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The '''social determinants of mental health''' (SDOMH) are “societal problems that disrupt optimal mental health, increase risk for and prevalence of mental illnesses, and worsen outcomes among individuals with mental illnesses.”[[User:Psg2022/sandbox# ftn1|[1]]] Much like the [[Social determinants of health|'''social determinants of health''']] (SDOH), SDOMH include the non-medical factors that play a role in the likelihood and severity of health outcomes, such as income levels, education attainment, access to housing, social inclusion, etc.[[User:Psg2022/sandbox# ftn2|[2]]] However, specifically when examining the topic of mental health, disparities in health outcomes are a result of a multitude of factors and social determinants, including fixed characteristics on an individual level – such as age, gender, race/ethnicity, and sexual orientation – and environmental factors that stem from social and economic inequalities – such as inadequate access to proper food, housing and transportation and exposure to pollution.[[User:Psg2022/sandbox# ftn3|[3]]]
The '''social determinants of mental health''' (SDOMH) are “societal problems that disrupt optimal mental health, increase risk for and prevalence of mental illnesses, and worsen outcomes among individuals with mental illnesses.<ref>{{Cite journal |last=Shim |first=Ruth S. |last2=Compton |first2=Michael T. |date=2020-01 |title=The Social Determinants of Mental Health: Psychiatrists’ Roles in Addressing Discrimination and Food Insecurity |url=https://psychiatryonline.org/doi/10.1176/appi.focus.20190035 |journal=FOCUS |language=en |volume=18 |issue=1 |pages=25–30 |doi=10.1176/appi.focus.20190035 |issn=1541-4094}}</ref> Much like the [[Social determinants of health|'''social determinants of health''']] (SDOH), SDOMH include the non-medical factors that play a role in the likelihood and severity of health outcomes, such as income levels, education attainment, access to housing, social inclusion, etc.<ref>{{Cite web |title=Social determinants of health |url=https://www.who.int/health-topics/social-determinants-of-health |access-date=2022-11-01 |website=www.who.int |language=en}}</ref> However, specifically when examining the topic of mental health, disparities in health outcomes are a result of a multitude of factors and social determinants, including fixed characteristics on an individual level – such as age, gender, race/ethnicity, and sexual orientation – and environmental factors that stem from social and economic inequalities – such as inadequate access to proper food, housing and transportation and exposure to pollution.<ref>{{Cite web |last=General |first=Office of the Surgeon |date=2021-12-07 |title=U.S. Surgeon General Issues Advisory on Youth Mental Health Crisis Further Exposed by COVID-19 Pandemic |url=https://www.hhs.gov/about/news/2021/12/07/us-surgeon-general-issues-advisory-on-youth-mental-health-crisis-further-exposed-by-covid-19-pandemic.html |access-date=2022-11-01 |website=HHS.gov |language=en}}</ref>


== Definitions and measurements ==
== Definitions and measurements ==
'''[[Mental health]]''' as defined by the [[World Health Organization|World Health Organization (WHO)]] in 2022 is “a state of mental well-being that enables people to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community.”[[User:Psg2022/sandbox# ftn4|[4]]] The concept of mental health cannot be examined independent from the various individual and social determinants that influence it because exposure to different conditions and circumstances, along with genetic predispositions, affects one’s experiences with mental health, illnesses, and/or disorders. On the other hand, a '''[[mental disorder]]''' is defined as “a clinically significant disturbance in an individual’s cognition, emotional regulation, or behaviour…[and]  is usually associated with distress or impairment in important areas of functioning.”[[User:Psg2022/sandbox# ftn5|[5]]]
'''[[Mental health]]''' as defined by the [[World Health Organization|World Health Organization (WHO)]] in 2022 is “a state of mental well-being that enables people to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community.<ref>{{Cite web |title=Mental health: strengthening our response |url=https://www.who.int/news-room/fact-sheets/detail/mental-health-strengthening-our-response |access-date=2022-11-01 |website=www.who.int |language=en}}</ref>The concept of mental health cannot be examined independent from the various individual and social determinants that influence it because exposure to different conditions and circumstances, along with genetic predispositions, affects one’s experiences with mental health, illnesses, and/or disorders. On the other hand, a '''[[mental disorder]]''' is defined as “a clinically significant disturbance in an individual’s cognition, emotional regulation, or behaviour…[and]  is usually associated with distress or impairment in important areas of functioning.<ref>{{Cite web |title=Mental disorders |url=https://www.who.int/news-room/fact-sheets/detail/mental-disorders |access-date=2022-11-01 |website=www.who.int |language=en}}</ref>


The concept of social determinants stems from the life course approach. It draws from theories that explain the social, economic, environmental, and physical patterns that result in health disparities and vary across different stages of life (e.g. prenatal, early years, working age, older ages).[[User:Psg2022/sandbox# ftn6|[6]]] The social determinants are more commonly examined in the context of healthcare access more broadly, however, recently the examination of social determinants of mental health has been gaining attention, as demonstrated by the increase of article publications studying this topic in the past decade (nearly 90% of articles in Google Scholar on “social determinants of mental” health issue have published since 2012).[[User:Psg2022/sandbox# ftn7|[7]]]
The concept of social determinants stems from the life course approach. It draws from theories that explain the social, economic, environmental, and physical patterns that result in health disparities and vary across different stages of life (e.g. prenatal, early years, working age, older ages).<ref>{{Cite journal |last=Jones |first=Nancy L. |last2=Gilman |first2=Stephen E. |last3=Cheng |first3=Tina L. |last4=Drury |first4=Stacy S. |last5=Hill |first5=Carl V. |last6=Geronimus |first6=Arline T. |date=2019-01 |title=Life Course Approaches to the Causes of Health Disparities |url=https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2018.304738 |journal=American Journal of Public Health |language=en |volume=109 |issue=S1 |pages=S48–S55 |doi=10.2105/AJPH.2018.304738 |issn=0090-0036}}</ref> The social determinants are more commonly examined in the context of healthcare access more broadly, however, recently the examination of social determinants of mental health has been gaining attention, as demonstrated by the increase of article publications studying this topic in the past decade (nearly 90% of articles in Google Scholar on “social determinants of mental” health issue have published since 2012).<ref>{{Cite book |last=World Health Organization |url=https://apps.who.int/iris/handle/10665/356119 |title=World mental health report: transforming mental health for all |date=2022 |publisher=World Health Organization |isbn=978-92-4-004933-8 |language=en}}</ref>


== Health Inequities ==
== Health Inequities ==
Globally, in 2019, 1 in every 8 individuals (12.5% of the population) lived with a mental disorder, however in 2020, due to the [[COVID-19|Coronavirus Disease 2019 (COVID-19)]] pandemic, that number grew dramatically by around 27%.
Globally, in 2019, 1 in every 8 individuals (12.5% of the population) lived with a mental disorder, however in 2020, due to the [[COVID-19|Coronavirus Disease 2019 (COVID-19)]] pandemic, that number grew dramatically by around 27%.


While mental illnesses and disorders have seen increased prevalence recently, studies have shown that mental health outcomes are worse for some populations and communities than others. One such inequity is that of gender: females are twice as likely to have a mental illness than males.[[User:Psg2022/sandbox# ftn8|[8]]][[User:Psg2022/sandbox# ftn9|[9]]][[User:Psg2022/sandbox# ftn10|[10]]]
While mental illnesses and disorders have seen increased prevalence recently, studies have shown that mental health outcomes are worse for some populations and communities than others. One such inequity is that of gender: females are twice as likely to have a mental illness than males.<ref>{{Cite journal |last=Weissman |first=Myrna M. |last2=Olfson |first2=Mark |date=1995-08-11 |title=Depression in Women: Implications for Health Care Research |url=https://www.science.org/doi/10.1126/science.7638596 |journal=Science |language=en |volume=269 |issue=5225 |pages=799–801 |doi=10.1126/science.7638596 |issn=0036-8075}}</ref><ref>{{Cite journal |last=Desai |first=Hirai D. |last2=Jann |first2=Michael W. |date=2000-07 |title=Women’s Health Series Major Depression in Women: A Review of the Literature |url=http://dx.doi.org/10.1016/s1086-5802(15)30400-9 |journal=Journal of the American Pharmaceutical Association (1996) |volume=40 |issue=4 |pages=525–537 |doi=10.1016/s1086-5802(15)30400-9 |issn=1086-5802}}</ref><ref>{{Cite book |last=World Health Organization |url=https://apps.who.int/iris/handle/10665/112828 |title=Social determinants of mental health |date=2014 |publisher=World Health Organization |isbn=978-92-4-150680-9 |language=en}}</ref>


== Fixed Characteristics ==
== Fixed Characteristics ==
Fixed characteristics refers to those that are genetic and biological and/or are not subjected to be influenced by the environment or social living conditions of an individual.[[User:Psg2022/sandbox# ftn11|[11]]]
Fixed characteristics refers to those that are genetic and biological and/or are not subjected to be influenced by the environment or social living conditions of an individual.<ref>{{Cite journal |last=Alegría |first=Margarita |last2=NeMoyer |first2=Amanda |last3=Falgàs Bagué |first3=Irene |last4=Wang |first4=Ye |last5=Alvarez |first5=Kiara |date=2018-11 |title=Social Determinants of Mental Health: Where We Are and Where We Need to Go |url=http://link.springer.com/10.1007/s11920-018-0969-9 |journal=Current Psychiatry Reports |language=en |volume=20 |issue=11 |pages=95 |doi=10.1007/s11920-018-0969-9 |issn=1523-3812}}</ref>


=== Gender ===
=== Gender ===
The second leading cause of global disability burden in 2020 was unipolar depression, and research showed that depression was twice as likely to be prevalent in women than in men. [[User:Psg2022/sandbox# ftn12|[12]]][[User:Psg2022/sandbox# ftn13|[13]]][[User:Psg2022/sandbox# ftn14|[14]]] Gender-based mental health disparities suggest that gender is a factor that could be leading to unequal health outcomes.
The second leading cause of global disability burden in 2020 was unipolar depression, and research showed that depression was twice as likely to be prevalent in women than in men. <ref>{{Cite journal |last=Weissman |first=Myrna M. |last2=Olfson |first2=Mark |date=1995-08-11 |title=Depression in Women: Implications for Health Care Research |url=https://www.science.org/doi/10.1126/science.7638596 |journal=Science |language=en |volume=269 |issue=5225 |pages=799–801 |doi=10.1126/science.7638596 |issn=0036-8075}}</ref><ref>{{Cite journal |last=Desai |first=Hirai D. |last2=Jann |first2=Michael W. |date=2000-07 |title=Women’s Health Series Major Depression in Women: A Review of the Literature |url=http://dx.doi.org/10.1016/s1086-5802(15)30400-9 |journal=Journal of the American Pharmaceutical Association (1996) |volume=40 |issue=4 |pages=525–537 |doi=10.1016/s1086-5802(15)30400-9 |issn=1086-5802}}</ref><ref>{{Cite book |last=World Health Organization |url=https://apps.who.int/iris/handle/10665/356119 |title=World mental health report: transforming mental health for all |date=2022 |publisher=World Health Organization |isbn=978-92-4-004933-8 |language=en}}</ref> Gender-based mental health disparities suggest that gender is a factor that could be leading to unequal health outcomes.


Research studies included in ''Lancet Psychiatry'' Women’s Mental Health Series focuses on understanding why some of these gendered disparities might exist.[[User:Psg2022/sandbox# ftn15|[15]]] Kuehner in her article ''Why is depression more common among women than among men?'' mentions several risk factors that contributes to these inequities, including the role of a women’s sex hormones and “blunted hypothalamic-pituitary-adrenal axis response to stress”.[[User:Psg2022/sandbox# ftn16|[16]]] Other factors include a woman’s increased likelihood to body shaming and rumination and stressors on an interpersonal level, as well as sexual abuse during childhood. Further, the prevalence of gender inequality and discrimination in society against women may also be a contributing factor. Li et al. finds that the monthly and lifespan fluctuations of sex hormones oestradiol and progesterone in women may also influence the gender gap, especially in the context of trauma-related, stress-related, and anxiety disorders, such as through increasing vulnerability to development of these disorders and permitting the continued persistence of symptoms for these disorders.[[User:Psg2022/sandbox# ftn17|[17]]]
Research studies included in ''Lancet Psychiatry'' Women’s Mental Health Series focuses on understanding why some of these gendered disparities might exist.<ref>{{Cite journal |last=Riecher-Rössler |first=Anita |date=2017-01 |title=Sex and gender differences in mental disorders |url=https://linkinghub.elsevier.com/retrieve/pii/S2215036616303480 |journal=The Lancet Psychiatry |language=en |volume=4 |issue=1 |pages=8–9 |doi=10.1016/S2215-0366(16)30348-0}}</ref>Kuehner in her article ''Why is depression more common among women than among men?'' mentions several risk factors that contributes to these inequities, including the role of a women’s sex hormones and “blunted hypothalamic-pituitary-adrenal axis response to stress”.<ref>{{Cite journal |last=Kuehner |first=Christine |date=2017-02 |title=Why is depression more common among women than among men? |url=https://linkinghub.elsevier.com/retrieve/pii/S2215036616302632 |journal=The Lancet Psychiatry |language=en |volume=4 |issue=2 |pages=146–158 |doi=10.1016/S2215-0366(16)30263-2}}</ref> Other factors include a woman’s increased likelihood to body shaming and rumination and stressors on an interpersonal level, as well as sexual abuse during childhood. Further, the prevalence of gender inequality and discrimination in society against women may also be a contributing factor. Li et al. finds that the monthly and lifespan fluctuations of sex hormones oestradiol and progesterone in women may also influence the gender gap, especially in the context of trauma-related, stress-related, and anxiety disorders, such as through increasing vulnerability to development of these disorders and permitting the continued persistence of symptoms for these disorders.<ref>{{Cite journal |last=Li |first=Sophie H |last2=Graham |first2=Bronwyn M |date=2017-01 |title=Why are women so vulnerable to anxiety, trauma-related and stress-related disorders? The potential role of sex hormones |url=https://linkinghub.elsevier.com/retrieve/pii/S2215036616303583 |journal=The Lancet Psychiatry |language=en |volume=4 |issue=1 |pages=73–82 |doi=10.1016/S2215-0366(16)30358-3}}</ref>


Increased likelihood of gender-based violence for women compared to men is also another risk factor that was studied by Oram et al. Researchers found that women have a higher risk of being subjected to domestic and sexual violence, thereby increasing their prevalence to post-traumatic stress, anxiety, and depression. Also notable to consider in the context of gender-based trauma are female genital mutilation, forced and early marriage, human trafficking, and honor crimes.  
Increased likelihood of gender-based violence for women compared to men is also another risk factor that was studied by Oram et al. Researchers found that women have a higher risk of being subjected to domestic and sexual violence, thereby increasing their prevalence to post-traumatic stress, anxiety, and depression. Also notable to consider in the context of gender-based trauma are female genital mutilation, forced and early marriage, human trafficking, and honor crimes.  


While women are reported to experience higher rates of depressive and anxiety related disorders, men are more likely to commit suicide than women: in the UK, suicide is the biggest cause of death for men 45 and younger, and in the likelihood of committing suicide, men are four times more likely in Russia and Argentina, three and a half times more likely in the United States, and three times more likely in Australia, than women, to name a few countries. [[User:Psg2022/sandbox# ftn18|[18]]] '''[[Gender differences in suicide]]''' are commonly explained by pressure for gender roles and higher risk-taking behavior among men. [[User:Psg2022/sandbox# ftn19|[19]]]
While women are reported to experience higher rates of depressive and anxiety related disorders, men are more likely to commit suicide than women: in the UK, suicide is the biggest cause of death for men 45 and younger, and in the likelihood of committing suicide, men are four times more likely in Russia and Argentina, three and a half times more likely in the United States, and three times more likely in Australia, than women, to name a few countries.<ref>{{Cite web |last=Schumacher |first=Helene |title=Why more men than women die by suicide |url=https://www.bbc.com/future/article/20190313-why-more-men-kill-themselves-than-women |access-date=2022-11-01 |website=www.bbc.com |language=en}}</ref> '''[[Gender differences in suicide]]''' are commonly explained by pressure for gender roles and higher risk-taking behavior among men. <ref>{{Cite journal |last=Murphy |first=George E |date=1998-07 |title=Why women are less likely than men to commit suicide |url=https://linkinghub.elsevier.com/retrieve/pii/S0010440X98900578 |journal=Comprehensive Psychiatry |language=en |volume=39 |issue=4 |pages=165–175 |doi=10.1016/S0010-440X(98)90057-8}}</ref>


=== Sexual orientation ===
=== Sexual orientation ===
In studies comparing mental health outcomes between members of the lesbian, gay, bisexual, transgender, queer (questioning), intersex, asexual and agender (LGBTQIA+) community with heterosexuals, the former showed increased risks of poor mental health.[[User:Psg2022/sandbox# ftn20|[20]]][[User:Psg2022/sandbox# ftn21|[21]]] In fact, LGBTQIA+ individuals are twice as likely to have a mental disorder compared to their heterosexual counterparts, and two and a half times more likely to experience anxiety, depression, and substance misuse. [[User:Psg2022/sandbox# ftn22|[22]]][[User:Psg2022/sandbox# ftn23|[23]]]
In studies comparing mental health outcomes between members of the lesbian, gay, bisexual, transgender, queer (questioning), intersex, asexual and agender (LGBTQIA+) community with heterosexuals, the former showed increased risks of poor mental health.<ref>{{Cite journal |last=Bränström |first=Richard |date=2017-05 |title=Minority stress factors as mediators of sexual orientation disparities in mental health treatment: a longitudinal population-based study |url=https://jech.bmj.com/lookup/doi/10.1136/jech-2016-207943 |journal=Journal of Epidemiology and Community Health |language=en |volume=71 |issue=5 |pages=446–452 |doi=10.1136/jech-2016-207943 |issn=0143-005X}}</ref><ref>{{Cite journal |last=Robertson |first=Lee |last2=Akré |first2=Ellesse-Roselee |last3=Gonzales |first3=Gilbert |date=2021-11-01 |title=Mental Health Disparities at the Intersections of Gender Identity, Race, and Ethnicity |url=https://www.liebertpub.com/doi/10.1089/lgbt.2020.0429 |journal=LGBT Health |language=en |volume=8 |issue=8 |pages=526–535 |doi=10.1089/lgbt.2020.0429 |issn=2325-8292}}</ref> In fact, LGBTQIA+ individuals are twice as likely to have a mental disorder compared to their heterosexual counterparts, and two and a half times more likely to experience anxiety, depression, and substance misuse. <ref>{{Cite journal |last=Semlyen |first=Joanna |last2=King |first2=Michael |last3=Varney |first3=Justin |last4=Hagger-Johnson |first4=Gareth |date=2016-12 |title=Sexual orientation and symptoms of common mental disorder or low wellbeing: combined meta-analysis of 12 UK population health surveys |url=http://www.biomedcentral.com/1471-244X/16/67 |journal=BMC Psychiatry |language=en |volume=16 |issue=1 |pages=67 |doi=10.1186/s12888-016-0767-z |issn=1471-244X}}</ref><ref>{{Citation |title=Current Issues in Lesbian, Gay, Bisexual, and Transgender (LGBT) Health: Introduction |date=2013-04-11 |url=http://dx.doi.org/10.4324/9780203057582-5 |work=Current Issues in Lesbian, Gay, Bisexual, and Transgender Health |pages=17–28 |publisher=Routledge |isbn=978-0-203-05758-2 |access-date=2022-11-01}}</ref>


Based on the '''[[minority stress]] model''', these mental health disparities among LGBTQIA+ people are due to discrimination and stigma. In fact, LGBTQIA+ individuals have expressed difficulty in accessing healthcare due to experienced discrimination and stigma, which as a result, causes them to not seek healthcare at all or rather delay it.[[User:Psg2022/sandbox# ftn24|[24]]]Further societal isolation and feelings of rejection may also contribute to the prevalence of mental disorders among this community.[[User:Psg2022/sandbox# ftn25|[25]]] In addition to the perceived and experienced stigma, LGBTQIA+ have an increased likelihood of being victims of violence. [[User:Psg2022/sandbox# ftn26|[26]]]These factors, alongside others, contribute significantly to differences in mental health experiences for members of the LGBTQIA+ community in comparison to their heterosexual counterparts, thereby result in mental health inequities by sexual orientation.
Based on the '''[[minority stress]] model''', these mental health disparities among LGBTQIA+ people are due to discrimination and stigma. In fact, LGBTQIA+ individuals have expressed difficulty in accessing healthcare due to experienced discrimination and stigma, which as a result, causes them to not seek healthcare at all or rather delay it.<ref>{{Cite journal |last=Safer |first=Joshua D. |last2=Coleman |first2=Eli |last3=Feldman |first3=Jamie |last4=Garofalo |first4=Robert |last5=Hembree |first5=Wylie |last6=Radix |first6=Asa |last7=Sevelius |first7=Jae |date=2016-04 |title=Barriers to healthcare for transgender individuals |url=https://journals.lww.com/01266029-201604000-00014 |journal=Current Opinion in Endocrinology, Diabetes & Obesity |language=en |volume=23 |issue=2 |pages=168–171 |doi=10.1097/MED.0000000000000227 |issn=1752-296X}}</ref>Further societal isolation and feelings of rejection may also contribute to the prevalence of mental disorders among this community.<ref>{{Cite journal |last=Hsieh |first=Ning |date=2014-07 |title=Explaining the Mental Health Disparity by Sexual Orientation: The Importance of Social Resources |url=http://journals.sagepub.com/doi/10.1177/2156869314524959 |journal=Society and Mental Health |language=en |volume=4 |issue=2 |pages=129–146 |doi=10.1177/2156869314524959 |issn=2156-8693}}</ref> In addition to the perceived and experienced stigma, LGBTQIA+ have an increased likelihood of being victims of violence.<ref>{{Cite web |title=hate-crimes-and-violence-against-lesbian-gay-bisexual-and-transgender-people-may-2009-19pp |url=http://dx.doi.org/10.1163/2210-7975_hrd-9800-0005 |access-date=2022-11-01 |website=Human Rights Documents online}}</ref>These factors, alongside others, contribute significantly to differences in mental health experiences for members of the LGBTQIA+ community in comparison to their heterosexual counterparts, thereby result in mental health inequities by sexual orientation.


=== Race/ethnicity ===
=== Race/ethnicity ===
Studies in the conducted in the United States have indicated that minorities have similar or smaller rates of prevalence for mental health disorders as their majority counterparts.[[User:Psg2022/sandbox# ftn27|[27]]] Blacks (24.6%) and Hispanics (19.6%) have lower depression rates than their White counterparts (34.7%) in the United States.[[User:Psg2022/sandbox# ftn28|[28]]] While racial/ethnic minority groups may have similar prevalence rates, the consequences because of mental illness are more prolonged – which may be partly explained due to the smaller access rates for mental health treatments.  In 2018, while 56.7% of the general US population who had a mental illness didn’t seek treatment, 69.4% and 67.1% Black and Hispanics didn’t access care. [[User:Psg2022/sandbox# ftn29|[29]]] Further, in the instances of some mental illnesses, such as schizophrenia, Blacks in the United States have been reported to have higher rates compared to their White counterparts, however, research suggests that this could be due to an overdiagnosis among clinicians and underdiagnosis for other illnesses, such as mood disorders, for which Blacks had lower reported prevalence rates for major depression. [[User:Psg2022/sandbox# ftn30|[30]]][[User:Psg2022/sandbox# ftn31|[31]]][[User:Psg2022/sandbox# ftn32|[32]]] These instances of misdiagnosis may be due to “lac of cultural understanding by health care providers,…language differences between patient and provider, stigma of mental illness among minority groups, and cultural presentation of symptoms.”[[User:Psg2022/sandbox# ftn33|[33]]]
Studies in the conducted in the United States have indicated that minorities have similar or smaller rates of prevalence for mental health disorders as their majority counterparts.<ref>{{Cite journal |last=Williams |first=David R. |date=2005-10-01 |title=The Health of U.S. Racial and Ethnic Populations |url=https://academic.oup.com/psychsocgerontology/psychsocgerontology/article/2965174/The |journal=The Journals of Gerontology: Series B |language=en |volume=60 |issue=Special_Issue_2 |pages=S53–S62 |doi=10.1093/geronb/60.Special_Issue_2.S53 |issn=1079-5014}}</ref>Blacks (24.6%) and Hispanics (19.6%) have lower depression rates than their White counterparts (34.7%) in the United States.<ref>{{Cite journal |last=Budhwani |first=Henna |last2=Hearld |first2=Kristine Ria |last3=Chavez-Yenter |first3=Daniel |date=2014-09-11 |title=Depression in Racial and Ethnic Minorities: the Impact of Nativity and Discrimination |url=http://dx.doi.org/10.1007/s40615-014-0045-z |journal=Journal of Racial and Ethnic Health Disparities |volume=2 |issue=1 |pages=34–42 |doi=10.1007/s40615-014-0045-z |issn=2197-3792}}</ref>While racial/ethnic minority groups may have similar prevalence rates, the consequences because of mental illness are more prolonged – which may be partly explained due to the smaller access rates for mental health treatments.  In 2018, while 56.7% of the general US population who had a mental illness didn’t seek treatment, 69.4% and 67.1% Black and Hispanics didn’t access care.<ref>{{Cite journal |last=Rubin |first=Rita |date=2020-06-23 |title=Pandemic Highlights Behavioral Health Disparities |url=https://jamanetwork.com/journals/jama/fullarticle/2767308 |journal=JAMA |language=en |volume=323 |issue=24 |pages=2452 |doi=10.1001/jama.2020.10318 |issn=0098-7484}}</ref> Further, in the instances of some mental illnesses, such as schizophrenia, Blacks in the United States have been reported to have higher rates compared to their White counterparts, however, research suggests that this could be due to an overdiagnosis among clinicians and underdiagnosis for other illnesses, such as mood disorders, for which Blacks had lower reported prevalence rates for major depression.<ref>{{Cite journal |last=Neighbors |first=Harold W. |last2=Trierweiler |first2=Steven J. |last3=Ford |first3=Briggett C. |last4=Muroff |first4=Jordana R. |date=2003-09 |title=Racial Differences in DSM Diagnosis Using a Semi-Structured Instrument: The Importance of Clinical Judgment in the Diagnosis of African Americans |url=http://dx.doi.org/10.2307/1519777 |journal=Journal of Health and Social Behavior |volume=44 |issue=3 |pages=237 |doi=10.2307/1519777 |issn=0022-1465}}</ref><ref>{{Cite journal |last=Strakowski |first=S |date=1996-07-08 |title=Racial influence on diagnosis in psychotic mania |url=https://linkinghub.elsevier.com/retrieve/pii/0165032796000286 |journal=Journal of Affective Disorders |language=en |volume=39 |issue=2 |pages=157–162 |doi=10.1016/0165-0327(96)00028-6}}</ref><ref>{{Cite journal |last=McGuire |first=Thomas G. |last2=Miranda |first2=Jeanne |date=2008-03 |title=New Evidence Regarding Racial And Ethnic Disparities In Mental Health: Policy Implications |url=http://www.healthaffairs.org/doi/10.1377/hlthaff.27.2.393 |journal=Health Affairs |language=en |volume=27 |issue=2 |pages=393–403 |doi=10.1377/hlthaff.27.2.393 |issn=0278-2715}}</ref>These instances of misdiagnosis may be due to “lack of cultural understanding by health care providers,…language differences between patient and provider, stigma of mental illness among minority groups, and cultural presentation of symptoms.


== Environmental factors ==
== Environmental factors ==

Revision as of 20:15, 1 November 2022

The social determinants of mental health (SDOMH) are “societal problems that disrupt optimal mental health, increase risk for and prevalence of mental illnesses, and worsen outcomes among individuals with mental illnesses.[1] Much like the social determinants of health (SDOH), SDOMH include the non-medical factors that play a role in the likelihood and severity of health outcomes, such as income levels, education attainment, access to housing, social inclusion, etc.[2] However, specifically when examining the topic of mental health, disparities in health outcomes are a result of a multitude of factors and social determinants, including fixed characteristics on an individual level – such as age, gender, race/ethnicity, and sexual orientation – and environmental factors that stem from social and economic inequalities – such as inadequate access to proper food, housing and transportation and exposure to pollution.[3]

Definitions and measurements

Mental health as defined by the World Health Organization (WHO) in 2022 is “a state of mental well-being that enables people to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community.[4]The concept of mental health cannot be examined independent from the various individual and social determinants that influence it because exposure to different conditions and circumstances, along with genetic predispositions, affects one’s experiences with mental health, illnesses, and/or disorders. On the other hand, a mental disorder is defined as “a clinically significant disturbance in an individual’s cognition, emotional regulation, or behaviour…[and]  is usually associated with distress or impairment in important areas of functioning.[5]

The concept of social determinants stems from the life course approach. It draws from theories that explain the social, economic, environmental, and physical patterns that result in health disparities and vary across different stages of life (e.g. prenatal, early years, working age, older ages).[6] The social determinants are more commonly examined in the context of healthcare access more broadly, however, recently the examination of social determinants of mental health has been gaining attention, as demonstrated by the increase of article publications studying this topic in the past decade (nearly 90% of articles in Google Scholar on “social determinants of mental” health issue have published since 2012).[7]

Health Inequities

Globally, in 2019, 1 in every 8 individuals (12.5% of the population) lived with a mental disorder, however in 2020, due to the Coronavirus Disease 2019 (COVID-19) pandemic, that number grew dramatically by around 27%.

While mental illnesses and disorders have seen increased prevalence recently, studies have shown that mental health outcomes are worse for some populations and communities than others. One such inequity is that of gender: females are twice as likely to have a mental illness than males.[8][9][10]

Fixed Characteristics

Fixed characteristics refers to those that are genetic and biological and/or are not subjected to be influenced by the environment or social living conditions of an individual.[11]

Gender

The second leading cause of global disability burden in 2020 was unipolar depression, and research showed that depression was twice as likely to be prevalent in women than in men. [12][13][14] Gender-based mental health disparities suggest that gender is a factor that could be leading to unequal health outcomes.

Research studies included in Lancet Psychiatry Women’s Mental Health Series focuses on understanding why some of these gendered disparities might exist.[15]Kuehner in her article Why is depression more common among women than among men? mentions several risk factors that contributes to these inequities, including the role of a women’s sex hormones and “blunted hypothalamic-pituitary-adrenal axis response to stress”.[16] Other factors include a woman’s increased likelihood to body shaming and rumination and stressors on an interpersonal level, as well as sexual abuse during childhood. Further, the prevalence of gender inequality and discrimination in society against women may also be a contributing factor. Li et al. finds that the monthly and lifespan fluctuations of sex hormones oestradiol and progesterone in women may also influence the gender gap, especially in the context of trauma-related, stress-related, and anxiety disorders, such as through increasing vulnerability to development of these disorders and permitting the continued persistence of symptoms for these disorders.[17]

Increased likelihood of gender-based violence for women compared to men is also another risk factor that was studied by Oram et al. Researchers found that women have a higher risk of being subjected to domestic and sexual violence, thereby increasing their prevalence to post-traumatic stress, anxiety, and depression. Also notable to consider in the context of gender-based trauma are female genital mutilation, forced and early marriage, human trafficking, and honor crimes.  

While women are reported to experience higher rates of depressive and anxiety related disorders, men are more likely to commit suicide than women: in the UK, suicide is the biggest cause of death for men 45 and younger, and in the likelihood of committing suicide, men are four times more likely in Russia and Argentina, three and a half times more likely in the United States, and three times more likely in Australia, than women, to name a few countries.[18] Gender differences in suicide are commonly explained by pressure for gender roles and higher risk-taking behavior among men. [19]

Sexual orientation

In studies comparing mental health outcomes between members of the lesbian, gay, bisexual, transgender, queer (questioning), intersex, asexual and agender (LGBTQIA+) community with heterosexuals, the former showed increased risks of poor mental health.[20][21] In fact, LGBTQIA+ individuals are twice as likely to have a mental disorder compared to their heterosexual counterparts, and two and a half times more likely to experience anxiety, depression, and substance misuse. [22][23]

Based on the minority stress model, these mental health disparities among LGBTQIA+ people are due to discrimination and stigma. In fact, LGBTQIA+ individuals have expressed difficulty in accessing healthcare due to experienced discrimination and stigma, which as a result, causes them to not seek healthcare at all or rather delay it.[24]Further societal isolation and feelings of rejection may also contribute to the prevalence of mental disorders among this community.[25] In addition to the perceived and experienced stigma, LGBTQIA+ have an increased likelihood of being victims of violence.[26]These factors, alongside others, contribute significantly to differences in mental health experiences for members of the LGBTQIA+ community in comparison to their heterosexual counterparts, thereby result in mental health inequities by sexual orientation.

Race/ethnicity

Studies in the conducted in the United States have indicated that minorities have similar or smaller rates of prevalence for mental health disorders as their majority counterparts.[27]Blacks (24.6%) and Hispanics (19.6%) have lower depression rates than their White counterparts (34.7%) in the United States.[28]While racial/ethnic minority groups may have similar prevalence rates, the consequences because of mental illness are more prolonged – which may be partly explained due to the smaller access rates for mental health treatments.  In 2018, while 56.7% of the general US population who had a mental illness didn’t seek treatment, 69.4% and 67.1% Black and Hispanics didn’t access care.[29] Further, in the instances of some mental illnesses, such as schizophrenia, Blacks in the United States have been reported to have higher rates compared to their White counterparts, however, research suggests that this could be due to an overdiagnosis among clinicians and underdiagnosis for other illnesses, such as mood disorders, for which Blacks had lower reported prevalence rates for major depression.[30][31][32]These instances of misdiagnosis may be due to “lack of cultural understanding by health care providers,…language differences between patient and provider, stigma of mental illness among minority groups, and cultural presentation of symptoms.

Environmental factors

Inadequate access to proper food

Housing

Transportation

Pollution

Lack of health insurance

Social factors

Discrimination

Stigma

Other Factors

Biological Factors

Interventions

References

[1]Shim, Ruth S., and Michael T. Compton. 2020. “The Social Determinants of Mental Health: Psychiatrists’ Roles in Addressing Discrimination and Food Insecurity.” FOCUS 18 (1): 25–30. https://doi.org/10.1176/appi.focus.20190035.

[2] https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1

[3] https://www.hhs.gov/sites/default/files/surgeon-general-youth-mental-health-advisory.pdf

[4] https://www.who.int/news-room/fact-sheets/detail/mental-health-strengthening-our-response

[5] https://www.who.int/news-room/fact-sheets/detail/mental-disorders

[6] Jones, Nancy L., Stephen E. Gilman, Tina L. Cheng, Stacy S. Drury, Carl V. Hill, and Arline T. Geronimus. 2019. “Life Course Approaches to the Causes of Health Disparities.” American Journal of Public Health 109 (S1): S48–55. https://doi.org/10.2105/AJPH.2018.304738.

[7] World Health Organization. 2022. World Mental Health Report: Transforming Mental Health for All. Geneva: World Health Organization. https://apps.who.int/iris/handle/10665/356119.

[8] Weissman, Myrna M., and Mark Olfson. 1995. “Depression in Women: Implications for Health Care Research.” Science 269 (5225): 799–801. https://doi.org/10.1126/science.7638596.

[9] Desai, H. D., and M. W. Jann. 2000. “Major Depression in Women: A Review of the Literature.” Journal of the American Pharmaceutical Association (Washington, D.C.: 1996) 40 (4): 525–37.

[10] World Health Organization. 2014. Social Determinants of Mental Health. Geneva: World Health Organization. https://apps.who.int/iris/handle/10665/112828.

[11] Alegría, Margarita, Amanda NeMoyer, Irene Falgàs Bagué, Ye Wang, and Kiara Alvarez. 2018. “Social Determinants of Mental Health: Where We Are and Where We Need to Go.” Current Psychiatry Reports 20 (11): 95. https://doi.org/10.1007/s11920-018-0969-9.

[12] Weissman, Myrna M., and Mark Olfson. 1995. “Depression in Women: Implications for Health Care Research.” Science 269 (5225): 799–801. https://doi.org/10.1126/science.7638596.

[13] Desai, H. D., and M. W. Jann. 2000. “Major Depression in Women: A Review of the Literature.” Journal of the American Pharmaceutical Association (Washington, D.C.: 1996) 40 (4): 525–37.

[14] World Health Organization. 2022. World Mental Health Report: Transforming Mental Health for All. Geneva: World Health Organization. https://apps.who.int/iris/handle/10665/356119.

[15] Riecher-Rössler, Anita. 2017. “Sex and Gender Differences in Mental Disorders.” The Lancet Psychiatry 4 (1): 8–9. https://doi.org/10.1016/S2215-0366(16)30348-0.

[16] Kuehner, Christine. 2017. “Why Is Depression More Common among Women than among Men?” The Lancet Psychiatry 4 (2): 146–58. https://doi.org/10.1016/S2215-0366(16)30263-2.

[17] Li, Sophie H, and Bronwyn M Graham. 2017. “Why Are Women so Vulnerable to Anxiety, Trauma-Related and Stress-Related Disorders? The Potential Role of Sex Hormones.” The Lancet Psychiatry 4 (1): 73–82. https://doi.org/10.1016/S2215-0366(16)30358-3.

[18] https://www.bbc.com/future/article/20190313-why-more-men-kill-themselves-than-women

[19] Murphy, G. E. 1998. “Why Women Are Less Likely than Men to Commit Suicide.” Comprehensive Psychiatry 39 (4): 165–75. https://doi.org/10.1016/s0010-440x(98)90057-8.

[20] Bränström, Richard. 2017. “Minority Stress Factors as Mediators of Sexual Orientation Disparities in Mental Health Treatment: A Longitudinal Population-Based Study.” Journal of Epidemiology and Community Health 71 (5): 446–52. https://doi.org/10.1136/jech-2016-207943.

[21] Robertson, Lee, Ellesse-Roselee Akré, and Gilbert Gonzales. 2021. “Mental Health Disparities at the Intersections of Gender Identity, Race, and Ethnicity.” LGBT Health 8 (8): 526–35. https://doi.org/10.1089/lgbt.2020.0429.

[22] Semlyen, Joanna, Michael King, Justin Varney, and Gareth Hagger-Johnson. 2016. “Sexual Orientation and Symptoms of Common Mental Disorder or Low Wellbeing: Combined Meta-Analysis of 12 UK Population Health Surveys.” BMC Psychiatry 16 (1): 67. https://doi.org/10.1186/s12888-016-0767-z.

[23] Kates, J, et al. “Health and Access To Care And Coverage For Lesbian, Gay, Bisexual, and Transgender Individuals in the U.S. Retrieved.” Kaiser Family Foundation. 2016. http://kff.org/report-section/health-and-access-to-care-and-coverage-for-lesbian-gay-bisexual-and-transgender-healthchallenges/

[24] Safer, Joshua D., Eli Coleman, Jamie Feldman, Robert Garofalo, Wylie Hembree, Asa Radix, and Jae Sevelius. 2016. “Barriers to Healthcare for Transgender Individuals.” Current Opinion in Endocrinology, Diabetes, and Obesity 23 (2): 168–71. https://doi.org/10.1097/MED.0000000000000227.

[25] Hsieh, Ning. 2014. “Explaining the Mental Health Disparity by Sexual Orientation: The Importance of Social Resources.” Society and Mental Health 4 (2): 129–46. https://doi.org/10.1177/2156869314524959.

[26] 15National Coalition of Anti Violence Programs. “National Report on Hate Violence against Lesbian, Gay, Bisexual, Transgender, Queer and HIVAffected Communities.” 2014. www.avp.org/storage/documents/2013_mr_ncavp_hvreport.pdf

[27] Williams, David R. 2005. “The Health of U.S. Racial and Ethnic Populations.” The Journals of Gerontology: Series B 60 (Special_Issue_2): S53–62. https://doi.org/10.1093/geronb/60.Special_Issue_2.S53.

[28] Budhwani H, Hearld K, and Chavez-Yenter D.Depression in Racial and Ethnic Minorities: the Impact of Nativity and Discrimination. Racial Ethn Health Disparities. 2015. 2(1):34-42

[29] Rubin, Rita. 2020. “Pandemic Highlights Behavioral Health Disparities.” JAMA 323 (24): 2452. https://doi.org/10.1001/jama.2020.10318.

Budhwani, Henna, Kristine Ria Hearld, and Daniel Chavez-Yenter. 2015. “Depression in Racial and Ethnic Minorities: The Impact of Nativity and Discrimination.” Journal of Racial and Ethnic Health Disparities 2 (1): 34–42. https://doi.org/10.1007/s40615-014-0045-z.

[30]  Neighbors, Harold W., Steven J. Trierweiler, Briggett C. Ford, and Jordana R. Muroff. 2003. “Racial Differences in DSM Diagnosis Using a Semi-Structured Instrument: The Importance of Clinical Judgment in the Diagnosis of African Americans.” Journal of Health and Social Behavior 44 (3): 237–56.

[31] Strakowski, S. 1996. “Racial Influence on Diagnosis in Psychotic Mania.” Journal of Affective Disorders 39 (2): 157–62. https://doi.org/10.1016/0165-0327(96)00028-6.

[32] McGuire, Thomas G., and Jeanne Miranda. 2008. “New Evidence Regarding Racial And Ethnic Disparities In Mental Health: Policy Implications.” Health Affairs 27 (2): 393–403. https://doi.org/10.1377/hlthaff.27.2.393.

[33] https://www.psychiatry.org/File%20Library/Psychiatrists/Cultural-Competency/Mental-Health-Disparities/Mental-Health-Facts-for-Diverse-Populations.pdf

  1. ^ Shim, Ruth S.; Compton, Michael T. (2020-01). "The Social Determinants of Mental Health: Psychiatrists' Roles in Addressing Discrimination and Food Insecurity". FOCUS. 18 (1): 25–30. doi:10.1176/appi.focus.20190035. ISSN 1541-4094. {{cite journal}}: Check date values in: |date= (help)
  2. ^ "Social determinants of health". www.who.int. Retrieved 2022-11-01.
  3. ^ General, Office of the Surgeon (2021-12-07). "U.S. Surgeon General Issues Advisory on Youth Mental Health Crisis Further Exposed by COVID-19 Pandemic". HHS.gov. Retrieved 2022-11-01.
  4. ^ "Mental health: strengthening our response". www.who.int. Retrieved 2022-11-01.
  5. ^ "Mental disorders". www.who.int. Retrieved 2022-11-01.
  6. ^ Jones, Nancy L.; Gilman, Stephen E.; Cheng, Tina L.; Drury, Stacy S.; Hill, Carl V.; Geronimus, Arline T. (2019-01). "Life Course Approaches to the Causes of Health Disparities". American Journal of Public Health. 109 (S1): S48–S55. doi:10.2105/AJPH.2018.304738. ISSN 0090-0036. {{cite journal}}: Check date values in: |date= (help)
  7. ^ World Health Organization (2022). World mental health report: transforming mental health for all. World Health Organization. ISBN 978-92-4-004933-8.
  8. ^ Weissman, Myrna M.; Olfson, Mark (1995-08-11). "Depression in Women: Implications for Health Care Research". Science. 269 (5225): 799–801. doi:10.1126/science.7638596. ISSN 0036-8075.
  9. ^ Desai, Hirai D.; Jann, Michael W. (2000-07). "Women's Health Series Major Depression in Women: A Review of the Literature". Journal of the American Pharmaceutical Association (1996). 40 (4): 525–537. doi:10.1016/s1086-5802(15)30400-9. ISSN 1086-5802. {{cite journal}}: Check date values in: |date= (help)
  10. ^ World Health Organization (2014). Social determinants of mental health. World Health Organization. ISBN 978-92-4-150680-9.
  11. ^ Alegría, Margarita; NeMoyer, Amanda; Falgàs Bagué, Irene; Wang, Ye; Alvarez, Kiara (2018-11). "Social Determinants of Mental Health: Where We Are and Where We Need to Go". Current Psychiatry Reports. 20 (11): 95. doi:10.1007/s11920-018-0969-9. ISSN 1523-3812. {{cite journal}}: Check date values in: |date= (help)
  12. ^ Weissman, Myrna M.; Olfson, Mark (1995-08-11). "Depression in Women: Implications for Health Care Research". Science. 269 (5225): 799–801. doi:10.1126/science.7638596. ISSN 0036-8075.
  13. ^ Desai, Hirai D.; Jann, Michael W. (2000-07). "Women's Health Series Major Depression in Women: A Review of the Literature". Journal of the American Pharmaceutical Association (1996). 40 (4): 525–537. doi:10.1016/s1086-5802(15)30400-9. ISSN 1086-5802. {{cite journal}}: Check date values in: |date= (help)
  14. ^ World Health Organization (2022). World mental health report: transforming mental health for all. World Health Organization. ISBN 978-92-4-004933-8.
  15. ^ Riecher-Rössler, Anita (2017-01). "Sex and gender differences in mental disorders". The Lancet Psychiatry. 4 (1): 8–9. doi:10.1016/S2215-0366(16)30348-0. {{cite journal}}: Check date values in: |date= (help)
  16. ^ Kuehner, Christine (2017-02). "Why is depression more common among women than among men?". The Lancet Psychiatry. 4 (2): 146–158. doi:10.1016/S2215-0366(16)30263-2. {{cite journal}}: Check date values in: |date= (help)
  17. ^ Li, Sophie H; Graham, Bronwyn M (2017-01). "Why are women so vulnerable to anxiety, trauma-related and stress-related disorders? The potential role of sex hormones". The Lancet Psychiatry. 4 (1): 73–82. doi:10.1016/S2215-0366(16)30358-3. {{cite journal}}: Check date values in: |date= (help)
  18. ^ Schumacher, Helene. "Why more men than women die by suicide". www.bbc.com. Retrieved 2022-11-01.
  19. ^ Murphy, George E (1998-07). "Why women are less likely than men to commit suicide". Comprehensive Psychiatry. 39 (4): 165–175. doi:10.1016/S0010-440X(98)90057-8. {{cite journal}}: Check date values in: |date= (help)
  20. ^ Bränström, Richard (2017-05). "Minority stress factors as mediators of sexual orientation disparities in mental health treatment: a longitudinal population-based study". Journal of Epidemiology and Community Health. 71 (5): 446–452. doi:10.1136/jech-2016-207943. ISSN 0143-005X. {{cite journal}}: Check date values in: |date= (help)
  21. ^ Robertson, Lee; Akré, Ellesse-Roselee; Gonzales, Gilbert (2021-11-01). "Mental Health Disparities at the Intersections of Gender Identity, Race, and Ethnicity". LGBT Health. 8 (8): 526–535. doi:10.1089/lgbt.2020.0429. ISSN 2325-8292.
  22. ^ Semlyen, Joanna; King, Michael; Varney, Justin; Hagger-Johnson, Gareth (2016-12). "Sexual orientation and symptoms of common mental disorder or low wellbeing: combined meta-analysis of 12 UK population health surveys". BMC Psychiatry. 16 (1): 67. doi:10.1186/s12888-016-0767-z. ISSN 1471-244X. {{cite journal}}: Check date values in: |date= (help)CS1 maint: unflagged free DOI (link)
  23. ^ "Current Issues in Lesbian, Gay, Bisexual, and Transgender (LGBT) Health: Introduction", Current Issues in Lesbian, Gay, Bisexual, and Transgender Health, Routledge, pp. 17–28, 2013-04-11, ISBN 978-0-203-05758-2, retrieved 2022-11-01
  24. ^ Safer, Joshua D.; Coleman, Eli; Feldman, Jamie; Garofalo, Robert; Hembree, Wylie; Radix, Asa; Sevelius, Jae (2016-04). "Barriers to healthcare for transgender individuals". Current Opinion in Endocrinology, Diabetes & Obesity. 23 (2): 168–171. doi:10.1097/MED.0000000000000227. ISSN 1752-296X. {{cite journal}}: Check date values in: |date= (help)
  25. ^ Hsieh, Ning (2014-07). "Explaining the Mental Health Disparity by Sexual Orientation: The Importance of Social Resources". Society and Mental Health. 4 (2): 129–146. doi:10.1177/2156869314524959. ISSN 2156-8693. {{cite journal}}: Check date values in: |date= (help)
  26. ^ "hate-crimes-and-violence-against-lesbian-gay-bisexual-and-transgender-people-may-2009-19pp". Human Rights Documents online. Retrieved 2022-11-01.
  27. ^ Williams, David R. (2005-10-01). "The Health of U.S. Racial and Ethnic Populations". The Journals of Gerontology: Series B. 60 (Special_Issue_2): S53–S62. doi:10.1093/geronb/60.Special_Issue_2.S53. ISSN 1079-5014.
  28. ^ Budhwani, Henna; Hearld, Kristine Ria; Chavez-Yenter, Daniel (2014-09-11). "Depression in Racial and Ethnic Minorities: the Impact of Nativity and Discrimination". Journal of Racial and Ethnic Health Disparities. 2 (1): 34–42. doi:10.1007/s40615-014-0045-z. ISSN 2197-3792.
  29. ^ Rubin, Rita (2020-06-23). "Pandemic Highlights Behavioral Health Disparities". JAMA. 323 (24): 2452. doi:10.1001/jama.2020.10318. ISSN 0098-7484.
  30. ^ Neighbors, Harold W.; Trierweiler, Steven J.; Ford, Briggett C.; Muroff, Jordana R. (2003-09). "Racial Differences in DSM Diagnosis Using a Semi-Structured Instrument: The Importance of Clinical Judgment in the Diagnosis of African Americans". Journal of Health and Social Behavior. 44 (3): 237. doi:10.2307/1519777. ISSN 0022-1465. {{cite journal}}: Check date values in: |date= (help)
  31. ^ Strakowski, S (1996-07-08). "Racial influence on diagnosis in psychotic mania". Journal of Affective Disorders. 39 (2): 157–162. doi:10.1016/0165-0327(96)00028-6.
  32. ^ McGuire, Thomas G.; Miranda, Jeanne (2008-03). "New Evidence Regarding Racial And Ethnic Disparities In Mental Health: Policy Implications". Health Affairs. 27 (2): 393–403. doi:10.1377/hlthaff.27.2.393. ISSN 0278-2715. {{cite journal}}: Check date values in: |date= (help)
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