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Unhealthy Treatment


Public health can do a great deal to improve the mental health status of people who are mistreated.”

Few would argue with the notion that that discrimination based on race, ethnicity, sexual orientation and other characteristics continues to be a problem in U.S. society, or that historical and current injustices have contributed to everything from economic inequalities to inequities in some physical health outcomes.

But to what extent does being on the receiving end of overt mistreatment, as well as subtler but no less pernicious structural biases, affect one’s mental health?

“We now have decades of research showing that when people are chronically treated differently, unfairly, or badly, it can have effects ranging from low self-esteem to a higher risk for developing stress-related disorders such as anxiety and depression,” says Dr. Vickie Mays, a Fielding School professor in the Department of Health Policy and Management whose research, in collaboration with Dr. Susan Cochran, professor in FSPH’s Department of Epidemiology, has helped to document the links.

And as Mays notes, when any one person’s mental health is affected, it can produce a domino effect extending beyond the individual. “We know that when people have a psychiatric disorder, it’s not good for any of us,” she says. “For example, it can affect parenting – a depressed mom might not be able to interact with her child in a way that best promotes that child’s development, leaving the child more vulnerable to certain behavioral disorders. In that sense, we all suffer from the effects of discrimination.”

Dr. Gilbert Gee, professor in FSPH’s Department of Community Health Sciences, sought in a 2007 study to determine the extent to which Asian Americans who reported being the victims of discrimination were more vulnerable to developing clinically diagnosable mental disorders. “Much of the research has focused on symptoms of sadness and anxiety resulting from the mistreatment, and that’s very important, but we wanted to look at clinical outcomes,” Gee says. Even after taking into account other potential causes of stress, Gee found a clear relationship between discrimination and increased risk of mental disorders.


Drs. Vickie Mays, Gilbert Gee and Susan Cochran are among the FSPH faculty taking a public health perspective on discrimination.
Drs. Vickie Mays, Gilbert Gee and Susan Cochran are among the FSPH faculty taking a public health perspective on discrimination.

Since that study, other research has reported similar results in African American and Latino populations, as well as in other populations around the world, Gee says. He also found, in a 2014 study of Latinas/os, that discrimination was significantly associated with increased risk of alcohol abuse among women and increased risk of drug abuse among men. In 2015, Gee and colleagues performed an analysis drawing from approximately 300 studies conducted around the world over the last three decades. This meta-analysis concluded that self-reported racial discrimination is consistently related to poor mental health.

Discrimination is incredibly complex and experienced in so many different ways that it can be difficult to pinpoint the process by which it undermines mental health. “There are so many different routes, some of them direct and some of them indirect,” Gee explains. He points out that while a hate crime occurring in a community is certain to affect the mental health status of the victim and the victim’s family, it can also have a spillover effect for acquaintances and non-acquaintances in the community. Poor treatment based on race, ethnicity, sexual orientation and other factors can occur through interpersonal insults as well as through more insidious routes. “If you don’t get a job and you’re left to wonder whether it had to do with your race or gender, that can have an impact on your mental health,” Gee says. “We know that when people are worried about things, it affects their mood.”

Emerging research using neuroimaging tools is helping to isolate the brain mechanisms at play in these scenarios. A study led by one of Gee’s postdoctoral fellows recorded South Asian women talking about their experiences of being treated poorly, then had the women listen to the recordings while their brains were scanned using functional magnetic resonance imaging. The parts of the brain that responded as the women listened were the same as those that regulate emotions and stress.

More recently, Mays has collaborated on a study showing that experiencing significant amounts of discrimination over time can lead to changes in the way the brain processes information – disrupting, for example, the regions involved in planning and decision-making. “When we’ve had these experiences and anticipate that other incidents might lead us to be discriminated against, it can interfere with our ability to cognitively function at our best,” Mays says.

For much of the 20th century, homosexuality was classified as a mental illness. That thinking began to change after the publication in 1957 of an influential paper by UCLA research psychologist Evelyn Hooker, in which experts administering mental health tests found no detectable difference between homosexual and hetero¬sexual men. The American Psychiatric Association and American Psychological Association stopped classifying homosexuality as a mental disorder in the 1970s. Now, Cochran is part of a group of experts working with the World Health Organization to eliminate the last remaining mental health diagnoses linked to homosexual¬ity from the organization’s International Classification of Diseases. “This recommendation, to remove diagnoses that have no scientific basis, is a way of cleansing our public health apparatus of the social animus directed at a group of people for reasons that have no health justification,” Cochran says.

She notes that the mental health impact of the poor treatment long directed at people who are gay could not even be adequately studied until the end of the 1990s, when health surveys first began to include questions about sexual orientation. Since that time, Cochran has used state and national data sets for studies in which she has found that lesbians and gay men report much higher levels of discrimination and experiences with disrespect and daily hassles than heterosexuals, and that these experiences are strongly correlated with current levels of psychological distress.

Amid changing societal attitudes toward homosexuality, Cochran and other researchers are interested in what impact the increased acceptance might have on the mental health of lesbian, gay and bisexual people. On the question of same-sex marriage, for example, Pew Research polling found that only 35 percent of Americans were in favor vs. 57 percent opposed in 2001, the year Cochran and Mays published a widely cited American Journal of Public Health paper pointing to high levels of discrimination corresponding with levels of mental distress among lesbians and gay men. By 2015, Pew had found that 55 percent of Americans supported same-sex marriage, vs. 39 percent opposed. “It’s certainly reasonable to anticipate that the levels of distress should go down as the levels of discrimination go down, although we haven’t seen much evidence of that yet,” says Cochran, who points out that even as attitudes toward homosexuality change, high levels of discrimination and poor treatment remain.

In May 2015, Mays addressed the American Psychological Association’s annual meeting with a presentation called “Racial/ Ethnic Minority Lives Matter: Bridging Science and Practice in Policy Solutions.” She argued that, even as research continues to unravel the mental health effects of discrimination, more action should be taken to apply what is already known. “Public health can do a great deal to improve the mental health status, as well as the physical health, of people who are mistreated,” Mays says. “There is science that can help us to design effective interventions.”

Among other strategies, Mays suggests that a coordinated public health effort is needed to better integrate what is known about the outcomes of discrimination into health care profiles. “We screen for mental health disorders when we are putting together an individual’s electronic health record, but maybe we also need to ask about their experiences with discrimination, which would identify people at risk who could benefit from prevention efforts,” Mays says. “And among patients who experience high levels of discrimination, we need to be concerned with the potential for distrust of the health care provider. It could be that if we want better health care outcomes, we should allow these patients to know more about the provider they are selecting to ensure it’s someone they are comfortable with.”

But Mays says the focus shouldn’t be only on the victims of discrimination. “We need to target prevention strategies at the perpetrators of racism, just like we’ve targeted people who are developing bullying behaviors, starting in the school system,” she says. “We can do more to learn about the processes that lead people to treat others this way, and how to disrupt those through early education.”

Gee believes public health can also do more to help shape future legislation that would both reduce discrimination and improve the mental health of its historic targets. “Policies that promote human rights can not only buttress the foundations of a civil society,” Gee says, “but they can also make for a healthier one.”

 "Public health can do a great deal to improve the mental health status of people who are mistreated."