Abstract
Psychiatry and allied disciplines have recognized the potency of structural and social determinants of mental health, yet there has been scant attention given to the roles of neurobiology in the links between structural and social determinants and mental health. In this article, we make the case for why greater attention must be given to structural and social determinants of biological psychiatry by researchers, practitioners, and policy-makers. After defining these terms and theoretical frameworks for considering their relevance in biological psychiatry, we review empirical research with marginalized and minoritized racial, ethnic, gender, sexual, and economic communities that reveals the ways in which structural and social determinants affect neurobiological functioning with implications for mental health. We give particular emphasis to developmental science and developmentally informed research, because structural and social determinants influence neurobiological adaptation and maturation across the lifespan. We conclude with recommendations for advancing research, practice, and policy that connect biological psychiatry with structural and social determinants of health. Foremost among these is diversifying the ranks of biological psychiatry, from classrooms through laboratories, hospitals, and community health centers. Transforming and advancing the understanding of the structural and social determinants of neurobiology and mental health is most likely to come through transforming the discipline itself.
Keywords
Disparities and inequities in mental health across diverse marginalized and minoritized communities are well documented (
1
,American Psychiatric Association
Disparities in mental health status and mental health care.
Disparities in mental health status and mental health care.
https://www.apa.org/advocacy/health-disparities/health-care-reform
Date: 2017
Date accessed: May 10, 2022
2
). Recognition of structural and social determinants of mental health is increasing (3
,4
). Many theories posit that the development and functioning of the brain and peripheral biological systems play key roles in the links between inequities and worse mental health across the lifespan (5
,6
). Yet, until recently, the roles that neurobiology plays in the developmental processes linking structural and social determinants with mental health have received relatively little attention.We present arguments and evidence in support of committing greater attention to structural and social determinants of biological psychiatry. First, we provide a brief overview of theoretical frameworks linking structural and social determinants with mental health via neurobiology, which cohere around a developmental perspective on health. Second, in our role as developmental scientists, this perspective is reflected in our review of relevant research examining structural and social determinants in relation to brain structure and function, diurnal and acutely reactive hypothalamic-pituitary-adrenal (HPA) axis functioning, and tonic (baseline) and phasic (reactive) aspects of the autonomic nervous system (ANS) and immune (inflammatory) system. Third, the article concludes with suggestions for translating these perspectives and empirical findings into actions for advancing research, training, practice, and policy in biological psychiatry and allied disciplines.
Definitions and Perspectives
Interpretations of structural and social determinants vary, and our perspective is informed by multiple sources (
7
, National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on Community-Based Solutions to Promote Health Equity in the United States. (2017): Communities in Action: Pathways to Health Equity. Weinstein NJ, Geller A, Negussie Y, Baciu A, editors. Washington, DC: National Academies Press.
8
, 9
). Consideration of this topic requires acknowledgment of the current and historically perpetuated geographic, political, economic, and societal conditions into which one is born and within which one lives. These conditions variably constrain or provide access to opportunities that promote healthy biopsychosocial adjustment. Collectively, one’s life conditions are seen as the roots of one’s health, including neurobiological and mental health (10
, 11
, - Ramsay S.E.
- Morris R.W.
- Whincup P.H.
- Subramanian S.V.
- Papacosta A.O.
- Lennon L.T.
- Wannamethee S.G.
The influence of neighbourhood-level socioeconomic deprivation on cardiovascular disease mortality in older age: Longitudinal multilevel analyses from a cohort of older British men.
J Epidemiol Community Health. 2015; 69: 1224-1231
12
), and these conditions vary across racial, ethnic, national, gender, sexual, economic, and other individual and community characteristics. Recognizing that variability exists in individuals’ life conditions necessitates also recognizing that lives begin on an uneven playing field for healthy development.Structural and social determinants are overlapping and interdependent constructs. Whether a measure or phenomenon is understood as operating at the structural or social level, or both simultaneously, can depend on how narrow or broad a lens one brings to that understanding. Acknowledging others may use the terms differently, or apply additional distinctions (i.e., institutional, systemic) (
7
), we define structural determinants as encompassing the political, economic, and social policies, practices, and values that function at national and local levels to affect the availability of resources, civil rights and protections, and overall cultural climate within which people live. When these determinants reinforce power structures that disadvantage some groups and place them in subordinate and underresourced positions relative to more dominant groups, such as the gender wage gap, redlining and neighborhood segregation, and voter suppression, the disadvantaged individuals and groups are structurally minoritized (National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on Community-Based Solutions to Promote Health Equity in the United States. (2017): Communities in Action: Pathways to Health Equity. Weinstein NJ, Geller A, Negussie Y, Baciu A, editors. Washington, DC: National Academies Press.
7
,National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on Community-Based Solutions to Promote Health Equity in the United States. (2017): Communities in Action: Pathways to Health Equity. Weinstein NJ, Geller A, Negussie Y, Baciu A, editors. Washington, DC: National Academies Press.
9
,13
,14
). Social determinants include people’s daily lived experiences resulting from these structural conditions, such as personal material resources, education and employment, neighborhood resources, health care access, and inclusive versus discriminatory treatment by others. More neurobiological research has focused on social than structural determinants (13
), although the latter may be the primary drivers of national and global health inequities (4
,9
).Several theoretical models position structural and social determinants as contributors to neurobiology and mental health. McEwen’s (
15
,16
) model of allostatic load (AL) posits that prolonged stress system activation due to chronically aversive life conditions eventually disrupts the ability of stress systems to flexibly modulate activity in response to daily challenges (17
), thereby eroding healthy functioning. The stress sensitization hypothesis contends that varying exposures to chronic or severe stressors in early-life primes biological stress systems for exaggerated reactivity in adolescence and adulthood (18
), which Hostinar et al. (19
) extended to distinguish multiple biopsychological repertoires of acute stress responses that may underlie resilience versus distinct psychopathologies. Meyer (20
), Myers (21
), and others have proposed minority stress models that apply these views directly to the experiences and development of marginalized populations. Informed by an intersectional perspective on the synergistic consequences of having multiple identity characteristics (22
), such as being racially marginalized and devalued for being transgender, minority stress models posit that both direct experiences of discrimination and lack of resources (social determinants) and overarching life conditions that maintain disadvantage, marginalization, and disempowerment (structural determinants) are neurotoxic, undermining mental health through their biological effects (23
,24
).These models of biological embedding, or “stress getting under the skin” (
25
), implicitly or explicitly reflect a lifespan developmental perspective. Structural and social determinants are relatively severe, chronic, and stable—often, multigenerational—conditions. These may influence developing neurobiological systems underlying mental health throughout the lifespan. This perspective pertains even when considering adult populations, and research indicates that adverse social and economic conditions in the first 2 decades of life predict mental and physical health disparities in adulthood and older age (26
,27
). In this review, we consider the evidence that structural and social determinants affect neurobiological maturation, and affect mental health through neurobiology, with particular focus on the first 2 decades of life.Evidence for Relations Between Social and Structural Determinants and Neurobiology
Of the social determinants, most research has focused on either household economic resources or individuals’ experiences of discrimination. Considering economics and the brain first, being raised in poverty is associated with structural and functional changes including reduced hippocampal volume, altered prefrontal cortex (PFC) activity to emotional and cognitive tasks, and reduced connectivity between the PFC and the amygdala (
28
, 29
, 30
), potentially attributable to experiencing more stressors at home (- Page M.E.
- Conger K.
- Guyer A.E.
- Hastings P.D.
- Thompson R.
Children and the intergenerational transmission of poverty: Research frontiers and policy implications.
Center for Poverty Research, University of California,
Davis2016
https://poverty.ucdavis.edu/research-paper/children-and-intergenerational-transmission-poverty-research-frontiers-and-policy
Date accessed: November 14, 2017
31
). Childhood poverty continues to leave a mark on the brain in adulthood. Men who were raised in highly disadvantaged neighborhoods showed less differentiation in structural brain networks (32
), and middle-aged individuals from lower socioeconomic status (SES) backgrounds have been found to have lower resting-state connectivity and reduced cortical thickness (33
), which are neural indices of less functionality and organizational efficiency. Conversely, increasing economic resources for impoverished children promotes healthier brain development. The Baby’s First Years randomized controlled trial of monthly cash transfers to low-income new mothers showed that financial support to families enhanced infants’ electroencephalography power in high-frequency bands associated with better cognitive, language, and social-emotional functioning (34
). For U.S. Mexican–origin adolescents living in poverty, increasing family income from age 10 to 16 years predicted stronger resting-state functional connectivity between the posterior cingulate gyrus and insula and the right inferior frontal gyrus, which are regions of the default mode network that support social cognition (35
); income changes were not associated with connectivity for youths living in more financially secure families.Economic hardship is linked with altered stress responses, including both reduced (hypocortisolism) (
36
) and exaggerated (hypercortisolism) (37
) diurnal and acute HPA activity, which can incur myriad physical and mental health problems (15
,16
,38
). Diurnal hypercortisolism is more prevalent in infants and younger children living in poverty (39
), whereas hypocortisolism emerges after more time spent in poverty (40
,41
), potentially reflecting the cumulative toll of AL. Exemplifying early emerging stress activation, Fernald and Gunnar (42
) reported that hypercortisolism in preschool-aged children living in low-income families in rural Mexico was alleviated through a cash-transfer program, compared with children in families who were not enrolled in the program. Exemplifying the suppressive effect of more chronically endured poverty, U.S. Mexican–origin adolescents who lived in deep poverty from age 10 to 16 years evinced HPA hyporeactivity (decreasing cortisol) following a social exclusion task, whereas youths who had not experienced poverty evinced cortisol increases from before to after the social challenge (43
).Childhood poverty predicts elevated tonic and reactive cardiovascular activity, especially blood pressure (
12
,44
), in adolescence and adulthood. Effects are less consistent in preadolescent children (45
, 46
, 47
), suggesting that ANS effects emerge over prolonged exposure to poverty or that adolescence may be a sensitive period for the effects of poverty on cardiovascular health (30
). Similarly, SES in childhood and adolescence is inversely associated with chronic inflammation, both concurrently and into adulthood (- Page M.E.
- Conger K.
- Guyer A.E.
- Hastings P.D.
- Thompson R.
Children and the intergenerational transmission of poverty: Research frontiers and policy implications.
Center for Poverty Research, University of California,
Davis2016
https://poverty.ucdavis.edu/research-paper/children-and-intergenerational-transmission-poverty-research-frontiers-and-policy
Date accessed: November 14, 2017
48
, 49
, 50
, 51
). These associations hold after accounting for changes in occupation and education over time (52
) and appear to magnify with age (53
). Studies of AL involving activity across multiple systems (i.e., HPA, ANS, immune) are consistent; children raised in poverty have increased AL in late adolescence (54
,55
) and adulthood (27
).Similarly to poverty, experiences of discrimination that target persons based on their nonmajority social status constitute severe and pervasive sources of social stress that affect numerous biological systems (
56
). Interpreting acute negative treatment as racial/ethnic discrimination evokes elevated anterior cingulate cortex (ACC) activity associated with emotion regulation in both Black adults in the United States (57
) and Turkish adults in Germany (58
), potentially reflective of stress and coping efforts. Experiencing more chronic racial discrimination predicts reduced total brain volume in Black youths with depressive symptoms (59
), disrupted white matter microstructure in Black women with trauma histories (60
), and increased activation and connectivity of multiple regions involved in vigilance, arousal, and emotion regulation in Black adults with trauma histories (61
,62
). Such findings reveal the cumulative toll of racial discrimination on brain health.Numerous studies indicate that marginalized individuals evince flatter diurnal cortisol slopes, especially for those who have experienced more discrimination (
23
,63
), manifested as both hypocortisolism (64
,65
) and hypercortisolism (66
,67
). Hypercortisolism also is evidenced by increased hair cortisol concentrations in adults who experienced more discrimination (68
). Racial discrimination experiences in early adolescence, but not early adulthood, predicted diurnal hypocortisolism in Black adults 20 years later (69
); pubertal maturation and identity formation processes may make early adolescence a particularly sensitive period for the neurotoxic effects of discrimination. Yet, Black mothers’ experiences of discrimination predicted their infants’ elevated acute cortisol reactivity at 12 months (70
), indicating that discrimination has effects across the lifespan, and again suggesting that stressful life contexts may initially increase HPA activity, before tonically suppressing it after chronic exposure.Sexual and gender identity discrimination is associated with disrupted adrenocortical functioning in lesbian, gay, bisexual, transgender, and queer (LGBTQ+) youths and adults. Sexual or gender minority status disclosure may increase discrimination exposure (
71
), and being “out” has been associated with elevated cortisol and distress (72
,73
). Conversely, those who are not “out” may perceive greater risk with disclosing (74
). Unlike other marginalized identity characteristics, family members typically do not share the sexual or gender identity of LGBTQ+ individuals. Lack of family support predicted stronger HPA reactivity in LGB young adults (75
). Identifying with multiple minoritized characteristics can carry biological burdens (23
,76
). LGBTQ+ Latinx young adults who experienced both heterosexist and racist discrimination were challenged in forming an integrated intersectional identity, which in turn predicted hypocortisolism (24
).Across adolescence and adulthood, discrimination is associated with activity of the cardiovascular and immune systems (
49
,56
,77
). As evidence of discrimination’s cumulative effect, African American adults’ experiences of discrimination predicted greater chronic inflammation only for those who also had experienced higher levels of discrimination 18 years earlier, in preadolescence (78
). This “double-hit model” again indicates that early adolescence may be a susceptible period for the pernicious neurobiological effects of discrimination against core identity characteristics. Indeed, meta-analyses have shown that from adolescence through late adulthood, chronic inflammation increased more in racially minoritized and impoverished than in majority and economically secure groups (53
). Inflammatory markers also were elevated in LGBTQ+ individuals versus heterosexual and cisgender individuals (79
), possibly exacerbated by lack of family support (80
) and discrimination experiences for those who are “out” (81
).Fewer studies have directly addressed links between structural determinants and neurobiology. Unequal prevalence of ethnic and racial minority groups across neighborhoods, often the intentional result of policy decisions pertaining to zoning, mortgages, and highway construction (
7
), during early adulthood predicted Black participants’ reduced brain volume in middle adulthood (National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on Community-Based Solutions to Promote Health Equity in the United States. (2017): Communities in Action: Pathways to Health Equity. Weinstein NJ, Geller A, Negussie Y, Baciu A, editors. Washington, DC: National Academies Press.
82
) and was concurrently linked to increased inflammation and AL in adults (83
). This latter finding was true for all racial/ethnic groups, over and above SES; hence, neighborhood segregation takes a biological toll on both advantaged majority group members and less advantaged and marginalized peoples. Structural racism quantified at the state level (e.g., racial differences in incarceration rates) predicted reduced hippocampal volume for Black and Latinx, but not White, preadolescents living in states with greater structural racial/ethnic stigma, independent of personal experiences of discrimination (84
); a similar effect was noted for girls, but not boys, living in states with more structural gender stigma. Analogously, LGB young adults who had spent their adolescence living in counties and states that were more stigmatizing of LGBTQ+ people had hyporeactive cortisol responses to an acute stressor, relative to LGB individuals who had been raised in less stigmatizing environments (85
). Similarly, beyond individual characteristics and state-level poverty, state-level structural racism predicted elevated prevalence of myocardial infarction for Black adults living in more versus less racist states; a weaker opposite tendency was noted for White adults (86
).As noted previously, chronic structural stressors may suppress HPA axis activity, whereas acute structural stressors may have the opposite effect. We found that young adults in California evinced diurnal hypercortisolism immediately following the 2016 Pulse Nightclub Massacre in Florida, which gradually declined over the subsequent 2 months (
87
). This could be seen as indicative of peripheral biological impacts from structural determinants related to lax gun control laws and strong beliefs in gun ownership rights that contribute to the U.S. public health crisis of mass gun violence (88
, 89
, 90
). This stress activation response was equally evident in those who shared or did not share identity characteristics with the majority of the 49 victims of the massacre (LGBTQ+, Latinx, male), paralleling evidence of elevated distress symptoms in the general Florida population following the massacre (91
). Again, such findings suggest that structural inequities may undermine the well-being of all people, not only the marginalized people who are most directly disadvantaged by those inequities.SES is a multifaceted construct that can demarcate exposure to various determinants (
92
), including where families live. Disparities between neighborhoods prospectively predict the prevalence of psychiatric disorders (93
, 94
, 95
, 96
). Whether neighborhood-level measures should be considered structural or social determinants is debatable. Local crime rates, median household value, and unemployment affect individuals’ daily experiences (social) and are the products of municipal, state, and national laws, policies, and practices (structural) (7
). Neighborhood characteristics have been associated with the neurobiology underlying mental health. Independent of family economic resources, living in neighborhoods with greater poverty, deterioration, and crime during childhood (National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on Community-Based Solutions to Promote Health Equity in the United States. (2017): Communities in Action: Pathways to Health Equity. Weinstein NJ, Geller A, Negussie Y, Baciu A, editors. Washington, DC: National Academies Press.
97
,98
) or adolescence (- Rakesh D.
- Seguin C.
- Zalesky A.
- Cropley V.
- Whittle S.
Associations between neighborhood disadvantage, resting-state functional connectivity, and behavior in the adolescent brain cognitive development study: The moderating role of positive family and school environments.
Biol Psychiatry Cogn Neurosci Neuroimaging. 2021; 6: 877-886
99
, 100
, 101
) was associated with patterns of neural reactivity indicative of accelerated brain maturation and either dampened or sensitized neural reactivity in multiple brain regions that control behavior and emotion. For example, reduced inferior frontal gyrus activation during a Go/No-Go task accounted for the association of greater neighborhood poverty and poorer response inhibition in children and adolescents (101
). Considering peripheral effects, as with lower family SES, lower neighborhood SES was associated with diurnal hypocortisolism in adolescents (102
). Neighborhood SES also is conflated with variation in exposure to pollutants that can have neurotoxic effects (103
). Independent of family and neighborhood SES, greater neighborhood-level exposure to air (e.g., particulate matter 2.5) and water (e.g., lead, arsenic) pollutants from age 10 to 16 years predicted stronger sympathetic and weaker parasympathetic influence over ANS activity at age 17 years in U.S. Mexican–origin adolescents, which could increase risk for myriad illnesses in adulthood (104
). Hence, neighborhood economic disadvantage exposes developing neurobiological systems to multiple kinds of threats.Social and Structural Determinants, Neurobiology, and Mental Health
Decades of research have shown that the central and peripheral systems affected by structural and social determinants are intricately linked to mental health (
2
,5
,23
,105
). Multiple neurobiological processes are theorized to function as mechanistic biomarkers, conveying structural and social determinants’ effects on mental health (15
,18
,19
,21
,106
). Evidence indicates that links between childhood adversities (e.g., family poverty) and later psychopathology are mediated through accelerated maturation of emotion processing via frontolimbic functional connectivity, and deficits in reward processing via functional connectivity of the salience network and the amygdala (107
). SES has consequences for family processes (92
), and links between family SES and brain functioning and development are themselves mediated by effects of economic adversity on family functioning (108
). The clinical implications of these effects on connectivity may be realized in transdiagnostic, symptom-relevant manifestations such as emotion dysregulation, attention inflexibility, and inefficiencies and biases in processing information. Considering other neurobiological mechanisms, diurnal hypercortisolism accounted for the association between heterosexist discrimination and elevated depressive symptoms in LGB young adults (109
). Neurobiological mediation is not always evident, however. In U.S. Mexican–origin adolescents, greater exposure to social threats including discrimination and crime predicted both internalizing problems and multisystem coupling of the PFC and ANS reactivity to emotional faces, but multisystem coupling did not mediate links between these social determinants and mental health (110
). Stronger downregulatory coupling of increased PFC activity with less ANS reactivity may have been an adaptation to chronically threatening contexts that could carry longer-term risks to mental health in the future (111
).Building on biopsychosocial models of mental health (
112
,113
), researchers have begun to examine the combined or moderating roles of social and structural determinants and brain structure and function in adolescent mental health (114
). U.S. Mexican–origin adolescents with larger hippocampal volumes showed more depressive symptoms when they experienced more neighborhood crime, but fewer symptoms when less exposed to crime (115
). Neighborhood crime was unrelated to symptoms in adolescents with smaller hippocampal volumes, suggesting that larger hippocampi may potentiate the effects of these social determinants. In this same sample, greater neighborhood and school crime exposure also predicted elevated externalizing problems, but only for adolescents with reduced activity in the posterior cingulate cortex, temporoparietal junction, and amygdala when thinking about how another person’s emotional cues made them feel, referred to as emotion introspection (116
). Adolescents with weaker neural evidence of emotional awareness, potentially indicative of dampened engagement with others’ emotional needs, appeared to be more affected by crime exposure.A moderated-mediation pattern involving the subgenual ACC, hostile environments, deviant behavior, and family connection also has been found with these Mexican-origin youths (
117
). Experiencing high levels of hostility at school predicted stronger subgenual ACC activation to social exclusion, which in turn predicted more deviant behavior. As found for attribution of racial discrimination (57
,58
), the brain’s processing of social exclusion may be a mechanism linking hostile experiences with deviant behavior, perhaps as the subgenual ACC becomes sensitized to social threat. This mediation effect was moderated, though. Adolescents who felt less family connection showed the most deviant behavior if they had high subgenual ACC reactivity to social exclusion, yet the least deviant behavior if subgenual ACC reactivity was low. Adolescents who felt more family connection were buffered from deviant behavior, regardless of their neural response to exclusion. Family connection functioned as a protective contextual factor and could be a potential target for biologically informed interventions.Advancing the Work on Structural and Social Determinants: Challenges in the Field
Given the accumulating evidence for the pervasive and enduring effects of structural and social determinants on neurobiology and mental health, an immediate reaction could be to do more, do better. Certainly more research is needed, and, we would argue, particularly more research on 1) how the effects of structural and social inequities on multiple neurobiological systems shape the course of mental health disparities across development, 2) what can be done to mitigate said effects of these inequities, and 3) how to reduce or remove the inequities themselves. Yet, this reaction may be too superficial, because there are challenges to reaching an effective understanding of social and structural determinants within biological psychiatry. These include representation of diversity within researchers and the populations they study, biological reductionism, and access to care and training.
There is a woeful lack of representation of diverse communities, and particularly of racially and ethnically minoritized and economically marginalized peoples, within biological psychiatry (
118
,119
), owing at least in part to histories of structural oppression and exclusion (120
,121
). Yet, there is a corollary of working in a homogeneous profession: most who have been privileged enough to do this work are, themselves, the products of the same systemic, structural, and social determinants that have excluded and harmed those who are underrepresented (122
,123
). The effects of being the beneficiaries of these determinants are, to be sure, quite different than the effects discussed previously, but they are likely to include unrecognized biases in the questions we ask, the approaches used to address those questions, the populations studied, what is prioritized in the data generated, the interpretations of those data, and the evaluation of others’ research (124
, 125
, 126
).One such bias is that, in studying neurobiology, many assume they are studying things that are objective, measurable, and interpretable as having consistent and specific meaning. We must escape assumptions of universality and biological reductionism. The same size of a brain region, the same magnitude of an event-related potential component, the same level of a circulating hormone will not necessarily have the same implication for mental health when observed between individuals with very distinct life histories. While plausible that some neurobiological processes may be expected to unfold in a similar manner regardless of life history, it requires additional research with diverse populations to ascertain where such commonalities exist.
Access to psychiatric providers and services is affected by limited regional access and insurance constraints, particularly in communities ridden with structural and social challenges. Marginalized communities have learned to mistrust researchers because of an extensive history of scientific abuses (
118
,127
) and failures to keep personally identifiable biological data protected (128
). This limits the pool from which to recruit research participants in clinical settings. Both psychiatric clinicians and researchers need training in understanding issues pertaining to cultural and diversity competency.Actionable Steps
Diversify Biological Psychiatry
The relatively scant empirical attention to structural and social determinants of neurobiology and mental health likely stems from limited diversity within the field of biological psychiatry (
129
). Most scientists have not come from marginalized, minoritized, or disadvantaged communities; consequently, they have not attended to the forces affecting those communities. Acknowledging that fact behooves the field to recruit, mentor, retain, and scaffold the success of researchers and scientist-practitioners who reflect the diverse populations with which the field should be engaging. This will require financial investments of fellowships and stipends to defray the high costs of education that individuals from economically marginalized backgrounds cannot be expected to shoulder, and also investments of time and effort for scientists from advantaged and majority positions to learn how to effectively mentor and scaffold people with different life experiences. Given their life experiences, this next generation of scientists may apply alternative theoretical frameworks, pose unasked questions, implement innovative approaches, achieve novel insights, and train future scientists differently. Compared with past and current scientific norms, such changes should be recognized as (at least) equally likely to be valid models of practicing biological psychiatry.A more diverse biological psychiatry would more effectively engage and work with diverse communities. Engaging in community partnerships through participatory action research and citizen science approaches could help biological psychiatry better identify the mental health issues of greatest relevance to a given community, and the research procedures that community is more likely to accept and support (
130
, 131
, 132
). Community partnerships could shift the field from deficits-based to strengths-based models of adaptation and resilience by recognizing and incorporating community-specific assets into our understanding of the multiple paths toward mental health and well-being across diverse populations. This also could help to strengthen the pipeline for engaging the interests of young people from diverse communities in the pursuit of biological psychiatry as a profession.- Friesen P.
Participatory neuroscience: Something to strive for?.
The neuroethics Blog. 2018; (Available at:)
https://neuronline.sfn.org/professional-development/participatory-neuroscience-something-to-strive-for
Date accessed: February 18, 2022
Integrate Structural and Social Determinants Into the Biologically Informed Practice of Psychiatry
Psychiatrists could be better supported to consider the roles of structural and social determinants of mental health when working with those living in disadvantaged contexts. The DSM-5 (
133
), used to define, classify, and diagnose mental disorders in the United States, has pending the DSM-5-Text Revision [DSM-5-TR (134
)] that will incorporate the impacts of racism and discrimination into the diagnosis and manifestations of mental disorders. This is a step in the right direction given the evidence reviewed above. Diagnostic tools could incorporate the impacts of structural and social determinants on mental health, for example, by including a life stress interview approach in assessments. Psychiatric service providers’ ability to better account for the life experiences of diverse clients, and what these may mean for their neurobiological adaptations to context, should contribute to more effectively person-centered care. For example, psychotherapy is less effective for Black youth living in more racist communities (135
); more research, informed by models of structural and social determinants of mental health, is needed to develop adequate health practices for this underserved population.Psychiatric assessment and diagnosis may be further aided by including biological assays of peripheral markers indicative of exposures to structural and social determinants of mental health. For example, testing blood for exposure to toxins such as lead or mercury that can result in psychiatric symptom–like behaviors (
136
) would be straightforward. More big data research with large samples of participants from diverse communities will be needed to confirm those for whom specific neural and peripheral biomarkers of exposures to adversity actually do confer susceptibility to mental health problems. From such efforts, physiological tests of hormones, cytokines, and other biomarkers that can be assessed from minimally invasive biospecimens may also become informative components of community-appropriate assessments.Preventive approaches to reduce suffering from mental disorders and promote good mental health must acknowledge that early-life periods constitute particularly key windows in which to apply prevention strategies (
137
). Implementing appropriate and valid screening measures, including assessments of contextual influences, in community settings frequented by all youth, such as schools, would reach those constituencies with less access to primary care. Prevention and intervention strategies must be designed with structural and social determinants in mind and then evaluated for evidence of efficacy and effectiveness.Translate Research Into Structural and Social Action
Standard interventions for individuals’ mental health problems typically treat the symptoms rather than the root causes of problems. Identifying and understanding neurobiological mechanisms by which adversity, classism, sexism, heterosexism, transphobia, and racism contribute to mental health disparities (
23
) is necessary for developing systems-level interventions to disrupt these fundamental structural and social causes of disease at both individual and community levels (14
,138
). Bolstering antidiscrimination policies may help dismantle barriers to access to housing, employment, education, and fair treatment among economic, ethnic, racial, sexual, and gender minorities. More inclusive laws, policies, and practices support healthier brain and peripheral physiological development (84
,85
), which in turn promote better mental and physical health.Some such laws and policies exist but often are not upheld, and governments need to be held accountable in exercising these protective measures (
139
). This extends to violence prevention and gun control legislation, social safety net programs, natural disaster emergency response programs, and pollution control efforts, all of which disproportionately adversely affect marginalized and minoritized communities (87
,140
, 141
, 142
, 143
). Simultaneously, new legislation being enacted in many jurisdictions that further marginalize already vulnerable populations, such as denying gender-affirming health care to transgender minors (144
) or restricting school curricula from addressing the topic of structural and social determinants (- Luneau D.
Breaking: Arizona house passes anti-transgender sports and medical care bans.
Hum Rights, (Campaign),
2022
https://www.hrc.org/press-releases/breaking-arizona-house-passes-anti-transgender-sports-and-medical-care-bans
Date accessed: April 25, 2022
145
), is itself imposing new structural inequities. Knowing the profound effects of structural and social determinants of mental health behooves psychiatric scientists and practitioners to become social and political advocates for positive change to improve the life contexts of those we study and treat.Globalize Biological Psychiatry
Internationalizing basic research, translational efforts, and social policy changes should be a priority. Mental health research involving neurobiology is being conducted in low- and middle-income countries (LMICs) (
146
,147
), yet it remains the case that biological psychiatrists overwhelmingly pursue their science in high-income countries. The majority of the world lives in LMICs, and they too are subject to structural and social determinants of neurobiology and mental health. There are mutual, bidirectional benefits to rectifying this disparity in empirical work across the global population. For example, increasing investment in the necessary physical and personnel infrastructure (equipment and training) for scientists and practitioners in LMICs to pursue biological psychiatry would advance theory, research, and practice with diverse cultures and communities, and would bring more diverse perspectives and approaches into scientific endeavors. The Fogarty International Center at the National Institutes of Health provides one example of how infrastructure and research grants can be targeted toward scientific capacity-building within LMICs.More work remains to validate biological and psychiatric constructs across cultures and countries. ICD-11 (
148
) is widely used in Europe and across the globe. Working to bridge future revisions of the DSM-5-TR and ICD-11 with globally informed understandings of structural and social determinants of mental health could advance the training of clinicians and researchers by, for example, recognizing variations in the relevant criteria for diagnoses within different cultures and communities, and across the lifespan.Globally, countries with steeper income gradients (more wealthy and more impoverished members, relative to fewer middle-income members) have overall worse health across the economic spectrum than countries with less economic disparity (
149
,150
). Even while acknowledging that marginalized and disempowered members suffer the most, living in a country with greater structural and social inequity is unhealthy for everyone in that country, paralleling research on the biological tolls of structural and social inequities (83
,87
). Translating biological psychiatry into advocacy for reducing collective stress stemming from economic and other disparities could promote better global mental health and well-being.Conclusions
The increasing empirical attention from biological psychiatry to structural and social determinants is revealing that they have pervasive and lifelong impacts on the brain and other neurobiological systems, with profound consequences for mental health. More research on these processes clearly is needed, and particularly for structural determinants, to advance both the science and the practice of biological psychiatry. Doing this work well will require creative thinking and novel approaches from scientists who have experience with and understanding of these structural and social determinants, and competence at building effective research partnerships with communities that have been disadvantaged by structural and social inequities. Building diversity within biological psychiatry and allied disciplines by involving more people who identify as members of marginalized racial, ethnic, gender, sexual, and economic groups will require intentional efforts for culture change within the field. Although diversifying the ranks of scientists serves to increase scientific innovation, the work of scientists from underrepresented backgrounds is systematically devalued (
126
), contributing to their greater likelihood of leaving academia (129
,131
). These inequities within our professions must be addressed, because to better promote national and global well-being, we need more research on the structural and social determinants of neurobiology and mental health, by the people who are best positioned to engage effectively with this challenging work.Acknowledgments and Disclosures
We thank Ms. Enya Daang for assistance in preparing the manuscript.
The authors report no biomedical financial interests or potential conflicts of interest.
References
- Disparities in mental health status and mental health care.(Available at:)https://www.apa.org/advocacy/health-disparities/health-care-reformDate: 2017Date accessed: May 10, 2022
- The social determinants of mental health: An overview and call to action.Psychiatr Ann. 2014; 44: 22-26
- Socioeconomic status and child development.Annu Rev Psychol. 2002; 53: 371-399
- Social Determinants of Mental Health.World Health Organization, Geneva2014: 1-54
- Neurobiological consequences of racial disparities and environmental risks: A critical gap in understanding psychiatric disorders.Neuropsychopharmacology. 2020; 45: 1247-1250
- How experience gets under the skin to create gradients in developmental health.Annu Rev Public Health. 2010; 31 (3p following 347): 329-347
National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on Community-Based Solutions to Promote Health Equity in the United States. (2017): Communities in Action: Pathways to Health Equity. Weinstein NJ, Geller A, Negussie Y, Baciu A, editors. Washington, DC: National Academies Press.
- A New Way to Talk About the Social Determinants of Health.Robert Wood Johnson Foundation, New York2010
- Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health.World Health Organization, Geneva2008: 1-40
- Inequality and mental disorders: Opportunities for action.Lancet. 2013; 382: 183-184
- The influence of neighbourhood-level socioeconomic deprivation on cardiovascular disease mortality in older age: Longitudinal multilevel analyses from a cohort of older British men.J Epidemiol Community Health. 2015; 69: 1224-1231
- Early childhood poverty, immune-mediated disease processes, and adult productivity.Proc Natl Acad Sci U S A. 2012; 109: 17289-17293
- Introduction to the special issue on structural stigma and health.Soc Sci Med. 2014; 103: 1-6
- Stigma as a fundamental cause of population health inequalities.Am J Public Health. 2013; 103: 813-821
- Stress, adaptation, and disease. Allostasis and allostatic load.Ann N Y Acad Sci. 1998; 840: 33-44
- Stress and the individual. Mechanisms leading to disease.Arch Intern Med. 1993; 153: 2093-2101
- Allostasis: A new paradigm to explain arousal pathology.in: Fisher S. Reason J. Handbook of Life Stress, Cognition and Health. John Wiley & Sons, Oxford1988: 629-649
- Developmental determinants of sensitivity and resistance to stress.Psychoneuroendocrinology. 2005; 30: 939-946
- The role of stress phenotypes in understanding childhood adversity as a transdiagnostic risk factor for psychopathology. J Psychopathol Clin Sci.
- Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence.Psychol Bull. 2003; 129: 674-697
- Ethnicity- and socio-economic status-related stresses in context: An integrative review and conceptual model.J Behav Med. 2009; 32: 9-19
- Demarginalizing the intersection of race and sex: A Black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics.Univ Chic Leg Forum. 1989; 140: 139-167
- Integrating the neurobiology of minority stress with an intersectionality framework for LGBTQ-Latinx populations.New Dir Child Adolesc Dev. 2018; 161: 91-108
- Challenges to identity integration indirectly link experiences of heterosexist and racist discrimination to lower waking salivary cortisol in sexually diverse Latinx emerging adults.Front Psychol. 2020; 11: 228
- Health psychology: What is an unhealthy environment and how does it get under the skin?.Annu Rev Psychol. 1997; 48: 411-447
- Childhood socioeconomic status and adult health.Ann N Y Acad Sci. 2010; 1186: 37-55
- History of socioeconomic disadvantage and allostatic load in later life.Soc Sci Med. 2012; 74: 75-83
- Socioeconomic status and structural brain development.Front Neurosci. 2014; 8: 276
- Childhood poverty and recruitment of adult emotion regulatory neurocircuitry.Soc Cogn Affect Neurosci. 2015; 10: 1596-1606
- Children and the intergenerational transmission of poverty: Research frontiers and policy implications.Center for Poverty Research, University of California, Davis2016 (Available at:)https://poverty.ucdavis.edu/research-paper/children-and-intergenerational-transmission-poverty-research-frontiers-and-policyDate accessed: November 14, 2017
- The effects of poverty on childhood brain development: The mediating effect of caregiving and stressful life events.JAMA Pediatr. 2013; 167: 1135-1142
- Socioeconomic deprivation and cortical morphology: Psychological, social, and biological determinants of ill health study.Psychosom Med. 2013; 75: 616-623
- Socioeconomic status moderates age-related differences in the brain’s functional network organization and anatomy across the adult lifespan.Proc Natl Acad Sci U S A. 2018; 115: E5144-E5153
- The impact of a poverty reduction intervention on infant brain activity.Proc Natl Acad Sci U S A. 2022; 119e2115649119
- Income change alters default mode network connectivity for adolescents in poverty.Dev Cogn Neurosci. 2018; 30: 93-99
- Hypocortisolism as a potential marker of allostatic load in children: Associations with family risk and internalizing disorders.Dev Psychopathol. 2011; 23: 881-896
- Can poverty get under your skin? Basal cortisol levels and cognitive function in children from low and high socioeconomic status.Dev Psychopathol. 2001; 13: 653-676
- In search of HPA axis dysregulation in child and adolescent depression.Clin Child Fam Psychol Rev. 2011; 14: 135-160
- Indicators of deprivation predict diurnal cortisol regulation during infancy.Dev Psychol. 2021; 57: 200-210
- Allostasis and allostatic load in the context of poverty in early childhood.Dev Psychopathol. 2011; 23: 845-857
- Socioeconomic status, subjective social status, and perceived stress: Associations with stress physiology and executive functioning.Behav Med. 2015; 41: 145-154
- Poverty-alleviation program participation and salivary cortisol in very low-income children.Soc Sci Med. 2009; 68: 2180-2189
- Patterns of poverty across adolescence predict salivary cortisol stress responses in Mexican-origin youths.Psychoneuroendocrinology. 2021; 132105340
- Childhood poverty and blood pressure reactivity to and recovery from an acute stressor in late adolescence: The mediating role of family conflict.Psychosom Med. 2013; 75: 691-700
- Prenatal adversities and Latino children’s autonomic nervous system reactivity trajectories from 6 months to 5 years of age.PLoS One. 2014; 9e86283
- Cumulative effects of early poverty on cortisol in young children: Moderation by autonomic nervous system activity.Psychoneuroendocrinology. 2013; 38: 2666-2675
- Age-adapted stress task in preschoolers does not lead to uniform stress responses.J Abnorm Child Psychol. 2019; 47: 571-587
- When do social inequalities in C-reactive protein start? A life course perspective from conception to adulthood in the Cardiovascular Risk in Young Finns Study.Int J Epidemiol. 2008; 37: 290-298
- Socioeconomic status trajectories across the life course, daily discrimination, and inflammation among Black and White adults.Psychoneuroendocrinology. 2021; 127105193
- Effects of socioeconomic position on inflammatory and hemostatic markers: A life-course analysis in the 1958 British birth cohort.Am J Epidemiol. 2008; 167: 1332-1341
- Socioeconomic status and inflammatory processes in childhood asthma: The role of psychological stress.J Allergy Clin Immunol. 2006; 117: 1014-1020
- Life course socioeconomic position is associated with inflammatory markers: The Framingham Offspring Study.Soc Sci Med. 2010; 71: 187-195
- Race, socioeconomic status, and low-grade inflammatory biomarkers across the lifecourse: A pooled analysis of seven studies.Psychoneuroendocrinology. 2021; 123104917
- Is resilience only skin deep?: Rural African Americans’ socioeconomic status-related risk and competence in preadolescence and psychological adjustment and allostatic load at age 19.Psychol Sci. 2013; 24: 1285-1293
- Childhood poverty and young adults’ allostatic load: The mediating role of childhood cumulative risk exposure.Psychol Sci. 2012; 23: 979-983
- “More than skin deep”: Stress neurobiology and mental-health consequences of racial discrimination.Stress. 2015; 18: 1-10
- An fMRI Investigation of attributing negative social treatment to racial discrimination.J Cogn Neurosci. 2011; 23: 1042-1051
- Neuroimaging evidence for a role of neural social stress processing in ethnic minority-associated environmental risk [published correction appears in JAMA Psychiatry 2014;71:888].JAMA Psychiatry. 2014; 71: 672-680
- Depressive symptomatology, racial discrimination experience, and brain tissue volumes observed on magnetic resonance imaging.Am J Epidemiol. 2019; 188: 656-663
- Effects of racial discrimination on white matter microarchitecture in trauma-exposed Black American women.Biol Psychiatry. 2021; 89: S109-S388
- Association of racial discrimination with neural response to threat in Black women in the US exposed to trauma.JAMA Psychiatry. 2021; 78: 1005-1012
- Racial discrimination and resting-state functional connectivity of salience network nodes in trauma-exposed Black adults in the United States.JAMA Netw Open. 2022; 5e2144759
- Discrimination and the HPA axis: Current evidence and future directions.J Behav Med. 2017; 40: 539-552
- Everyday discrimination and diurnal cortisol during adolescence.Horm Behav. 2016; 80: 76-81
- Association between perceived racism and physiological stress indices in Native Hawaiians.J Behav Med. 2012; 35: 27-37
- Perceived discrimination and diurnal cortisol: Examining relations among Mexican American adolescents.Horm Behav. 2012; 61: 541-548
- Associations between self-reported discrimination and diurnal cortisol rhythms among young adults: The moderating role of racial-ethnic minority status.Psychoneuroendocrinology. 2014; 50: 280-288
- Race moderates the association of perceived everyday discrimination and hair cortisol concentration.Stress. 2020; 23: 529-537
- Developmental histories of perceived racial discrimination and diurnal cortisol profiles in adulthood: A 20-year prospective study.Psychoneuroendocrinology. 2015; 62: 279-291
- The development of the cortisol response to dyadic stressors in Black and White infants.Dev Psychopathol. 2018; 30: 1995-2008
- The psychological implications of concealing a stigma: A cognitive-affective-behavioral model.Psychol Bull. 2007; 133: 328-345
- Stigma and diurnal cortisol among transitioning transgender men.Psychoneuroendocrinology. 2017; 82: 59-66
- Gay and bisexual men who disclose their sexual orientations in the workplace have higher workday levels of salivary cortisol and negative affect.Ann Behav Med. 2005; 30: 260-267
- Sexual orientation and disclosure in relation to psychiatric symptoms, diurnal cortisol, and allostatic load.Psychosom Med. 2013; 75: 103-116
- Familial social support predicts a reduced cortisol response to stress in sexual minority young adults.Psychoneuroendocrinology. 2014; 47: 241-245
- Cortisol profiles differ by race/ethnicity among young sexual minority men.Psychoneuroendocrinology. 2017; 75: 1-4
- Perceived discrimination and cardiovascular health disparities: A multisystem review and health neuroscience perspective.Ann N Y Acad Sci. 2018; 1428: 170-207
- Youth adversities amplify the association between adult stressors and chronic inflammation in a domain specific manner: Nuancing the early life sensitivity model.J Youth Adolesc. 2019; 48: 1-16
- Systemic inflammation as a driver of health disparities among sexually diverse and gender-diverse individuals.Psychoneuroendocrinology. 2021; 129105215
- Father support is protective against the negative effects of perceived discrimination on CRP among sexual minorities but not heterosexuals.Psychoneuroendocrinology. 2019; 110104368
- Disparities in social health by sexual orientation and the etiologic role of self-reported discrimination.Arch Sex Behav. 2016; 45: 1317-1327
- Racial residential segregation in young adulthood and brain integrity in middle age: Can we learn from small samples?.Am J Epidemiol. 2022; 191: 591-598
- Contextual predictors of cumulative biological risk: Segregation and allostatic load.Soc Sci Q. 2011; 92: 1338-1362
- Smaller hippocampal volume among Black and Latinx youth living in high-stigma contexts.J Am Acad Child Adolesc Psychiatry. 2022; 61: 809-819
- Structural stigma and hypothalamic–pituitary–adrenocortical axis reactivity in lesbian, gay, and bisexual young adults.Ann Behav Med. 2014; 47: 39-47
- Structural racism and myocardial infarction in the United States.Soc Sci Med. 2014; 103: 42-50
- Adrenocortical responses of emerging adults in California in the two months following the Pulse Night Club massacre: Evidence for distal stress responses.Compr Psychoneuroendocrinol. 2022; 10100129
- Guns, culture or mental health? Framing mass shootings as a public health crisis.Health Commun. 2018; 33: 1211-1222
- International student perceptions of American gun culture and school shootings: A public health examination.Violence Vict. 2019; 34: 972-991
- Rooting out gun violence.N Engl J Med. 2016; 374: 175-176
- Shattering core beliefs: Psychological reactions to mass shooting in Orlando.J Psychiatr Res. 2017; 85: 56-58
- Understanding the processes through which economic hardship influences families and children.in: Crane R. Marshall E. Handbook of Families and Poverty: Interdisciplinary Perspectives. SAGE Publications, Thousand Oaks, CA2008: 64-81
- Neighbourhood level social deprivation and the risk of psychotic disorders: A systematic review.Soc Psychiatry Psychiatr Epidemiol. 2016; 51: 941-950
- Predicting psychosis-spectrum diagnoses in adulthood from social behaviors and neighborhood contexts in childhood.Dev Psychopathol. 2020; 32: 465-479
- Associations between neighbourhood characteristics and depression: A twin study.J Epidemiol Community Health. 2018; 72: 202-207
- The association between neighbourhood-level deprivation and depression: Evidence from the South African National Income Dynamics Study.BMC Psychiatry. 2017; 17: 395
- Beyond family-level adversities: Exploring the developmental timing of neighborhood disadvantage effects on the brain.Dev Sci. 2021; 24e12985
- Associations between neighborhood disadvantage, resting-state functional connectivity, and behavior in the adolescent brain cognitive development study: The moderating role of positive family and school environments.Biol Psychiatry Cogn Neurosci Neuroimaging. 2021; 6: 877-886
- An fMRI study of inhibitory control and the effects of exposure to violence in Latin-American early adolescents: Alterations in frontoparietal activation and performance.Soc Cogn Affect Neurosci. 2019; 14: 1097-1107
- Lower neighborhood quality in adolescence predicts higher mesolimbic sensitivity to reward anticipation in adulthood.Dev Cogn Neurosci. 2016; 22: 48-57
- Neighborhood poverty predicts altered neural and behavioral response inhibition.Neuroimage. 2020; 209116536
- Neighborhood, family, and subjective socioeconomic status: How do they relate to adolescent health?.Health Psychol. 2006; 25: 704-714
- Understanding the cumulative impacts of inequalities in environmental health: Implications for policy.Health Aff (Millwood). 2011; 30: 879-887
- The impact of social disadvantage on autonomic physiology of Latinx adolescents: The role of environmental risks.New Dir Child and Adolesc Dev. 2022; 2022: 91-124
- Racism as a determinant of health: A systematic review and meta-analysis.PLoS One. 2015; 10e0138511
- How does sexual minority stigma “get under the skin”? A psychological mediation framework.Psychol Bull. 2009; 135: 707-730
- Early life stress and brain function: Activity and connectivity associated with processing emotion and reward.Neuroimage. 2020; 209116493
- Processes linking socioeconomic disadvantage and neural correlates of cognitive control in adolescence.Dev Cogn Neurosci. 2021; 48100935
- Minority stress predicts depression in lesbian, gay, and bisexual emerging adults via elevated diurnal cortisol.Emerg Adulthood. 2016; 4: 365-372
- Tuning of brain-autonomic coupling by prior threat exposure: Implications for internalizing problems in Mexican-origin adolescents.Dev Psychopathol. 2019; 31: 1127-1141
- Developmental adaptation to stress: An evolutionary perspective.Annu Rev Psychol. 2019; 70: 111-139
- A multiple-levels-of-analysis perspective on research in development and psychopathology.in: Beauchaine T.P. Hinshaw S.P. Child and Adolescent Psychopathology. John Wiley & Sons Inc, Hoboken, NJ2008: 27-57
- Differential susceptibility to the environment: An evolutionary–neurodevelopmental theory.Dev Psychopathol. 2011; 23: 7-28
- Adolescent psychopathology: The role of brain-based diatheses, sensitivities, and susceptibilities.Child Dev Perspect. 2020; 14: 104-109
- Hippocampal volume as an amplifier of the effect of social context on adolescent depression.Clin Psychol Sci. 2017; 5: 632-649
- Adolescent externalizing problems: Contributions of community crime exposure and neural function during emotion introspection in Mexican-origin youth.J Res Adolesc. 2018; 28: 551-563
- Do hostile school environments promote social deviance by shaping neural responses to social exclusion?.J Res Adolesc. 2018; 28: 103-120
- A systematic review of barriers and facilitators to minority research participation among African Americans, Latinos, Asian Americans, and Pacific Islanders.Am J Public Health. 2014; 104: e16-e31
- Diversity in clinical and biomedical research: A promise yet to be fulfilled.PLoS Med. 2015; 12e1001918
- Uprooting institutionalized racism as public health practice.Am J Public Health. 2018; 108: 457-458
- Building a Better Race: Gender, Sexuality, and Eugenics From the Turn of the Century to the Baby Boom.University of California Press, Berkeley, California2001
Ledgerwood A, da Silva Frost A, Kadirvel S, Maitner A, Wang YA, Maddox KB (in press): Methods for advancing an open, replicable, and inclusive science of Social cognition. In: Hugenberg K, Johnson K, Carlston DE, editors. Oxford Handbook of Social Cognition. Oxford, UK: Oxford University Press.
- Psychology must grapple with Whiteness.Nat Rev Psychol. 2022; 1: 125-126
- Gender-heterogeneous working groups produce higher quality science.PLoS One. 2013; 8e79147
- Sex and gender bias in the experimental neurosciences: The case of the maternal immune activation model.Transl Psychiatry. 2019; 9: 90
- The diversity–innovation paradox in science.Proc Natl Acad Sci U S A. 2020; 117: 9284-9291
- Why ethnic minority groups are under-represented in clinical trials: A review of the literature.Health Soc Care Community. 2004; 12: 382-388
- Is deidentification sufficient to protect health privacy in research?.Am J Bioeth. 2010; 10: 3-11
- NINDS strategies for enhancing the diversity of neuroscience researchers.Neuron. 2020; 107: 212-214
- Applying a developmental lens to youth-led participatory action research: A critical examination and integration of existing evidence.Youth Soc. 2019; 53: 26-53
- Power to the people: Addressing big data challenges in neuroscience by creating a new cadre of citizen neuroscientists.Neuron. 2016; 92: 658-664
- Participatory neuroscience: Something to strive for?.The neuroethics Blog. 2018; (Available at:)https://neuronline.sfn.org/professional-development/participatory-neuroscience-something-to-strive-forDate accessed: February 18, 2022
- Diagnostic and Statistical Manual of Mental Disorders.5th ed. American Psychiatric Publishing, Washington, DC2013
- Diagnostic and Statistical Manual of Mental Disorders.5th ed, Text Revision. American Psychiatric Publishing, Washington, DC2022
- Meta-analysis: Are psychotherapies less effective for Black youth in communities with higher levels of anti-Black racism?.J Am Acad Child Adolesc Psychiatry. 2022; 61: 754-763
- Environmental and Chemical Toxins and Psychiatric Illness.American Psychiatric Publishing, Washington, DC2002
- Preventive psychiatry: A blueprint for improving the mental health of young people.World Psychiatry. 2021; 20: 200-221
- Social conditions as fundamental causes of disease.J Health Soc Behav. 1995; : 80-94
- Sexual orientation and gender identity in human rights impact assessment.Impact Assess Proj Appraisal. 2013; 31: 135-145
- Air pollution, racial disparities, and COVID-19 mortality.J Allergy Clin Immunol. 2020; 146: 61-63
- Race and ethnic group disparities in emotional distress among older adults during the COVID-19 pandemic.Gerontologist. 2021; 61: 262-272
- Gun deaths in America.FiveThirtyEight, 2016 (Available at:)http://fivethirtyeight.com/features/gun-deaths/Date accessed: March 1, 2022
- The environmental “riskscape” and social inequality: Implications for explaining maternal and child health disparities.Environ Health Perspect. 2006; 114: 1150-1153
- Breaking: Arizona house passes anti-transgender sports and medical care bans.Hum Rights, (Campaign), 2022 (Available at:)https://www.hrc.org/press-releases/breaking-arizona-house-passes-anti-transgender-sports-and-medical-care-bansDate accessed: April 25, 2022
- Teacher anti-CRT bills coast to coast: A state by state guide.Forbes, 2022 (Available at:)
- Mental health symptoms and inflammatory markers among HIV infected patients in Tanzania [published correction appears in BMC Public Health 2021;21:1535.BMC Public Health. 2021; 21: 1113
- Association of differential symptoms of stress to hair cortisol and cortisone concentrations among pregnant women in Kenya.Stress. 2020; 23: 556-566
- International Classification of Diseases, Eleventh Revision (ICD-11), World Health Organization (WHO) 2019/2021.
- Layers of inequality: Power, policy, and health.Am J Public Health. 2014; 104: S8-S10
- Keating D.P. Hertzman C. Developmental Health and the Wealth of Nations: Social, Biological, and Educational Dynamics. The Guilford Press, New York1999
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Publication history
Published online: June 16, 2022
Accepted:
June 6,
2022
Received in revised form:
May 17,
2022
Received:
March 8,
2022
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