Socioenvironmental Factors Underlying Racial/Ethnic Inequities in Psychosis Risk

Background and Purpose: Psychotic disorders are inequitably distributed by race in the United States, although it is not known whether this is due to assessment biases or inequitable distributions of socioenvironmental risk factors. Psychotic experiences are sub-clinical hallucinations and delusions used to study the etiology of psychosis, which are based on self-report and therefore not subject to potential clinician biases. In this study, we tested whether the prevalence of psychotic experiences varied by race and if this variance was explained by socioenvironmental risk factors.

Methods: Data on demographics, psychotic experiences, and socioenvironmental risk factors were collected through the National Survey of Poly-victimization and Mental Health, a national probability sample of U.S. young adults aged 18-29 years (N = 1019), collected in 2021. Psychotic experiences included delusional mood, paranoia/persecution, thought control, and auditory hallucinations, as well as a composite measure indicating a positive response to any psychotic experiences item. Logistic regression analyses were used to determine whether psychotic experiences prevalence varied by race/ethnicity and, if so, whether this was statistically explained by measures of income, education, urban/rural living, and trauma exposure.

Results: Psychotic experiences were significantly more likely to be reported by Black/African American respondents, odds ratio (95% confidence interval) = 2.42 (1.66 - 3.51), and Latin American respondents, OR (95% CI) = 1.95 (1.43 - 2.65), compared to White respondents, X²(df=3) = 34.99, p<0.001. Hallucinations were more commonly reported by Latin American respondents, while all other psychotic experience sub-types were most frequently reported by Black respondents. Psychotic experiences were significantly associated with police violence exposure, discrimination, adverse childhood experiences, and educational attainment. These factors statistically explained racial differences in likelihood of any psychotic experiences and all individual psychotic experience sub-types except for delusions of thought control. Specifically, racial/ethnic differences in prevalence of psychotic experiences were reduced to small and statistically insignificant effects for both Black, OR (95% CI) = 1.23 (0.78 - 1.97), and Latin American, OR (95% CI) = 1.30 (0.90 - 1.86) respondents when taking into account sociodemographic risk factors.

Conclusion and Implications: Previously observed racial differences in the psychosis literature extend beyond clinical schizophrenia to the sub-clinical range of the psychosis continuum, and therefore, are unlikely to be explained entirely by clinician biases, although cross-cultural measurement equivalence may still be a concern. However, racial disparities in psychosis appear to be driven by features of structural racism and discrimination, including police violence exposure and disparities in educational attainment and trauma exposure. These factors appear to contribute to inequities in risk for the development of psychosis that cannot be explained by clinician biases. These data support the importance of developing psychosocial interventions aimed at reducing racism, discrimination, and structural and interpersonal violence. Funding, resources, and policies to support efforts to address these modifiable risk factors are warranted.