society. For example, a recent national survey decades in conceptualizing and measuring the assessed discrimination as both acute major expe- stressors that may be distinctive to or more preva- riences (e.g., not being hired for a job or being lent among socially stigmatized racial and ethnic unfairly harassed by the police) and chronic minority populations and how these stressors can minor experiences captured by the Everyday affect their physical and mental health. These Discrimination Scale (e.g., being treated with less stressors are viewed as interconnected and driven courtesy and respect than others and receiving by exposures in social contexts, structures, and poorer service in restaurants and stores; American roles (Pearlin et al. 1981). This article provides an Psychological Association 2016). This study overview of research that suggests that the mental found that 69% of American adults reported expe- health of racial-ethnic socially stigmatized popula- riencing at least one experience of discrimination tions is embedded in these larger contextual factors. and 61% reported experiencing everyday discrim- It begins with an overview of the research on racial ination. Importantly, these experiences were pat- discrimination and health and then situates this terned by race. For example, 35% of African research in the need to more clearly document the Americans and Native Americans, 25% of Latinos, other pathways by which racism can also adversely 22% of Asians, and 18% of whites reported that affect mental health. for unfair reasons, they had not been hired for a job. Similarly, 34% of American Indians, 23% of blacks, 19% of Hispanics, and 11% of Asians and RACIAL DISCRIMINATION AND non-Hispanic whites reported that they experi- MENTAL HEALTH enced everyday discrimination almost every day In recent decades, research on racial discrimination or at least once a week (American Psychological and mental health has been a rapidly growing area Association 2016). of scientific investigation. However, racial discrimi- nation is best understood as one of the pathways by which racism affects health (Williams and Early Empirical Research on Racial Mohammed 2013). The term racism refers to an Discrimination organized system that is premised on the categoriza- Early studies of discrimination and health found tion and ranking of societal groups into races that self-report measures of discrimination were (Bonilla-Silva 1996). The dominant group deval- inversely associated with good mental and physical ues, disempowers, and differentially allocates desir- health. Reviews of this early literature revealed that able societal opportunities and resources to racial most studies were cross-sectional, assessed mental groups categorized as inferior. Supporting and health outcomes or other self-reported indicators of 468 Journal of Health and Social Behavior 59(4) health, and focused on African American adults in Recent Empirical Research on the United States (Krieger 1999; Williams, Neighbors, Discrimination and Mental Health: and Jackson 2003). Although these findings were Adults consistent with the notion that experiences of discrimination were neglected psychosocial stress- A recent review documented that discrimination is ors, there were serious scientific limitations. There positively associated with measures of depression was the possibility of shared response bias between and anxiety symptoms and psychological distress as self-reported measures of discrimination and self- well as defined psychiatric disorders (Lewis et al. reported measures of health in cross-sectional anal- 2015). For example, in the NSAL, among African yses. It was possible that mentally ill individuals American and Caribbean Black adults 55 years and could be (mis)perceiving discrimination that did older, positive but small associations were evident not even exist. There was also concern that key psy- between both racial and nonracial everyday dis- chological confounding factors such as social crimination and the risk of any lifetime (LT) disor- desirability, negative affect, neuroticism, or self- der as well as LT mood and anxiety disorders. esteem could drive the observed associations. Discrimination was also associated with a small Subsequent research has addressed these meth- increased risk of depressive symptoms and serious odological concerns. An important early study psychological distress (Mouzon et al. 2017). analyzed longitudinal data from 779 black adults Similarly, in the National Latino and Asian in the National Study of Black Americans (NSBA; American Study (NLAAS), everyday discrimina- Brown et al., 2000). This study found that psycho- tion was associated, in multivariate models, with logical distress and diagnosed major depression at increased odds of any DSM-IV disorder (odds ratio Wave 2 (1987–1988) were unrelated to reports of [OR] = 1.90), depressive disorder (OR = 1.72), and discrimination at Wave 3 (1988–1989), indicating anxiety disorder (OR = 2.24) among Asian that poor mental health did not predict subsequent Americans (Gee et al. 2007). Discrimination was reports of discrimination. The study also found also associated with comorbidity. Compared to per- that racial discrimination at Wave 2 was positively sons with no disorders, everyday discrimination associated with psychological distress but not was associated with a two-fold risk of having two depression at Wave 3. Although the majority of disorders and a three-fold risk of having three or studies of discrimination and health are still cross- more disorders. This pattern in the overall sample of sectional, there are a growing number of prospec- Asian Americans was similar to that observed tive studies that link changes over time in among the subset who were immigrants. In the discrimination to increases in symptoms of dis- NLAAS and NSAL national studies, among Latino, tress and depression (Lewis, Cogburn, and Asian, African American, and Caribbean Black Williams 2015; Paradies et al. 2015; Pascoe and adults, everyday discrimination was positively asso- Richman 2009; Schulz et al. 2006; Wallace, ciated with both 12-month (OR = 4.59) and lifetime Nazroo, and Bécares 2016; Williams and psychotic experiences (OR = 4.27; Oh et al. 2014). Mohammed 2009). Personality traits are not rou- This pattern was evident for visual (OR = 3.75) and tinely included as potential confounders in studies auditory (OR = 5.65) hallucinatory experiences as of self-reported discrimination. However, several well as delusional ideation (OR = 7.21). studies have found that the association between Discrimination has also been associated with discrimination and health remains robust after increased risk of mental disorders in international adjustment for personality characteristics such as contexts. For example, in the national South Africa hostility, neuroticism, social desirability, negative Study of Stress and Health, acute and chronic non- affect, and trait anxiety (Lewis et al. 2015; racial discrimination were moderately associated Williams and Mohammed 2009). Research has with elevated risk of 12-month and lifetime rates of also documented that discrimination is associated any disorder, even after adjustment for other stress- with a broad range of disease states (e.g., cancer, ors and potentially confounding psychological fac- cardiovascular disease, diabetes) and preclinical tors (Moomal et al. 2009). For example, chronic indicators of disease (e.g., allostatic load, inflam- everyday nonracial discrimination was associated mation, shorter telomere length, body mass index with increased risk of lifetime mood (OR = 1.68), [BMI], incident obesity, coronary artery calcifica- anxiety (OR = 1.94), and substance use disorders tion, cortisol dysregulation, and oxidative stress) (OR = 1.72) in the fully adjusted models. The UK that are not assessed via self-report (Lewis et al. Household Longitudinal Study also assessed 2015; Paradies et al. 2015). discrimination in four domains and related those Williams 469 exposures to changes in mental health from Wave 1 and physical health (Larson et al. 2007). A national to Wave 3 (Wallace et al. 2016). It found a dose- study in South Africa also found that experiences of response relationship between the number of expe- discrimination were positively related to psycholog- riences of discrimination with the degree of ical distress and reduced the residual association deterioration in mental health over time, as mea- between race and distress after adjustment had been sured by a scale of psnychological distress. The made for SES (Williams et al. 2008). study found that those participants who had reported only one prior experience of discrimina- tion had greater deterioration in mental health (1.93 Empirical Research on Discrimination points lower on a scale of psychological distress) than those who reported none. Those who reported and Mental Health: Children and two or more experiences of discrimination at one Adolescents prior time point had even greater mental health Research reveals that exposure to discrimination and deterioration (2.98 points lower). The level of men- its negative consequences for mental health begins tal health decline further increased for those who early in life. A review of research of discrimination reported two or more experiences of discrimination among children and adolescents found 121 studies at one time point and one incident at the other time (and 461 outcomes) that had examined the associa- point (5.65 points lower), with the greatest degree tion between discrimination and health among per- of mental health deterioration evident among those sons 0 to 18 years old (Priest et al. 2013). Exposure who reported two or more experiences of discrimi- to discrimination predicted worse mental health nation at both time points (8.26 points lower). (e.g., anxiety and depression symptoms) in 76% of Based on in-depth qualitative interviews, the 127 associations examined. Similarly, discrimi- Fleming, Lamont, and Welburn (2012) conclude nation was inversely associated with positive mental that incidents of racial discrimination matter so pro- health (e.g., resilience, self-worth, self-esteem) in foundly for mental health because they are experi- 62% of the 108 associations examined. As in studies ences of exclusion that trigger feelings of a of adults, most studies are cross-sectional, but there “defilement of self.” This includes feelings of being is also an emerging body of longitudinal research. overscrutinized, overlooked, underappreciated, For example, a study in rural Georgia of 714 black misunderstood, and disrespected. Importantly, adolescents, aged 10 to 12 at baseline, assessed their experiences of discrimination violate cultural exposure to discrimination three times over the next expectations of fairness, morality, dignity, and five years (Brody et al. 2006 ). It found that increases rights. Pearlin and colleagues (2005) had earlier in racial discrimination were associated with con- argued that stressors linked to race may be espe- duct problems and depressive symptoms, with the cially pathogenic because they could be perceived association between discrimination and conduct as a direct attack on an individual’s identity. problems stronger for boys but no gender difference Most studies of discrimination and health have evident for depressive symptoms. not explored the role of discrimination in contribut- Several studies in this review documented that ing to racial disparities in health. However, a few parental exposure to discrimination can adversely studies in the United States and internationally have affect the child. For example, a study of black ado- documented that perceived discrimination makes an lescents found that parental racial discrimination incremental contribution over socioeconomic status was associated with symptoms of anxiety and (SES) in accounting for racial-ethnic inequities in depression in the child independent of the child’s mental health and self-reported measures of physi- experiences of racial discrimination (Gibbons et al. cal health. This is evident for measures of distress 2004). In this study, parental experiences of dis- and global measures of mental and physical health crimination were also associated with substance use in community and national studies in the United in children that was mediated by both parental and States (Pole et al. 2005; Ren, Amick, and Williams child anxiety and depression (Gibbons et al. 2004). 1999; Williams et al. 1997). This has also been Another study of 10- and 11-year-olds found that observed, in national data from New Zealand, for mother reports of racial discrimination were associ- Maori-European disparities on a global measure of ated with poor parental mental health, which in turn mental health and three other indicators of self- adversely affected parenting behaviors and parent- reported health (Harris et al. 2006). A similar pattern ing satisfaction (Murry et al. 2001). has been documented in Australia for Aboriginal– A large study in the United Kingdom, the non-Aboriginal variations in self-reported mental Millennium Cohort Study, examined longitudinally 470 Journal of Health and Social Behavior 59(4) the pathways by which maternal discrimination threats linked to potential experiences of discrimi- among ethnic minority mothers can affect four nation and other dangers in one’s immediate envi- domains of social and emotional behavior in chil- ronment (Williams, Lavizzo-Mourey, and Warren dren—conduct, peer problems, emotional symp- 1994). The Heightened Vigilance Scale was devel- toms, and hyperactivity (Bécares, Nazroo, and oped as a companion measure to the Everyday Kelly 2015). The study found that adjusted for Discrimination Scale and seeks to capture efforts to sociodemographic factors and mother’s mental protect oneself from discrimination and minimize health in the year 2006, there were three pathways exposure (Williams et al. 1997). Studies with this by which maternal racial-ethnic discrimination in scale or abbreviated versions of it highlight the 2006 was associated with children’s social and importance of assessing the health consequences of emotional behavior in 2012. First, maternal dis- race-related vigilance. Research reveals that race- crimination in 2006 directly predicted child out- related vigilance is positively associated with large comes in 2012. In addition, mother’s discrimination arterial elasticity (a preclinical index of cardiovas- in 2006 was associated with poorer maternal mental cular function) for African American boys but not health and harsh parenting practices in 2008, and girls (Clark, Benkert, and Flack 2006), the risk of both of these factors were associated with child sleep difficulties and racial disparities in sleep social and emotional development in 2012. (Hicken et al. 2013), the odds of for A recent systematic review documented how chil- blacks and Hispanics but not whites, and the racial dren can often be the unintended victims of discrimi- gap in hypertension (Hicken et al. 2014) and waist nation because of their links to other individuals circumference and BMI among black women (Heard-Garris et al. 2018). This review found 30 (Hicken, Lee, and Hing 2018). studies that had examined the association between Vigilance also matters for mental health. A study vicarious discrimination (secondhand exposure to of Baltimore adults found that blacks have higher racism) and child health. Most of the studies were levels of heightened vigilance than whites, and vig- longitudinal and had been published after 2011. Two- ilance was positively associated with depressive thirds of the studies focused on African Americans in symptoms and contributed to the black-white dis- urban areas of the United States, but there were also parity in depression (LaVeist et al. 2014). Similarly, studies of Asian Americans, Hispanics, whites, and Lindström (2008) found that a single-item measure indigenous groups in Australia, New Zealand, and the of anticipatory ethnic discrimination was associated United States. Socio-emotional and mental health with lower levels of psychological health in a outcomes were most frequently assessed, and the national sample of adults in Sweden. A study of review found that in almost half of the examined Latino college students also found that the anticipa- associations, indirect exposure to racism by children tion of being discriminated against led to greater was inversely related to child health. There is clearly concern and threat emotions before an encounter a need for sustained research attention that would with a potential perpetrator of discrimination and comprehensively characterize both direct and indirect more stress and greater cardiovascular responses exposure to discrimination and document how these after the encounter (Sawyer et al. 2012). Our cur- experiences accumulate over the life course to affect rent understanding is limited with regard to all of the onset and course of illness (Gee, Walsemann, and the contexts and conditions that give rise to percep- Brondolo 2012; Heard-Garris et al. 2018). Greater tions of threat, the optimal ways to assess vigilance attention needs to be given in future research to iden- with regard to discrimination, and the ways in tifying sensitive periods, the interdependence in which vigilance combines with other risk factors to exposures among persons, latency periods, stress pro- affect mental health. liferation processes, and effects that may be linked to historical period and birth cohort (Gee et al., 2012). Discrimination and Other Stressors Discrimination must be understood and assessed Vigilance and the Threat of Exposure to within the context of other mechanisms of racism. Discrimination Social disadvantages and stressors often cluster in Discrimination, like other stressors, can affect people and places. In addition, institutional/struc- health through both actual exposure and the threat tural racism can give rise to what Pearlin and col- of exposure. Heightened vigilance refers to living in leagues (2005) called stress proliferation processes, a state of psychological arousal in order to monitor, in which an initial stressor can initiate or exacerbate respond to, and attempt to protect oneself from stressors in other domains of life. Thus, living and Williams 471 working conditions created by racism can initiate isolation, marginalization, and other social ills that and sustain differential exposure to a broad range of tend to co-occur with segregation (Cutler and stressors that at face value may not appear to be Glaeser 1997; Williams and Collins 2001). However, related to racism. These can include “traditional prior assessments of stressors have failed to fully stressors” such as violence, criminal victimization, capture all of the stress-inducing aspects of what neighborhood conditions, financial stress, and rela- Chester Pierce (1975) called the “extreme mundane tionship stress. According to Pearlin and colleagues, environment” of disadvantaged neighborhoods. these are the “serious stressors,” patterned by social A recent qualitative study of Baltimore residents disadvantage, that capture major hardships, con- who resided in public housing illustrates how seg- flicts, and disruptions in life and are especially viru- regation can create the concentration of poverty and lent when they are chronic and recur in major social poor housing and neighborhood conditions that roles and domains (Pearlin et al. 2005). trigger a range of acute and chronic secondary An example of the comprehensive assessment stressors (Turney, Kissane, and Edin 2013). The of stressors comes from the Chicago Community study found that residents were exposed to high Adult Health Study. This study measured stressors levels of stressors linked to the social environment, in eight domains that reflect key arenas in which including pervasive witnessing shootings, seeing people operate (e.g., home, work, neighborhood) drug activity, resorting to violence to defend one- and major roles/statuses they occupy (Sternthal, self, high levels of break-ins and theft, incessant Slopen, and Williams 2011). The stressors included shouting and cursing, undesirable role models for a brief battery of acute life events (lifetime trau- children, unsafe places to raise children, and the matic experiences and recent life events); child- resultant constant worry about child safety. In addi- hood adversity; chronic stressors in relationships, tion, stressors linked to the physical environment finances, neighborhoods, and at work; and acute included broken elevators, roach and rodent infesta- and chronic life experiences of discrimination tion, trash buildup, dampness in the walls, (everyday discrimination, discrimination at work, extremely hot (or cold) interior temperatures, the and major experiences of discrimination). Blacks absence of green open spaces, crumbling sidewalks, and American-born Hispanics tended to have higher graffiti, litter, and inadequate lighting. It is not clear prevalence of each of the individual classes of that existing batteries to capture acute and chronic stressors and greater clustering of multiple stressors stressors capture all of these aspects of stressful compared to whites. The analyses found that each exposures. This is important because failure to stressor was positively associated with depressive measure stress comprehensively underestimates the symptoms in models that considered all eight negative effects of stressors on physical and mental stressors simultaneously. Moreover, in models that health (Thoits 2010). counted the number of domains in which an indi- Comprehensively capturing the full mental vidual scored high on stress, the study found a health impact of exposure to discrimination requires graded association between the number of stressors careful attention to the changing nature of racism in and an increase in depressive symptoms. In addi- society and assessing it in all of the contexts where tion, the study found that the association between it becomes evident. Research on discrimination in SES (especially income) and depressive symptoms online contexts illustrates this point. A recent study was reduced substantially after coefficients for of Latino adolescents found that both individual stress were added to the model, suggesting that online discrimination (derogatory text, images, and stress exposure operates apart from SES but also symbols directly targeted at individuals because of through exposure to stressors that accompany low their race and ethnicity) and vicarious online dis- SES (Sternthal et al. 2011). crimination (derogatory incidents targeted to peo- However, research attention is needed to fully ple of one’s own racial or ethnic group) were characterize the ways in which institutional mecha- adversely related to adolescent mental health nisms of racism shape exposure to stressors. For (Umaña-Taylor et al. 2015). example, residential racial segregation is recog- nized as one of the most striking and consequential legacies of institutional racism that has pervasive Capturing “Hidden” Aspects of Race- negative effects on living conditions and health related Stressors on Mental Health (Williams and Collins 2001). It is a major contribu- A related need is to give more systematic attention tor to racial differences in income, education, and to understanding how some life experiences that are employment and the concentration of poverty, not explicitly linked to racism can indeed reflect the 472 Journal of Health and Social Behavior 59(4) effects of racism and better documenting their con- Thus, despite similar rates of cocaine use among tribution to mental health. For example, the death of black and white Americans and despite crack and a loved one is a standard indicator of stress on scales powder cocaine having the same chemical makeup of life events, but the ways in which such exposures and similar physiologic effects, black people were are driven by the larger racism in the society is not more likely to be charged for drug possession and typically understood and appreciated. Debra serve markedly longer prison sentences than whites Umberson’s (2017) research on community (Free 1997). bereavement illustrates the value of this approach. Incarceration in turn has negative ripple effects She shows that structural conditions linked to rac- on mental health for families and communities. The ism lead to lower life expectancy for African incarceration of a father is positively associated Americans. A consequence of the large racial differ- with poor school outcomes and behavioral prob- ences in life expectancy is that compared to whites, lems in his children (Wildeman, Goldman, and black Americans are exposed to more deaths of Turney 2018). In contrast, there is not a consistent friends and relatives from early childhood through association between maternal incarceration and late life and to more losses earlier in the life course. mental health and school outcomes. Factors that For example, compared with whites, black children exacerbate the effects of parental incarceration are three times as likely to lose a mother by age 10, include the presence of domestic violence, parental and black adults are more than twice as likely to lose residence in the home before incarceration, child a child by age 30 and a spouse by age 60. Umberson sex being male, and child race being white. Some (2017) indicates that this elevated rate of bereave- studies have also quantified the impact of parental ment and loss of social ties is a unique stressor that incarceration on racial disparities in child health adversely affects levels of supportive social ties and and well-being (Wildeman et al. 2018). These stud- mental (and physical health) across the life course. ies reveal that mass incarceration has increased The criminal justice system has also been identi- racial inequities in children’s behavioral and mental fied as an instrument of institutional racism, a soci- health problems by 15% to 25% for externalizing etal system that generates policies and procedures problems and 24% to 46% for internalizing prob- that have differential negative effects on stigma- lems. In addition, the black-white disparity in infant tized racial ethnic populations. Emerging evidence mortality would be 10% lower if mass incarceration suggests that policies within this system that have did not exist. differential impact on racial groups are an example Aggressive policing can also adversely affect of institutional racism. With approximately 700 per the mental health of those targeted and the larger 100,000 citizens incarcerated at any given time, the community. A study in New York City of 1,261 United States has the largest number and highest young men aged 18 to 26 years assessed whether rate of incarcerated people in the world (Wildeman and how many times they had been stopped by the and Wang 2017). The rates of incarceration police and what had occurred during the encounter increased dramatically in the 1970s. Disparities in (Geller et al. 2014). The study found that the fre- surveillance, prosecution, and sentencing have been quency of stops, intrusiveness of the encounter, and associated with a 10-fold increase in risk of incar- perception of injustice and disrespect in the encoun- ceration for non-Hispanic blacks compared to white ter were all positively associated with symptoms of men in the United States, often reinforced by poli- posttraumatic stress disorder (PTSD) and anxiety. cies that have differentially criminalized substance These associations were robust after adjustment for abuse and mental illness (Wildeman and Wang race, education, public housing residence, and 2017). criminal activity. One factor contributing to the marked increase There are also frequent media reports of inci- in incarceration rates for racial minorities was the dents of police violence directed toward black, laws that linked criminal penalties for cocaine to an Latino, and Native American communities, and arbitrary distinction of whether cocaine was used in there is emerging evidence that the steady drumbeat powder form or as crack cocaine, the cheaper, solid, and reminders of these police shootings can be adulterated version of the former. The 1986 Anti- chronic stressors that adversely affect the mental Drug Abuse Act created a 100:1 sentence disparity— health of the larger community. A recent nationally a mandatory minimum prison sentence of five years representative, quasi-experimental study found that for a defendant possessing 5 grams of crack cocaine police killings of unarmed black Americans wors- (primarily used by blacks) or 500 grams of powder ened mental health among blacks in the general cocaine (primarily used by whites; Free 1997). population but had no effect on whites (Bor et al. Williams 473

2018). The effect was not evident for police shoot- levels of negative stereotypes in the population. A ings of armed black men. Each police killing led to recent national study documented that it is not only a per capita increase of .14 poor mental health days adult members of disadvantaged racial-ethnic per month in the three months after the event. At the groups that are stereotyped negatively, but even population level, police killings of unarmed black young children (aged zero to eight years) and youth Americans resulted in 55 million poor mental of color in the United States face high levels of neg- health days annually in the black American ative racial stereotyping from adults who work with community. them (Priest et al. 2018). The study analyzed the Other evidence indicates that witnessing com- stereotypes held by white adults who work or volun- munity violence is also a risk factor for mental teer with children across the United States, examin- health problems (Clark et al. 2008). A study of 386 ing their reported views towards adults, teenagers, women receiving care at an urban health center and children from a range of racial and ethnic back- reported on the location and timing of witnessing grounds (blacks, Hispanics, whites, Native Americans, incidents of violence in their neighborhoods. The Asians, and Arab Americans). The study found high study found that women who witnessed violence in levels of negative racial stereotyping toward non- their community were twice as likely to report whites of all ages among adults working or volun- depressive and anxiety symptoms compared to teering with children. The highest levels of negative those who reported no violence (adjusted for mari- stereotypes were found toward blacks across all ste- tal status, age, education, and intimate partner vio- reotypes measured (lazy, unintelligent, violent, and lence victimization). There is also an emerging having unhealthy habits), with Native Americans body of evidence that suggests that there may be a and Hispanics seen as similarly negative on several complex pattern of association between the stressor stereotypes. of community violence and mental health, at least Negative stereotyping by whites was most pro- for male adolescents of color (Gaylord-Harden, So, nounced toward adults but was seen even toward Bai, Henry, et al. 2017; Gaylord-Harden, So, Bai, young children. For example, young black chil- and Tolan 2017). In longitudinal studies of African dren (aged zero to eight years) were almost three American and Latino male adolescents in Chicago, times more likely as white adults to be rated as this research has found that higher levels of expo- being lazy, with Native American and Hispanic sure to community violence is positively associated children also more likely to be considered lazy with aggression, delinquency, and PTSD symptoms than white adults. Young black children were more such as hyperarousal. However, the association than twice as likely to be rated as unintelligent or between violence and depressive symptoms is cur- violence-prone compared to white children of the vilinear, with depressive symptoms increasing only same age, with Hispanic children also seen as up to a point, then beginning to decline. The authors more unintelligent or violence-prone than white suggest that youth of color may become emotion- children. Some of the strongest levels of negative ally desensitized to community violence as vio- stereotyping by white adults working with chil- lence increases. Moreover, both emotional numbing dren were reported toward teenagers, with black and physiological arousal mediate the association and Native American teens being almost 10 times between violence exposure and aggressive and more likely to be viewed as lazy than white adults. delinquent behavior in these adolescent males. African American and Hispanic teens were Future research needs to explore the extent to which between one-and-a-half to two times more likely these patterns are generalizable to other population to be considered violence-prone and unintelligent subgroups and the extent to which community vio- than white adults and teens. lence is a unique stressor in terms of its effect on mental health and behavior. Provider Biases and Access and Quality of Care CULTURAL RACISM AND Cultural racism can trigger unconscious bias that can MENTAL HEALTH result in reduced access to health-enhancing oppor- Research also reveals that racism is deeply embed- tunities and resources for nondominant racial-ethnic ded in American culture and can contribute to groups. This has been well documented in the case of adversely affecting mental health in multiple ways medical care, including mental healthcare. Research (Williams and Mohammed 2013). One indicator of reveals that high levels of negative stereotypes, the persistence of racism in the culture is the high through normal, subtle, and often subconscious 474 Journal of Health and Social Behavior 59(4) processes, can guide expectations and interactions 2016). In this study, 326 licensed psychotherapists with others in ways that reduce the quality of service in New York City received voice mail messages provided by mental health professionals to persons from black and white middle-class and working- who belong to stigmatized social groups (American class callers seeking an appointment. Each message Psychological Assocation Presidential Task Force on used a racially distinctive name and a race- and Preventing Discrimination and Promoting Diversity class-based speech pattern. The study found that 2012). Importantly, even the most well-meaning and middle-class seekers were offered appointments at consciously egalitarian individual who holds a nega- a rate almost three times higher than their working- tive stereotype of a social group will likely discrimi- class peers. Among the middle class, whites were nate against a member of that group when he or she more likely than blacks to get appointments. And has an encounter with that individual. These are uni- among middle-class males, white males were more versal processes, and all persons are capable of them. than twice as likely to get an appointment than their Considerable scientific research indicates that black counterparts. Appointment offer rates did not these processes affect the care provided by physi- differ by gender, but women were more likely than cians and other clinicians. A landmark 2003 report men to get an offer of an appointment during their from the National Academy of Medicine con- preferred time range. Future research needs to cluded that across virtually every type of medical quantify the contribution of provider biases to the intervention, from the most simple to the most well-documented patterns of racial and ethnic ineq- sophisticated, blacks and other minorities receive uities in seeking mental healthcare, engagement fewer procedures and poorer quality medical care with treatment, and the severity and course of than whites (Smedley, Stith, and Nelson 2003). disease. Most physicians, like other professionals and ordi- nary Americans, have an implicit preference for whites over blacks (Sabin et al. 2009), and this Internalized Racism implicit bias among providers is often associated Internalized racism (or internalized stigma or self- with biased treatment recommendations in the care stereotyping) is another pathway by which cultural of black and other minority patients (van Ryn et al. racism can harm mental health. It refers to the 2011). Provider implicit bias is also associated acceptance and personal endorsement by marginal- with poorer quality of patient-provider communi- ized racial populations of the negative societal cation and lower patient evaluation of the quality beliefs and stereotypes about the inherent deficien- of the medical encounter, including provider non- cies of one’s group in the larger society. It is theo- verbal behavior (Cooper et al. 2012; van Ryn et al. rized that the endorsement of the superiority of 2011). whiteness and the devaluing of nonwhite groups by For example, a study of 422 patients indepen- stigmatized individuals can lead to feelings of dently observed over five years in a psychiatric worthlessness, low self-esteem, and poor psycho- emergency room (ER) illustrates how race can play logical well-being that can adversely affect their a role in mental healthcare (Segal, Bola, and Watson identity, self-competence, and health behavior 1996). The study found that after adjusting for psy- (Kwate and Meyer 2011). chotic disorders, severity of disturbance, danger- Several studies have empirically examined the ousness, psychiatric history, use of restraints, time association of internalized racism and mental spent in ER, and other factors, compared to other health. The Nadanolitization Scale was an early patients, black patients received, on average, one measure of internalized racism (Taylor and Grundy additional dose of psychiatric medication, one addi- 1996). It captures the extent to which blacks are tional antipsychotic dose, and an additional half socially uncomfortable with other blacks and dose of antipsychotic medication by injection. In endorse traditional racist stereotypes of blacks such addition, clinicians spent less time to evaluate a as blacks are mentally defective (intellectually, black patient than a white one, and the tendency to morally, emotionally) or blacks are physically overmedicate black patients was lower when clini- gifted (athletically, sexually, artistically). Research cians’ efforts to engage the patient in treatment by Jerome Taylor and colleagues revealed that (e.g., elicit information, include patient in planning, internalized racism was associated with higher con- respond with empathy) were rated as higher. sumption of alcohol and higher levels of psycho- A recent phone-based experimental study docu- logical distress and depressive symptoms (Taylor, mented discrimination by race, gender, and class in Henderson, and Jackson 1991; Taylor and Jackson getting access to mental healthcare (Kugelmass 1990, 1991). Williams 475

In the NSBA, internalized racism was assessed (Aronson et al. 2013). This may be especially by capturing the degree of agreement with positive important in the context of mental healthcare where and negative stereotypes of black people. A study the quality of patient-provider interpersonal inter- of the 2,107 black American adults in that sample action can be a critical contributor to the quality of found that both the rejection of positive stereotypes the therapeutic relationship. and the endorsement of negative stereotypes were Unlike the case of discrimination and health, associated with lower levels of self-esteem research on internalized racism and mental health (Brown, Sellers, and Gomez 2002). More recently, is in its infancy. At the present time, we are the NSAL has also measured internalized racism unaware of the optimal assessment of internalized by capturing the extent to which blacks endorse racism and the mechanisms and processes by negative stereotypes of blacks. One study found which this type of racism adversely affects mental that African Americans who had high levels of health. However, it is urgent that future research racial identity but also scored high on internalized addresses this gap given that studies with the racism were more likely to have lower levels of Nadanolitization Scale using nonrepresentative mastery and higher levels of depressive symptoms community and student samples have estimated (Hughes et al. 2015). Another study using this that one in three blacks score high on internalized same sample found that internalized racism was racism (Taylor and Grundy 1996). A similar esti- positively associated with depressive symptoms mate comes from a study of Indigenous adults in and serious psychological distress among African Australia in which internalized racism was mea- Americans, US-born Caribbean Blacks, and sured by a four-item scale that captured agreement foreign-born Caribbean Blacks (Mouzon and with not feeling good about being Indigenous, McLean 2017). However, African Americans had wanting Indigenous people to think and act more the highest levels of internalized racism, followed like other Australians, disagreeing that Indigenous by US-born Caribbean Blacks and then foreign- people have fewer opportunities than other born Caribbean Blacks, and the association with Australians, and reporting not being accepted by mental health symptoms was weakest for the for- other Indigenous people (Paradies and Cunningham eign-born group. Another study using the NSAL 2009). The study found that one-third of Aboriginal data found, surprisingly, that among Caribbean adults had high levels of internalized racism. We Blacks but not African Americans, internalized are also not clear about the factors that increase the racism was associated with a reduced risk of hav- likelihood that processes of internalized racism are ing major depressive disorder in the past year triggered. For example, research reveals that expo- (Molina and James 2016). sure of American Indians to mascots can adversely The internalization of negative cultural images affect a sense of self-esteem and community worth by stigmatized groups may also create expectations, (Fryberg et al. 2008). Future research needs to anxieties, and reactions that can not only adversely identify the extent to which processes of internal- affect psychological well-being but also decrease ized racism are operative within this context or if motivation for socioeconomic attainment (Kwate there are other processes linked to cultural racism and Meyer 2011). Research in the United States that are at work. reveals that when a stigma of inferiority was acti- vated under experimental conditions, student per- OTHER KEY PRIORITIES FOR formance on an examination was adversely affected (Steele 1997). African Americans who were told in FUTURE RESEARCH advance that blacks perform more poorly on exams There are a number of emerging mental risks that than whites, women who were told that they per- require more systematic attention to identify and form more poorly than men, and white men who effectively address current and future sources of were told that they usually do worse than Asians all stress and mental health challenges for populations had lower scores on an examination than control of color. These include hostility and stress in the groups who were not confronted with a stigma of current political environment, the complex relation- inferiority (Fischer et al. 1996; Steele 1997). ships between mental health and physical health, the Limited scientific evidence also indicates that the mental health consequences of climate change and presence of in the encounter of a other emerging environmental risks, identifying minority patient with a provider may adversely sources of psychological resilience, and understand- affect the quality of interaction with the provider ing and confronting patterns of increased mental and patient adherence to medical recommendations health risks. 476 Journal of Health and Social Behavior 59(4)

Hostility and Stress in the Larger Democrats and 26% of Republicans were similarly Culture stressed. Recent studies have documented that residing in communities with high levels of racial There is an urgent need to quantify and better under- prejudice is associated with an elevated risk of mor- stand the mental health consequences of stressors tality, especially for racial minorities who reside in linked to the increasing levels of racial hostility and those communities (Chae et al. 2015; Lee et al. political polarization in recent years. The election of 2015; Leitner et al. 2016). Similarly, elevated mor- President Barack Obama played a critical role. A tality risk has been found among lesbian, gay, and review of research on this topic revealed that his bisexual individuals living in areas with high levels election led to the rise of the Tea Party movement of anti-gay prejudice (Hatzenbuehler et al. 2014). with its racist rhetoric, declining white support for However, inadequate research attention has been the Democratic party, and increases in the belief given to documenting the short-term and long-term among whites that racism no longer exists that was mental health consequences of residence in hostile combined with opposition to efforts to address environments and the specific mechanisms that racial inequities (Parker 2016). His election also undergird these associations. triggered a large increase in racial animosity in Relatedly, research also suggests that anti- social media that included the emergence of anti- immigrant policies and initiatives can trigger hostil- Obama Facebook pages, hate websites, and the pro- ity toward immigrants that can lead to perceptions liferation online of historical racial stereotypes that of vulnerability, fear, and psychological distress for are no longer utilized in most mainstream media both immigrants who are directly targeted and those outlets (Moody 2012). The campaign of Donald who are not direct targets (Szkupinski Quiroga, Trump further brought to the surface preexisting Medina, and Glick 2014). A study in Arizona docu- negative attitudes toward immigrants, Muslims, and mented that this hostility in the environment led to racial and ethnic minorities. A national but nonrep- reductions in the use of healthcare and social ser- resentative survey of 2,000 kindergarten through vices among Hispanic women, with the effect being grade 12 teachers documented that more than half of larger among Latinas who were US-born than them indicated that since the Trump presidential among those who were foreign-born (Toomey et al. campaign had begun, there had been an increase 2014). Descriptions of federal immigration raids among some of their students in using slurs, name- also suggest that they can have negative emotional calling, and saying bigoted and hostile things about effects on an entire community (Novak, Geronimus, immigrants, minorities, and Muslims, and many and Martinez-Cardoso 2017). A recent study students in these targeted groups were afraid and assessed the relationship between a large immigra- worried about potential negative effects on their tion raid at a meat-processing plant and birth out- families after the election (Costello 2016). For comes in the surrounding community. It found that example, some African American children whose there was an increase in low birthweight to infants families had been in the United States for centuries born to Hispanic but not non-Hispanic white moth- were concerned about a return to slavery and black ers in the year after the raid compared to those born people being sent back to Africa. in the year before the raid (Novak et al. 2017). And in the wake of Trump’s election, there was Similarly, a study in a midwestern US community a marked spike in hate crimes and harassment with found that immigration enforcement stressors and K–12 schools being the most commonly reported levels of self-rated ill health were higher for the location where these incidents of harassment had Latino community residents who were interviewed occurred (Lenz 2016). This hostility in the larger after an immigration raid compared to those inter- environment contributed to high levels of fear and viewed before the raid (Lopez et al. 2017). More stress in the population. A national survey con- systematic efforts are needed to document and ducted by the American Psychological Association quantify this stress, fear, and vulnerability and in January 2017 reported that two-thirds of all assess their consequences for mental health. An ear- American adults said that they were stressed about lier body of research found that increases in hostil- the future of the country. Moreover, 69% of blacks, ity in the media and general society against 57% of Asians, 56% of Hispanics, and 42% of non- Muslims and persons from the Middle East in the Hispanic whites reported that the outcome of the wake of the September 11, 2011, terrorist attacks 2016 presidential election was a very significant or were associated with an increased risk of low birth- somewhat significant source of stress (American weight and preterm birth for Arab American women Psychological Association 2017). Some 72% of (Lauderdale 2006) and elevated levels of mental Williams 477 health symptoms among persons from the Middle discrimination and that both John Henryism and East (Padela and Heisler 2010). discrimination were associated with the increased odds of major depression but that John Henryism Understanding Complex Interactions did not moderate the relationship between discrimi- nation and depression (Hudson et al. 2016). between Physical Health and Mental Analyses of longitudinal data also indicate that Health Risks African American and Hispanic youth who experi- Several lines of evidence suggest that among racial ence upward socioeconomic mobility report greater minorities, there are complex and sometimes para- increases in acute and chronic discrimination com- doxical associations between mental and physical pared to their peers whose SES was stable (Colen health that we need to better understand so that we et al. 2018). These experiences of discrimination can improve overall health. First, some evidence are adversely related to health and partially contrib- suggests that psychological resources and positive uted to disparities in health between these minority emotional health can be associated with negative young adults and their white counterparts. This effects on physical health. For example, a study that research is broadly consistent with a larger paradox followed a sample of relatively economically disad- in the research literature between mental and physi- vantaged African American adolescents in the rural cal health risks among African Americans. African southeast over time found that those low socioeco- Americans tend to have worse health than whites nomic status (SES) youth with high self-control and on virtually every indicator of physical health, but self-regulation at age 11 succeeded academically as noted earlier, despite higher levels of stress, they and emotionally in young adulthood and at age 20 have lower rates of stress-related mental health out- used fewer drugs and drank less alcohol (Brody comes, such as major depression, than whites. We et al. 2013). However, these same youth had greater do not understand what drives this phenomenon. obesity, higher , and higher levels of Analyses of national data revealed that lower levels stress hormones and epigenetic aging (based on of depression among blacks than whites was evi- DNA methylation profiles) than their low SES peers dent across virtually every demographic subgroup who were low on self-control and their higher SES defined by sex, age, and education—a finding that peers (Chen et al. 2015; Miller et al. 2015). is not consistent with the view that the observed Similarly, in the National Longitudinal Study of pattern is due to selection bias because of limited Adolescent to Adult Health, lower levels of depres- coverage of some subgroups of the black popula- sion are associated with college completion irre- tion in surveys due to incarceration or homeless- spective of childhood disadvantage and for all ness (Barnes, Keyes, and Bates 2013). Other recent racial-ethnic groups (blacks, whites, and Hispanics; analyses have documented that neither high levels Gaydosh et al. 2018). In contrast, college comple- of social support among blacks (Mouzon 2013) nor tion is associated with lower metabolic syndrome the elevated levels of religious involvement among for whites irrespective of exposure to childhood African Americans compared to whites account for disadvantage, but among black and Hispanic youth, the racial differences in depression (Mouzon 2017). college completion is associated with higher meta- A novel hypothesis to account for this paradox was bolic syndrome among those from disadvantaged that engagement in unhealthy behaviors (eating, childhood environments. Future research needs to alcohol and tobacco use) to cope with stress is more better understand the contexts and exposures that protective of depression risk for blacks than whites appear to have opposite effects on mental health (Jackson, Knight, and Rafferty 2010). Using a large versus physical health. One useful framework is national sample, Keyes, Barnes, and Bates (2011) John Henryism, or high-effort, active coping, that is did not find support for this hypothesis. Engaging a positive attribute among well-resourced racial in unhealthy behaviors was not associated with minorities but is associated with worse health reduced risk of depression for blacks or whites. So among those who lack the resources to facilitate the paradox remains as an important scientific success (are low SES) or encounter blocked oppor- question to be answered. tunity (James 1994). However, it is unclear how Future research must also pay greater attention processes linked to John Henryism and blocked to the contribution that mental health symptoms opportunity relate to each other and can combine to among racial-ethnic minorities may play in the ele- affect physical and mental health. One national vated risk of chronic physical conditions. A recent study of African Americans found that education study that pooled data from 16 prospective studies was positively associated with experiences of racial in the United Kingdom and followed people for 478 Journal of Health and Social Behavior 59(4) about 10 years found that higher levels of distress can provide shade, reduce wastewater loads, reduce were associated with increased risk of cancer of all air pollution, and reduce noise pollution. However, sites, cancers not related to smoking, as well as leu- disadvantaged SES and racial-ethnic groups are kemia and colorectal, prostate, pancreatic, and more vulnerable to heat exposure because they are esophageal cancer (Batty et al. 2017). The associa- more likely to have higher rates of illness (e.g., car- tions persisted after adjustment for demographic diovascular disease, respiratory, renal, diabetes), factors, SES, and smoking and alcohol use. A reside in high-crime areas (fear of assault is a bar- graded stepwise risk was evident between psycho- rier to opening windows or traveling to cooler loca- logical distress and prostate and colorectal cancer. tions), and occupy poorer quality housing This research highlights the value of sustained (Gronlund 2014). They also have lower access to research attention that would enable us to better working fans, cool public spaces, and air condition- understand how risk and protective factors relate to ing (Gronlund 2014). All of these factors suggest each other and combine over time to affect physical that the mental health burden will be greater for and mental health and the relationship between socially disadvantaged racial and ethnic popula- them. tions. Inadequate attention has been given to exam- ining the short- and long-term mental health impact of natural or manmade environmental crises. Climate Change, Environmental Risks, and Mental Health As we look to the future, it is also important to give Protective Factors attention to assessing the mental health conse- A few studies have identified psychosocial resources quences of the stressors that may emerge from natu- that can reduce the negative effects of the stress of ral and manmade disasters. For example, a monthly discrimination on mental health. Religious involve- survey in Flint, Michigan, during the time of the ment has reduced the negative effects of discrimina- recent water crisis found that community respon- tion on health in two national studies. In prospective dents reported stress, anxiety, depression, and fear analyses using data from the NSBA, higher levels of within the community due to the ongoing crisis religious involvement (church attendance and seek- (Cuthbertson et al. 2016). These negative mental ing religious guidance in everyday life) reduced the health consequences were viewed as being related positive association between racial discrimination not only to the actual contamination of the water but and psychological distress (Ellison, Musick, and also to distrust of the official response to the crisis Henderson 2008). In the national survey of Midlife and the inadequacy of the response (Cuthbertson Development in the U.S. (MIDUS), church atten- et al. 2016). Similarly, a review of research on the dance buffered the adverse effect of discrimination mental health impact of a devastating earthquake in on negative affect among African Americans but not Japan in 2011 found long-term negative mental whites (Bierman 2006). In a study of 414 rural low- health impacts for the population affected (Ando income black mothers, church-based social support et al. 2017). While posttraumatic stress symptoms captured by a 21-item scale that assessed support tended to decline over time and initial increases in from one’s relationship with God, with the congre- suicide decreased two years after the quake, ele- gation, and from the clergy buffered the negative vated symptoms of depression persisted during the effect of discrimination on depressive symptoms entire follow-up period. These findings suggest the (Odom, Vernon-Feagans, and Family Life Project need for long-term and ongoing mental health sup- Key Investigators 2010). A measure of optimism port for communities and populations that face high also reduced the negative effect of discrimination on levels of exposure to traumatic experiences. depression. Relatedly, a study using a 31-item mea- Climate change is also likely to exacerbate the sure of trait mindfulness in a nonrepresentative challenges faced by vulnerable populations and add community sample of 605 adults found that mind- to their mental health burden. For example, because fulness reduced the negative effects of discrimina- of climate change, many cities are likely to get tion on depressive symptoms (Brown-Iannuzzi warmer and heat waves are expected to last longer, et al. 2014). increase in frequency, and be more intense (Jesdale, The receipt of social support from family mem- Morello-Frosch, and Cushing 2013). Prior research bers and friends is widely recognized as a psycho- has found that there are large racial disparities in social resource that can reduce the negative effects heat-related deaths. Urban tree canopy can mitigate of stressful life experiences on health. A few studies the negative effects of extreme heat, and urban trees have documented a similar pattern for the stress of Williams 479 discrimination. A study of 714 black adolescents, constant threat and fear, high levels of hopelessness, ages 10 to 12 at baseline and interviewed three and low perceived economic opportunity. Accordingly, times over five years, found that the negative effects they lived in the moment because of their uncer- of discrimination on depressive symptoms were tainty about their future. Changing the current tra- reduced among those adolescents who had had high jectory of stress and mental health problems will levels of support from their parents and friends require significant investment in enabling youth to (Brody et al. 2006). A subsequent follow-up of this develop skills and resources to confront and cope same study found that high levels of social support with the stressors they face. (caregiver emotional and instrumental support and peer support) reduced the negative effect of dis- crimination on allostatic load (Brody et al. 2014). CONCLUSION Future research is needed to better understand Understanding the ways in which the social context the conditions under which particular aspects of reli- of populations of color affect their mental health gious involvement, social support, and psychologi- requires detailed and comprehensive characteriza- cal resources can reduce the negative effects of the tion of the exposures in their social context that can stress of discrimination on mental health. Research affect health. The overview of the research provided is also needed to characterize the full range of here highlights the multiple ways in which racism resources that might play a role in ameliorating the can affect mental health. Other conditions linked to negative impacts of discrimination on mental health. race and ethnicity can also play a role in shaping the mental health of disadvantaged populations, and we need to understand these stressors in their full com- Emerging Mental Health Challenges plexity. Future research must characterize this full There is evidence of large and worsening mental range of risk factors and resources that may be health challenges for minority youth. Suicide data unique to or more prevalent among stigmatized are illustrative. Native Americans have the highest racial and ethnic populations and identify how they rates of suicide. It is the eighth leading cause of combine with each other over the life course to death overall and the second leading cause for indi- affect patterns of mental health. Such research must viduals between the ages of 10 and 34 (Odafe et al. be attentive to the changing social context of racial- 2016). There are also marked increases in suicide ethnic status and incorporate emerging threats to rates among Hispanics, especially among adoles- mental health as well as opportunities that may arise cents and young adults. Suicide is the third leading to promote enhanced mental wellbeing. cause of death for blacks aged 15 to 24, and although blacks still have lower suicide rates than whites, an ACKNOWLEDGMENTS increase in suicide among black youth in recent decades has narrowed the racial gap. A recent study The author thanks Sandra Krumholz for her assistance in documented that suicide was the leading cause of preparing the manuscript. death among school-aged children in the United States (Bridge et al. 2015). The study found that FUNDING although overall suicide rates for children aged 5 to The author disclosed receipt of the following financial 11 years had remained stable between 1993 to 1997 support for the research, authorship, and/or publication of and 2008 to 2012, the rate had declined for whites this article: Preparation of this paper was supported in part and remained stable for Hispanics and other racial by the National Institute on Minority Health and Health groups but had almost doubled for blacks. Disparities (NIMHD) of the National Institutes of Health More research is needed to identify the determi- under Award Number R01 MD009719. The content is nants of these challenges and identify how they can solely the responsibility of the author and does not neces- be effectively addressed. A recent study (Edwards sarily represent the official views of the National Institutes of Health. et al. 2017) of 365 emerging adults (96% African American), aged 18 to 24 and affiliated with a uni- versity in a northeastern metro area, sheds light on REFERENCES the significant stressful challenges that youth per- American Psychological Association. 2016. “Stress ceive. The young adults report that their biggest in America: The Impact of Discrimination. Stress concerns were aggressive policing, high levels of in America Survey.” Retrieved October 29, 2018 community violence, and the instability of their (https://www.apa.org/news/press/releases/stress/ housing. These youth reported that they faced 2015/impact-of-discrimination.pdf). 480 Journal of Health and Social Behavior 59(4)

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