Psychotic Disorders and Structural Racism: On Considering Complexity

In a policy statement issued in October 2020, the American Public Health Association officially declared that structural racism is a public health crisis, and in April 2021, the Centers for Disease Control and Prevention followed suit in declaring racism a "serious public health threat. STRUCTURAL RACISM AND MENTAL HEALTH Nowhere is the impact of structural racism more directly relevant than in considering mental health problems, which are filtered directly through the cultural lens of society in ways that can exacerbate its effects. Because they are so highly stigmatized, psychotic disorders are particularly sensitive to "racial and political currents" that underlie the evaluation, diagnosis, and management of these conditions.4 In this issue of AJPH, Misra et al. In my clinical experience, I have witnessed my Black patients who were hospitalized for stabilization during a mental health crisis removed from their second-generation antipsychotic medications and switched to high doses of haloperidol, a firstgeneration antipsychotic medication that was specifically associated (via print advertisements from pharmaceutical companies to prescribers) with images of aggressive and hostile Black men in the 1 960s.5,6 I have directly observed psychiatrists and other mental health providers misinterpret adaptive suspicious behaviors and symptoms of distress in Black patients as paranoid delusions, leading to misdiagnoses of psychotic illness. The structural level of discrimination within the health care system has effectively penetrated all other levels, including institutions (such as the institution of psychiatry) and individuals.5 The history ofthe reconceptualization of schizophrenia from a psychotic illness affecting docile White women who did not meet gendered, patriarchal expectations for their roles in society to an illness centrally defined as one in which Black men were hostile, aggressive, and "delusional" for seeking to assert their civil rights and rejecting notions of White superiority is well documented.5 However, one cannot overstate the impact that this reconceptualization, codified into various editions ofthe Diagnostic and Statistical Manual of Mental Disorders,11 has had on the modern conceptualization of schizophrenia and other psychotic disorders. [...]the bias that clinicians bring to their assessment, including misdiagnosis and overdiagnosis, is the foundation for inequities through racialized perceptions ofthe very definitions of what psychosis is and how it presents in different populations.

COVID-19, Structural Racism, and Mental Health Inequities: Policy Implications for an Emerging Syndemic.

The complex interactions between the 2019 coronavirus disease (COVID-19) pandemic, structural racism, and mental health inequities have led to devastating health, economic, and social consequences. The intersection of these three conditions, which meets criteria for a syndemic (synergistic epidemics), presents numerous policy challenges-and opportunities. Addressing these issues in a unified manner, using a syndemic theory approach, can lead to significant progress and effective solutions for otherwise intransigent problems in society. This article proposes steps that can be taken to protect "essential workers" and other "vulnerable" populations; engage and empower communities; optimize community-led crisis response interventions; improve data collection about the intersection of COVID-19, structural racism, and mental health inequities; support school-based interventions; expand financial supports for mental health service delivery; expand health care insurance coverage to increase access and lower out-of-pocket costs; and promote workforce diversity. Emphasis on local, state, and federal policy interventions that prioritize equity and justice and focus on collective health and well-being will ultimately lead us on a more sustainable and equitable path.

Transforming Mental Health And Addiction Services.

Even with great advances in behavioral health policy in the last decade, the problems of mental illness and addiction persist in the United States-so more needs to be done. In this article, which is part of the National Academy of Medicine's Vital Directions for Health and Health Care: Priorities for 2021 initiative, we describe the steps needed to improve outcomes, focusing on three strategies. We argue for transforming the behavioral health system to meet people where they are, decriminalizing mental illness and substance use disorders to facilitate recovery, and raising awareness of social context and social needs as essential to effective care. We call for supporting structures in the workforce and structures of accountability, outcome measurement, and more generous financing of behavioral health care. These steps have costs, but the enormous benefits of a major transformation in behavioral health policy far outweigh the expenses.