The COVID-19 pandemic, with its striking inequities in mortality rates between Whites and stigmatized racial/ethnic groups in the US and UK, and the recent global protests about police violence have raised questions about and increased interest in the potential impacts of racism on health and particularly on mental health.

Racism is an organized societal system in which the dominant White group categorizes individuals into “races” and devalues, disempowers, and differentially allocates resources to ethnic groups considered to be inferior¹. The ideology of inferiority permeates societal systems and institutions ensuring that racism is not limited to individual beliefs and behaviors¹. Racism operates through institutional, interpersonal and cultural pathways. Here we provide a brief overview of these levels of racism and how they can adversely affect mental health.

Institutional or structural racism can be defined as racial discrimination that is embedded in institutional structures and poli­cies¹. Examples of institutional racism include residential segregation, racialized immigration policy, and racialized incarceration. For example, in the US, residential segregation, the physical separation of races by enforced residence in particular places, is a central determinant of racial inequities in health. Residing in areas with concentrated poverty and social disadvantage can adversely affect mental health by leading to high levels of exposure to stressors (psychosocial, physical and chemical) and reduced access to opportunities and resources, including schooling, employment, and health services. Empirical analyses reveal that eliminating residential segregation in the US would erase racial differences in income, education and unemployment, and reduce racial differences in single motherhood by two thirds¹.

Immigration policies often reproduce ideologies of belonging and othering that are patterned by race/ethnicity and can adversely affect racialized immigrant groups. Research documents that exclusionary immigration policies with restrictions on rights and aggressive anti-immigrant policy enforcement have negative effects on mental health².

Racialized incarceration also has mental health consequences. The US have the largest incarcerated population globally, with an overrepresentation of Blacks and Latinos³. This has facilitated a historic shift from mental illness being treated in hospitals to being treated in carceral systems, which has led to jails and prisons in the US becoming the largest providers of mental health care. A national study in the US found that prior arrest history was associated with the prevalence of major depressive disorder among African Americans and Caribbean Blacks⁴. In addition, other US research reveals that aggressive policing, such as the killing of unarmed African Americans, leads to declining mental health for the entire Black population in the state in which the incident occurs¹.

Self-reported interpersonal discrimination is the most studied domain of racism in the mental health literature. A review of literature reviews and meta-analyses published between 2013 and 2019 on discrimination and health identified eight reviews focused on mental health⁵. Although most studies came from the US, there were studies from some 20 countries. This body of research indicates that discrimination was positively associated with increased risk of major mental disorders and inversely related to positive mental health outcomes such as life satisfaction and self-esteem. The accumulation of experiences of discrimination over time was associated with increasing risk of mental health problems. Exposure to discrimination was also associated with adverse changes in personality over time, such as increases in neuroticism.

Although the majority of studies have been cross-sectional, a growing number of prospective studies link discrimination to mental health risk. Some studies have also documented that the association between discrimination and mental health is robust to adjustment for potential psychological confounders such as neuroticism⁶. In addition, racial discrimination is also linked to worse mental health and increase in risky behavior for children and adolescents⁷. In addition to direct exposure to racial discrimination, vicarious exposure, through parental or caregiver experiences of discrimination, is also associated with worse mental health outcomes⁸.

Cultural racism refers to the racist ideologies that are present in the media, stereotypes, and norms of society that undergird institutional and interpersonal racism¹. It can affect mental health in multiple ways. First, cultural racism can initiate and sustain policies that create conditions which are harmful to mental health, such as housing decisions to maintain residential segregation which facilitates increased exposure to traumatic experiences and a broad range of physical and social stressors. Second, some members of stigmatized racial groups internalize the negative racial stereotypes of the culture, which in turn can lead to increased psychological distress and substance use. Third, cultural racism can also trigger stereotype threat – expectations and anxieties activated by a stigmatized group when negative stereotypes about their group are made salient. Research reveals that stereotype threat can lead to increased anxiety, reduced self-regulation, and impaired decision making, which can also affect patient-provider communication and adherence to medical advice¹.

Furthermore, cultural racism can lead to individual-level unconscious bias in clinicians that can trigger discrimination adversely affecting the quality of clinical care. For example, research has documented racial differences in the application of psychiatric diagnostic criteria, so that Latinos are diagnosed with anxiety disorders more frequently than White people reporting the same symptoms⁴. Similarly, clinicians exposed to the same symptoms are more likely to diagnose African Americans with psychotic disorders than mood disorders compared to Whites⁴.

Future research is needed to better understand the intersection of racial discrimination with other forms of group discrimination (e.g., gender-related) and identify how multiple forms of discrimination may impact mental health. Emerging evidence indicates that multiple forms of discrimination, such as racism and heterosexism, are associated with increased risk of mental health problems⁹. Additionally, our current understanding is limited about the potential intergenerational impacts of racism and their related epigenetic effects, with emerging evidence suggesting that these processes are likely to be operative¹.

Research on racism and mental health, to date, has focused more on documenting that racism matters than on identifying interventions to minimize the adverse effects of exposure to racism and reduce the occurrence of racism in the first place. Some evidence suggests that psychosocial resources such as social ties and religious involvement can reduce some of the negative effects of discrimination on mental health⁶. However, effectively addressing the multifactorial impacts of racism on mental health will require multilevel societal interventions that seek to build racial equity into homes, schools, neighborhoods and workplaces to minimize current racial economic gaps and improve socioeconomic and living conditions for the disadvantaged.

Interventions around resiliency and cultural/structural competency in the medical field have shown some promise, but more concerted attention is needed to address the multiple and interconnected systems through which racism operates^{1, 3}. Diversifying the mental health workforce in terms of including underrepresented racial/ethnic groups and professional experience (e.g., medicine, social work, religion) is also a necessary step towards addressing inequities in mental health care³. Comprehensive, coordinated, strategic initiatives are needed both within and outside of psychiatry and medicine to better understand, prevent and effectively intervene on the effects of racism on mental health.

COVID-19大流行，白人与美国和英国受污名化的种族/族裔群体之间的死亡率显着不平等，以及最近有关警察暴力的全球抗议活动引起了人们对种族主义对健康的潜在影响的关注，并引起了人们的更多关注尤其是心理健康方面。

种族主义是一种有组织的社会体系，其中占支配地位的白人将个人归类为“种族”，贬低，剥夺了他们的权能，并以不同的方式将资源分配给了劣等族裔¹。自卑意识形态渗透到社会制度和制度中，确保种族主义不仅限于个人的信仰和行为¹。种族主义通过体制，人际关系和文化途径运作。在这里，我们简要概述了这些种族主义水平以及它们如何对心理健康产生不利影响。

机构或结构种族主义可以被定义为被嵌入在体制结构和POLI-CIES种族歧视¹。制度种族主义的例子包括居住隔离，种族化的移民政策和种族化的监禁。例如，在美国，居住隔离是指在特定地方通过强制居住来实现种族之间的实际隔离，这是种族之间健康不平等的主要决定因素。居住在贫困集中和社会处境不利的地区，可能导致心理压力，心理，物理和化学因素的大量暴露，并减少获得包括学校教育，就业和保健服务在内的机会和资源的机会，从而对心理健康产生不利影响。实证分析表明，消除美国的居住隔离将消除收入，教育和失业方面的种族差异，并使单身母亲的种族差异减少三分之二^1。。

移民政策通常会重现以种族/民族为特征的归属感和其他意识形态，并可能对种族化的移民群体产生不利影响。研究文件指出，排他性移民政策对权利有限制，并且积极执行反移民政策对心理健康有负面影响²。

种族化监禁也对心理健康造成影响。美国是全球被监禁人口最多的国家，黑人和拉丁美洲人的比例过高³。这推动了历史性的转变，从医院治疗的精神疾病转变为在大肠系统的治疗，这导致美国的监狱和监狱成为最大的精神卫生保健提供者。在美国进行的一项全国研究发现，先前的逮捕史与非洲裔美国人和加勒比海黑人中主要的抑郁症患病率有关[ ^4]。此外，美国的其他研究表明，积极的警务（例如杀害手无寸铁的非洲裔美国人）会导致事件发生州的整个黑人人口的心理健康状况下降¹。

自我报告的人际歧视是心理健康文献中对种族主义研究最多的领域。在2013年至2019年期间发表的有关歧视与健康的文献综述和荟萃分析的综述中，发现有八篇关注心理健康的综述⁵。尽管大多数研究来自美国，但已有来自约20个国家的研究。这项研究表明，歧视与重大精神障碍风险的增加呈正相关，与积极的心理健康结果（如生活满意度和自尊）呈负相关。随着时间的流逝，歧视经验的积累与精神健康问题的风险增加有关。受到歧视也与人格随时间的不利变化有关，例如神经质的增加。

尽管大多数研究都是横断面研究，但越来越多的前瞻性研究将歧视与精神健康风险联系起来。一些研究还证明，歧视与心理健康之间的关联对于适应潜在的心理混杂因素（如神经质^6）具有很强的适应性。此外，种族歧视还与较差的心理健康和儿童和青少年的危险行为增加有关⁷。除了直接暴露于种族歧视之外，通过父母或照料者的歧视经验进行的替代暴露也与较差的心理健康结果有关⁸。

文化种族主义是指在媒介，刻板印象和社会规范中所存在的种族主义意识形态，这些意识形态是制度和人际种族主义的基础¹。它可以通过多种方式影响心理健康。首先，文化种族主义可以发起和维持创造不利于心理健康的条件的政策，例如做出维持居住隔离的住房决定，这有利于增加遭受创伤经历的机会以及各种各样的身体和社会压力。第二，受污名化的种族群体的某些成员将文化的负面种族刻板印象内化，这反过来又会导致心理困扰和物质使用增加。第三，文化种族主义也可能引发刻板印象威胁–当对他们的群体的负面刻板印象变得明显时，被污名化的群体会激发期望和焦虑。研究表明，刻板印象威胁会导致焦虑加剧，自我调节能力降低以及决策受损，¹。

此外，文化种族主义可能导致临床医生在个人层面上无意识的偏见，从而可能引发歧视，从而对临床护理质量产生不利影响。例如，研究已证明在应用精神病学诊断标准时存在种族差异，因此与报告相同症状的白人相比，拉丁美洲人被诊断出患有焦虑症的频率更高⁴。同样，与白人相比，暴露于相同症状的临床医生比情绪障碍更容易诊断出患有精神病的非洲裔美国人⁴。

需要进行进一步的研究，以更好地理解种族歧视与其他形式的群体歧视（例如，与性别有关）的交集，并确定多种形式的歧视如何影响心理健康。越来越多的证据表明，多种形式的歧视，例如种族主义和异性恋，与精神健康问题的风险增加有关[ ^9]。此外，我们目前对种族主义的潜在代际影响及其相关的表观遗传效应的理解是有限的，新兴证据表明这些过程可能是有效的¹。

迄今为止，对种族主义和心理健康的研究更多地集中在证明种族主义至关重要，而不是确定干预措施以最大程度地减少暴露于种族主义的不利影响并首先减少种族主义的发生。一些证据表明，社会关系和宗教参与等社会心理资源可以减少歧视对心理健康的负面影响⁶。但是，要有效解决种族主义对心理健康的多方面影响，就需要采取多层次的社会干预措施，力求在家庭，学校，社区和工作场所建立种族平等，以最大程度地减少当前的种族经济差距，并改善处境不利者的社会经济和生活条件。

在医学领域围绕复原力和文化/结构能力进行的干预已显示出一定的希望，但是需要更多的共同关注以解决种族主义通过其运作^1，3所造成的多重和相互联系的系统。在包括人数不足的种族/族裔群体和专业经验（例如医学，社会工作，宗教）在内的方面，使精神卫生工作人员多样化也是解决精神卫生保健不平等³的必要步骤。精神病学和医学内外都需要采取全面，协调，战略性的举措，以更好地了解，预防和有效干预种族主义对心理健康的影响。