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Clinical Review COVID-19 and Mental Health Disparities in the Black American Population

Description The current COVID-19 pandemic has amplified health disparities that have long existed for minoritized groups in the United States. There have been disproportionate effects on the mental and physical health of the Black American population, specifically because of longstanding racial, social, and economic injustices. To fully understand the current state of Black mental health and the extent to which COVID-19 has impacted it, we examine historical examples of unjust mental health practices throughout generations. We then explore why depression, suicidality, and other mental illnesses may have a profound effect on a commu-nity that has been made vulnerable to socioeconomic shifts. The complex interplay of indi- vidual stress, generational trauma, targeted violence, and mass catastrophe undermines the mental well-being of many Black Americans. This issue requires a multi-systems approach to improve trust in medicine and increase access to quality mental healthcare.


Introduction
Since the start of the COVID-19 pandemic, individuals, communities, governments, and corporations have been challenged to create a new normal in the face of a deadly and contagious respiratory illness. A worldwide shutdown in 2020 was the impetus for a series of adjustments to everyday life. Numerous businesses implemented new work-from-home policies, and some closed their doors for good. School closings strained parents, students, and teachers to discover new ways to educate and learn. Social distancing and masking policies became standard in nearly every establishment. From business and finance to housing, public education, and healthcare, the pandemic touched almost every aspect of our lives. Undoubtedly, the most consequential effect was the millions of lives lost around the globe. In the United States (U.S.) alone, there have been over 84 million total cases to date (June 9, 2022) and 1 million deaths from COVID-19. 1 Unsurprisingly, minoritized communities have been disproportionately affected by the physical and mental toll of COVID-19. There have been disproportionate effects on the psychological and physical health of the Black American population due to longstanding racial, social, and economic injustices.

Disparities in COVID-19 Physical Health Outcomes in Black Americans
It is well established that Black Americans face an increased risk of severe disease from COVID-19. 2 Data reveals that Blacks are 1.1 times more likely than Whites to become ill with COVID-19, 2 times as likely to die from infection, and nearly 3 times as likely to be hospitalized. 3 Although Black people comprise about 13% of the U.S. population, they accounted for over 18% of deaths at the pandemic's peak. 4 There are many contributors to these disparate outcomes, including higher rates of underlying chronic medical conditions, barriers to timely and quality healthcare services, increased likelihood of working in service industries (that were also incredibly vulnerable to the financial impacts of the economic downturn), and increased likelihood of living in crowded, low-income neighborhoods that facilitate the transmission of the virus. 2 Furthermore, Black people are overrepresented in the criminal justice system, which increases the risk of exposure due to challenges with social distancing, handwashing, and quarantining. 2 As of April 2021, 1 in 3 incarcerated people in state prisons have had COVID-19, and nearly 3000 of the 661 000 infected among prisoners and staff have died. 5 These numbers are likely underrepresented due to limitations with testing in this population.

The Framework for Black Mental Health in America
Alas, these disparities in COVID-19 outcomes extend beyond the Black body. The Black mind, that is, the overall mental health state of Black America, is not immune to inequities in care. Differences in the experience of behavioral healthcare for marginalized groups have long existed. To fully understand the impact of the pandemic on Black mental health, we must first turn a critical eye to pre-pandemic America.

Pre-pandemic Mental Health Disparities in the Black American Population
Prior to the current pandemic, the state of Black mental health in America was plagued by inequity. Blacks disproportionately receive inadequate and less culturally sensitive care, resulting in more severe, chronic, and undertreated mental health disorders. 6 National data from 2017 reveals that nearly 90% of Black Americans over the age of 12 with a substance use disorder did not receive treatment. 6 Likewise, 65.4% of Black Americans with major depression and 42% with serious mental illness did not receive mental healthcare. 2 Respectively, these figures compare with 58.6% and 35.9% of Americans overall. 2 Studies have consistently shown that Black patients who present with the same symptoms as their White counterparts are more likely to be diagnosed with more severe, less treatable psychotic disorders, such as schizophrenia, than a mood disorder, like major depression or anxiety. 6 Consequently, Black Americans with mental illness are more susceptible to overdiagnoses, higher rates of institutionalization, and improper treatment plans. For example, in the school setting, Black students are more likely to be disciplined than their White peers rather than treated for mental illness. 7 One vital strategy to overcome these historical and contemporary disparities is representation and diversity within the healthcare system. While it is widely understood that Black mental health providers deliver more appropriate care to Black patients, less than 2% of American Psychological Association members are Black, and only 2% of psychiatrists are Black. 6 These factors are further compounded by the longstanding effects of slavery, racial segregation, over-incarceration, police brutality, and systematic oppression that relentlessly undermine the mental well-being of Black Americans.

A Short History of Mental Healthcare and Black America
To understand the current mental health state of Black America is to acknowledge an enduring history of racist mental healthcare practices. Beginning in the 1800s, the pervasive thought that enslaved Black people were inferior led to harmful mental health diagnoses that would ensure the perpetuity of such institutions. For instance, Dr. Samuel Cartwright, a Louisiana physician, coined the terms drapetomania and dysaethesia aethiopia to categorize as mentally ill enslaved people who attempted to flee captivity or were resistant to work. 8,9 A former leader of the Georgia Lunatic Asylum, Dr Theophilus O. Powell, argued that freedom for enslaved people caused them to become increasingly insane. 8 These antiquated arguments, which are widely discredited today, set the framework for further injustices.
Throughout the 1920s, sterilization of perceivably unfit or undesirable people became widespread due to the eugenics movement in America. 8 Institutionalized people, many of whom were Black and potentially misdiagnosed, were subject to these procedures without consent. 8 Discriminatory practices persisted as political and social unrest intensified in the following decades. Segregated and poor-quality mental healthcare facilities marked the civil rights era for Black people. Many were put to work instead of engaging in psychotherapy due to the belief that they were incapable of practicing thoughtful exercise. 9 Furthermore, the additions of "aggressive" and "hostile" to the diagnostic criteria for schizophrenia in the Diagnostic and Statistical Manual of Mental Disorders (DSM-II) allowed for misdiagnosis, particularly of Black men who engaged in civil rights protests, armed robberies, and property destruction. 10 The hypothesis that political uprisings in inner cities were caused by mental illness led to discriminatory treatment strategies. Pharmaceuticals were advertised for "out of control" Black patients. 9 Lobotomies (psychosurgery which involves severing connections in the brain) were commonly performed. 8 Though we have progressed as an institution, such history is the foundation from which our current mental healthcare system has evolved.

COVID-19 and Disparate Black Mental Health Outcomes
Through this historical lens, one may appreciate the unique challenges to mental healthcare that Black Americans face and how the current pandemic has affected this community. During its peak, Americans of all races were especially vulnerable to developing depression and anxiety as financial and social tensions amplified. Rates of substance use disorders and suicidal thoughts increased as well. 11 At all severity levels, depressive symptoms rose. The most significant increase occurred in those with severe disease across majority and minority racial/ethnic groups. 12 Although overall rates of suicide seem to have decreased during the height of the pandemic, a Maryland study revealed an increase in suicide by 94% among Black residents compared to a 45% decrease among White residents. 13 Additionally, the development of major depressive disorder is heavily influenced by social determinants of health. 12 These same determinants account for disparate physical health outcomes. Accordingly, the Black population has been made especially vulnerable to the impacts of COVID-19 on mental health.
Meanwhile, mass coverage of police brutality overwhelmed media outlets and sparked social justice movements across the country. Systematic barriers to healthy food, safe housing, quality public education, and reliable transportation heightened during an increased need. The complex interplay of individual stress, generational trauma, targeted violence, and mass catastrophe undermines mental well-being for many Black Americans. Even with an abundance of resources and support, dealing with these various layers of oppression is challenging. Clearly, better and more accessible mental healthcare for Black Americans is needed.

Recommendations
Several approaches are required to dismantle such a convoluted and entrenched system of inequities. Various organizations, including the Substance Abuse and Mental Health Services Administration (SAMHSA) and the American Psychiatric Association (APA), provide recommendations for policy, health literacy, community, and healthcare providers to improve access to quality care for Black Americans. Some recommendations are summarized in Figure 1. 2,14 Conclusion COVID-19 has amplified the physical and mental health disparities facing Black America. Social determinants of health that underpinned poorer health outcomes from COVID-19 also influenced mental health outcomes during the pandemic. Compounding factors of individual stress, generational trauma, and mass violence against Black people create stressors that would be challenging for any individual to process. The landscape of mental health in Black America is tainted by centuries of racism and systematic oppression, which require a multi-system approach to improve trust in medicine and increase access to quality mental healthcare.

Conflicts of Interest
The author declares he has no conflicts of interest.
Dr Taylor is an employee of HCA Florida Osceola Hospital, a hospital affiliated with the journal's publisher.
This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.