All types of discrimination impacted metal health, substance abuse, and well-being

Both current and past discrimination—whether racial, sexual, age-related, or physical in nature—have a substantial adverse impact on mental health, substance abuse, and personal well-being among young adults in the U.S., according to findings from a nationally representative longitudinal study.

Interpersonal discrimination is widespread in the U.S., and the adverse health outcomes that proliferate as a result of discrimination are well established; however, there are substantial gaps in evidence regarding the impact of discrimination over time and during specific developmental periods, “such as the transition to adulthood (i.e., ages 18–28), a sensitive developmental window that sets the stage for health trajectories over the life course,” Adam Schickedanz, MD, PhD, of the David Geffen School of Medicine at the University of California, Los Angeles, and colleagues wrote in Pediatrics.

For their analysis, Schickedanz and colleagues set out to assess the short-term, long-term, and cumulative effects of interpersonal discrimination on both mental and behavioral health among young adults over one decade (2007-2017), as well as whether these associations differed based on the type of discrimination experienced.

“In this longitudinal study of a nationally representative sample of young adults, we found short-term, long-term, and cumulative associations between frequency of discrimination and adverse mental health, behavioral health, and well-being outcomes,” they found. “Increased frequency of discrimination was positively associated with higher prevalence of languishing, psychological distress, mental illness diagnosis, poor self-reported health, and drug use cross-sectionally and in 2- to 6-year lagged models. Cumulative high-frequency discrimination was also associated with higher prevalence of languishing, psychological distress, mental illness diagnosis, poor self- reported health, and drug use.”

Notably, while there were small differences in outcomes between different types of discrimination, their overlapping confidence intervals (CIs) suggested that the differences were nearly indistinguishable.

“The similar patterns seen across different types of discrimination provide evidence supporting a common pathway linking discrimination of various types with adverse mental health and well-being outcomes,” the study authors wrote. “In particular, our lagged models provide strong evidence that discrimination of all types has downstream associations with adverse mental health, substance use, and well-being outcomes.”

For their study, Schickedanz and colleagues used data from the Panel Study of Income Dynamics (PSID) and its Transition to Adulthood supplement (TAS), which included information on discrimination, mental health outcomes, self-reported health, and sociodemographic characteristics. They looked at six waves of the TAS—2007, 2009, 2011, 2013, 2015, and 2017.

Experiences of interpersonal discrimination were measured using the Everyday Discrimination Scale, which asks participants how often they experienced the following in day-to-day life:

  • Were treated with less courtesy.
  • Received poorer service.
  • Others treated you as stupid.
  • Others acted afraid of you.
  • Others treated you as dishonest.
  • Others acted superior to you.

Responses were scored using a six-point scale (1=never; 6=almost every day). Participants were asked whether they attributed the main reason for their experiences to their ancestry or national origin, sex, racial and ethnic identity, age, height and/or weight, other physical appearance, or another reason.

Mental health and well-being were evaluated using self-reported mental illness diagnosis, the Kessler Psychological Distress Scale (K6) score, and the Languishing and Flourishing (L/F) score. The study authors also collected data on substance use and self-reported health.

The final study sample consisted of 1,834 individuals ages 18-28, with an average participation of three TAS waves and an average response rate of 90% over all six waves. Overall mean age was 22.7 years; 53% of respondents were male, and 67% were White, 15% were Black, 14% were Hispanic, 3% were Asian American or Native Hawaiian and other Pacific Islander, and 1% were Indigenous or other.

Approximately 93% of the sample reported experiencing at least some discrimination over the six study waves (93% of White participants, 91% of Black participants; 94% of Hispanic participants; and 93% of remaining racial and ethnic identities). The main reasons for discrimination were ageism (26%), physical appearance discrimination (19%), sexism (14%), and racism (13%).

“Increased discrimination frequency was associated with higher prevalence of languishing (relative risk [RR] 1.34 [95% CI 1.2-1.4]), psychological distress (RR 2.03 [95% CI 1.7–2.4]), mental illness diagnosis (RR 1.26 [95% CI 1.1–1.4]), drug use (RR 1.24 [95% CI 1.2–1.3]), and poor self-reported health (RR 1.26 [95% CI 1.1-1.4]) in the same wave,” the study authors found. “Associations persisted 2 to 6 years after exposure to discrimination. Similar associations were found with cumulative high-frequency discrimination and with each discrimination subcategory in cross-sectional and longitudinal analyses.”

Schickedanz and colleagues concluded that their findings help shed light on “the multidimensional impact of discrimination on behavioral health and well-being and provides evidence supporting the recent shift in health care to address the effects of discrimination on mental health, substance use, and well-being… As the Covid-19 pandemic has brought on new mental health challenges, particularly for those in vulnerable populations, we have an opportunity to rethink and improve our mental health services to better address discrimination and provide more equitable delivery.”

In a commentary accompanying the study, Jennifer R. Walton, MD, MPH, of the College of Medicine at The Ohio State University in Columbus, and Adiaha Spinks-Franklin, MD, MPH, of Baylor College of Medicine in Houston, called on clinicians to not only be aware of the potential negative health consequences of discrimination, but to also be aware of their own implicit biases and how they approach their own practice.

“Clinicians should know 3 aspects vital to combating discrimination in health care: the impact of interpersonal discrimination, the role of implicit bias in perpetuating disparities, and decolonizing medical education and training,” they explained.

First, Walton and Spinks-Franklin asked physicians to be aware of interpersonal discrimination, or microaggressions, which can take the form of a lack of respect towards an individual or marginalizing, undervaluing, or scapegoating a person.

“Within the health care setting, this can include making disparaging comments to a patient or colleague about their weight, accented speech, name, or religious affiliation,” they wrote. “Acts of interpersonal discrimination in health care also include failing to provide translation services for patients who are fluent in languages other than spoken English; making assumptions about a patient’s intelligence on the basis of their economic status, educational level, or geographic origin; or refusing to see patients who are members of sexual or gender minority groups.”

Second, they emphasized the importance of addressing implicit biases embedded in the health care system. Evidence suggests clinicians tend to harbor similar biases regarding race, sex, weight, age, and mental illness to those seen among the general public, and those biases can have a dramatic influence on how physicians communicate with patients, how they treat them, and how satisfied the patient is with their care. They pointed to the Joint Commission report on implicit bias in health care as a useful tool for developing strategies to address bias, “including perspective-taking (the cognitive aspect of compassion that can reduce bias and deter unconscious stereotypes and prejudices), emotional self-regulation (experiencing positive emotions during patient encounters to build rapport, trust, and connection), and partnership building (working collaboratively with patients toward a common goal).”

Third, they wrote that it will be necessary to address bias and discrimination in medical curricula and continuing medical education. They highlighted three specific strategies that could help in this regard:

  • Adding a new Accreditation Council for Graduate Medical Education (ACGME) competency—Structural Competency, Health Equity, and Social Responsibility—to address “structural competency (e.g., understand implicit and/or explicit race and/or gender bias and its effects on health outcomes, health inequities, and patient care), structural action (e.g., incorporate direct interventions on patients’ social and structural determinants of health into all physician functions), and structural responsibility (e.g., examine the ethics of patient care decisions, with a focus on structural vulnerability and reducing the inequities faced by historically marginalized and oppressed populations).”
  • Completing the American Board of Pediatrics’ updated entrustable professional activity number 14, “Use Population Health Strategies and Quality Improvement Methods to Promote and Address Racism, Discrimination, and Other Contributors to Inequities Among Pediatric Populations. Spinks-Franklin was part of the task force that worked to update this activity.
  • Per a suggestion from researchers at the Royal College of Physicians, create a checklist for determining whether clinicians’ biases influence clinical decision making.

“Clinician biases and discriminatory actions in practice and/or in training against patients based on their demographic characteristics can lead to serious health consequences,” Walton and Spinks-Franklin concluded. “Clinicians play a central role in recognizing and addressing interpersonal discrimination in health care settings and during patient encounters. Institutions have a responsibility of addressing interpersonal discrimination within the work environment and with patient care activities. Committing to reducing and eliminating interpersonal discrimination in health care will promote a healthier society.”

  1. Both current and past discrimination have a substantial adverse impact on mental health, substance abuse, and personal well-being among young adults in the U.S., regardless of the reason for discrimination, according to findings from a nationally representative longitudinal study.

  2. Researchers argued that the similar patterns seen across different types of discrimination provide evidence supporting a common pathway linking discrimination of various types with adverse mental health and well-being outcomes.

John McKenna, Associate Editor, BreakingMED™

The study authors had no relevant relationships to disclose.

Spinks-Franklin was appointed to an American Board of Pediatrics task force to update entrustable professional activity 14, is a member of the American Board of Pediatrics Developmental Behavioral Pediatrics Subboard, and is an expert consultant for

Cat ID: 146

Topic ID: 87,146,730,138,139,192,146,925