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Cited by 139Suicide and Self-Harm StudiesRacial and Ethnic Identity ResearchMental Health Treatment and Access

Structural Racism and Suicide Prevention for Ethnoracially Minoritized Youth: A Conceptual Framework and Illustration Across Systems

Open access
Alvarez, Kiara, Polanco-Roman, Lillian, Samuel Breslow, Aaron, Molock, Sherry·2022·American Journal of Psychiatry
DOI 10.1176/appi.ajp.21101001PMC PMC9765395
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Abstract

Suicide rates among ethnoracially minoritized youth (i.e., youth of color) peak before the age of 30, and striking disparities in access to mental health services have been identified in this age group. However, suicide prevention strategies have yet to fully address structural racism as a mechanism in producing disparities in risk, protective factors, and access to quality effective intervention for youth of color. Such an approach is critical to provide more culturally responsive mental health care. Through an adapted socio-ecological model, the authors propose the Structural Racism and Suicide Prevention Systems Framework and illustrate pathways through which structural racism impacts suicide prevention and intervention for youth of color in the United States. The authors contextualize the impact of structural racism in three key settings where youth suicide prevention occurs: mental health services, schools, and the interface between crisis care and law enforcement. The authors posit that critical attention must be paid to the intersection of mutually reinforcing, interdependent systems rather than to systems in isolation. The authors then propose recommendations to address structural racism in suicide prevention, including macro-level interventions to improve societal conditions, research strategies to inform structural solutions, training approaches to address institutional racism, and clinical approaches to address the impact of racism and racial trauma on youths and families.

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Crossref · 10.1176/appi.ajp.21101001

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Claims the paper makes

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  • Premisecitation

    Micro-level interventions that address individual behavior in isolation, without addressing structural racism as a determinant of health, inevitably replicate systemic inequities.

    “As a result, micro-level interventions that address individual behavior in isolation, without addressing structural racism as a determinant of health, inevitably replicate systemic inequities (26).”
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  • Premisecitation

    The ecological-developmental approach is consistent with theories of how racism impacts health, including mental health, via biological, social, and psychological pathways.

    “The ecological-developmental approach is consistent with theories of how racism impacts health, including mental health, via biological, social, and psychological pathways (including through racial inequality in socioeconomic status, but also via multiple other independent mechanisms) (34).”
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  • Interpretationreasoning

    Suicide prevention strategies have yet to comprehensively target structural racism as a mechanism producing disparities in suicide risk factors, protective factors, and intervention access and quality.

    “Despite emerging attention to structural determinants of mental health, suicide prevention strategies have yet to comprehensively target structural racism as a mechanism producing disparities in suicide risk factors, protective factors, and intervention access and quality.”
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    Latina girls have reported the highest rates of suicidal ideation and attempts for decades in the national Youth Risk Behavior Survey.

    “Latina girls have reported the highest rates of suicidal ideation and attempts for decades in the national Youth Risk Behavior Survey”
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    The majority of youth suicides occur in an initial attempt.

    “Considering that the majority of youth suicides occur in an initial attempt (21)”
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    Premisecitation

    Structural racism not only impacts how services are delivered but is also codified into law, policy, and practices of policing and criminalization that affect suicide-related outcomes.

    “Structural racism not only impacts how services are delivered, but is also codified into law, policy, and practices of policing and criminalization that affect suicide-related outcomes (28, 42).”
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    Previous estimates show that up to 90% of youth suicide decedents had a psychiatric disorder.

    “which is considerably less than previous estimates showing that up to 90% of youth suicide decedents had a psychiatric disorder (13)”
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    Premisecitation

    The proposed framework relies on an ecological systems perspective describing individuals embedded within social, political, and economic systems that shape behaviors and access to resources necessary to promote health.

    “This framework relies on an ecological systems perspective, which describes how individuals are embedded within social, political, and economic systems that shape behaviors and access to resources necessary to promote health (23, 29).”
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    • cites [29] Bronfenbrenner U, 1992

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    Interpretationreasoning

    The effects of racism culminate in adverse outcomes at the individual level but cannot be explained or addressed via an individual-level focus alone.

    “Though the effects of racism culminate in adverse outcomes at the individual level, they cannot be explained or addressed via an individual-level focus alone.”
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    Study design and conductnone given

    Comparative estimates of suicide rates for children ages 5-12 are based on small sample sizes and should be interpreted cautiously.

    “It should be noted that comparative estimates of suicide rates for children of this age are based on small sample sizes and therefore should be cautiously interpreted.”
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    Premisecitation

    For Black, Asian/Pacific Islander, and American Indian people, suicide risk peaks in adolescence and young adulthood, while for White people it is higher in middle age and later life.

    “Specifically, risk for suicide is highest in adolescence and young adulthood for Black, Asian/Pacific Islander, and American Indian individuals, in contrast to higher risk in middle age and later life for White individuals (1, 2).”
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    In a probability-based study of nearly 300 public middle and high schools nationwide, schools with a greater percentage of Black students were more likely to implement a zero-tolerance policy and more likely to use excessively punitive discipline techniques.

    “In fact, in a probability-based study of nearly 300 public middle and high schools nationwide, schools with a greater percentage of Black students were more likely to implement a zero-tolerance policy and more likely to use excessively punitive discipline techniques (67).”
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    Black youth and youth with psychiatric problems, including suicidal behaviors, are overrepresented in institutional settings.

    “This information is especially concerning as Black youth and youth with psychiatric problems (50), including suicidal behaviors (51) are overrepresented in institutional settings.”
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    The national average ratio of school psychologists to students is 1:1,233, with some states reporting more than 1:10,000, exceeding the recommended 1:500.

    “Although the National Association for School Psychologists recommends a ratio of one school psychologist per 500 students, the national average is 1:1,233, with some states reporting more than 1:10,000 (54, 55).”
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    • cites [55] Whalen DJ, J Am Acad Child Adolesc Psychiatry

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    Interpretationreasoning

    These barriers reflect structural racism and converge to increase vulnerability to suicide-related risk for youth of color.

    “These barriers reflect structural racism and converge to increase vulnerability to suicide-related risk for youth of color.”
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    Interpretationcitation

    Youth of color experience longer care delays and present with more severe symptoms, making them more vulnerable to coercive or punitive responses common in acute and crisis care.

    “This finding suggests that youth of color experience longer care delays and present with more severe symptoms, which makes them more vulnerable to coercive or punitive responses common in acute and crisis care.”
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    Premisecitation

    Black youth report lower school belongingness, less school equity, and greater adjustment problems in schools with greater racial disparities in disciplinary actions.

    “Additionally, Black youth report lower school belongingness, less school equity, and greater adjustment problems in schools with greater racial disparities in disciplinary actions (70).”
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    • cites [70] Balfour ME, Psychiatr Serv

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    Premisecitation

    The expansion of SRO programs has translated into a 'school-to-prison' pipeline whereby student behaviors are criminalized, resulting in increased arrests particularly among Black students.

    “This change has translated into a ‘school-to-prison’ pipeline whereby student behaviors are criminalized, resulting in increased arrests particularly among Black students (59).”
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    Interpretationreasoning

    Structural racism limits the impact of school-based services, which disproportionately disadvantages youth of color.

    “However, structural racism limits the impact of school-based services, which, in turn, disproportionately disadvantages youth of color.”
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    Interpretationreasoning

    The barriers seen in schools replicate patterns observed in community-based suicide prevention services that yield delays or limit access to mental health care, which exacerbates symptoms and increases vulnerability to suicide-related risk.

    “The barriers seen in schools replicate patterns observed in community-based suicide prevention services that yield delays or limit access to mental health care, which exacerbates symptoms and increases vulnerability to suicide-related risk.”
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    Premisecitation

    Across studies, encounters with police during pathways to mental health care tend to be negative, with the most profoundly negative experiences among youth of color.

    “Across studies, encounters with police during pathways to mental health care tend to be negative, with the most profoundly negative experiences among youth of color (87).”
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    Interpretationreasoning

    Addressing problems as complex and societally rooted as structural racism and suicide prevention requires the integration of macro-level population health perspectives with expertise in microsystem-level mental health interventions.

    “We argue that addressing problems as complex and societally rooted as structural racism and suicide prevention requires the integration of macro-level population health perspectives with expertise in microsystem-level mental health interventions.”
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    Premisecitation

    Systems are complex, yet since people create and operate them, they can be changed.

    “Came and Griffith note that “systems are complex; but because they are people-made and people-run, they can be transformed” (113).”
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    Interpretationcitation

    Youth of color, particularly those with mental health concerns, describe living in a 'climate of fear', with police interactions potentially both a suicidal precipitant and a reason to avoid suicide crisis care.

    “As a result, youth of color, particularly those with mental health concerns, describe living in a ‘climate of fear’ (84), with police interactions potentially both a suicidal precipitant and a reason to avoid suicide crisis care.”
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    Interpretationreasoning

    The increase in emergency service utilization among youth of color suggests increased access to acute care yet also demonstrates overreliance on emergency services among youth of color.

    “This increase in emergency service utilization among youth of color suggests increased access to acute care yet also demonstrates overreliance on emergency services among youth of color.”
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    Premisecitation

    Black women, American Indian/Alaska Native men and women, and Latino men all have a higher lifetime risk of being killed by police compared to their White peers.

    “Black women, American Indian/Alaska Native men and women, and Latino men all have a higher lifetime risk of being killed by police compared to their White peers (82).”
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    Premisecitation

    Black adults who report negative interactions with police and Latinx youth who have experienced immigration raids and high rates of deportation in their communities are significantly more likely to report medical mistrust.

    “Indeed, Black adults who report negative interactions with police (88) and Latinx youth who have experienced immigration raids and high rates of deportation in their communities (89) are significantly more likely to report medical mistrust.”
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    Studies have examined the impact of more supportive school climate and same-sex marriage policies in reducing suicidal ideation and attempts, demonstrating analytic strategies linking macro and meso-level context to individual outcomes.

    “Studies in this area have examined the impact of more supportive school climate and same-sex marriage policies in reducing suicidal ideation and attempts, thus demonstrating analytic strategies linking macro and meso-level context to individual outcomes (102–104).”
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    Interpretationcitation

    Structural racism in suicide prevention is enacted within and across systems, so strategies for systemic change are complex and multifaceted.

    “Since structural racism in suicide prevention is enacted within and across systems, strategies for systemic change are therefore complex and multifaceted (90).”
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    Premisecitation

    The need for system-level approaches is reflected in documented associations between public policy and suicide rates by state in the U.S. as well as calls to measure and mitigate political determinants of suicide and racial disparities in suicide prevention.

    “The need for such system-level approaches is reflected in documented associations between public policy and suicide rates by state in the U.S. (92) as well as calls to measure and mitigate political determinants of suicide and racial disparities in suicide prevention (91, 93).”
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    Premisecitation

    Institutional racism's effect on psychiatry was widely discussed more than half a century ago.

    “Though the impact of institutional racism on the field of psychiatry was broadly discussed over 50 years ago (117–119)”
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    • cites [117] Thomas A, 1972

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    Premisecitation

    The Radical Healing framework helps communities of color thrive amid structural racism by promoting communal orientation, critical awareness, radical hope, resilience and resistance, and cultural authenticity and self-knowledge.

    “The Radical Healing framework is another example in which communities of color are empowered to thrive in the face of structural racism by promoting: collectivism, critical consciousness, radical hope, strength and resistance, and cultural authenticity and self-knowledge (129).”
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    Premisecitation

    One example is a racial-socialization family intervention for Black families in which the caregiver and child jointly process and prepare for racialized experiences.

    “A family intervention grounded in racial socialization developed for use with Black families, whereby the caregiver-child dyad actively processes and prepares for racialized experiences, is one example (128).”
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  • The paper relies on this without support.

    In youth suicide, only a small number of prevention and intervention strategies have proven effective.

    “Research in youth suicide is already a challenging endeavor in which few prevention and intervention strategies have demonstrated evidence of effectiveness.”

  • The paper relies on this without support.

    Police-led crisis intervention teams are the standard national approach for crisis intervention.

    “In terms of crisis care, given that police-led CITs are the national default in terms of crisis intervention, we recommend further mixed-methods investigations into how suicidal youth of color experience CITs.”

  • The paper relies on this without support.

    Structural racism can be dismantled only through structural solutions.

    “Ultimately, only structural solutions can dismantle structural racism.”

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    Structural racism's effects are most apparent at the collective level.

    “As the effects of structural racism are most evident on a collective level, so too should be the approach toward suicide prevention.”
4 of 4

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References 116 · Cited by 139

Research works printed but not linked: 14

  1. 2021, Office of the Surgeon General. Protecting Youth Mental Health: The US Surgeon General’s Advisory
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  3. Lau KSL, 2018, J Behav Health Serv Res, 45, 237
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Authors
Alvarez, K., Polanco-Roman, L., Samuel Breslow, A., & Molock, S.
Affiliations
  • Disparities Research Unit, Massachusetts General Hospital and Department of Medicine, Harvard Medical School, Boston (Alvarez); Department of Psychology, The New School, New York (Polanco-Roman); PRIME Center for Health Equity, Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Bronx, NY (Breslow); Health Equity Research Lab, Cambridge Health Alliance, Cambridge, Mass. (Breslow); Department of Psychological & Brain Sciences, The George Washington University, Washington...
  • The New School (US)
ORCID
Venue
American Journal of Psychiatry
Publisher
American Psychiatric Association Publishing
Published
2022-06-01
Volume
179
Issue
6
Pages
422-433
ISSN
  • 0002-953X (ISSN-L)
  • 1535-7228
DOI
10.1176/appi.ajp.21101001
PMC
PMC9765395
OpenAlex
W4281294494
Semantic Scholar
cb49f127bdb2f68a9d3ddd047244593129558f88
Cited by
139
References
116
Citations by year
2026: 28 · 2025: 38 · 2024: 35 · 2023: 29 · 2022: 9
FWCI
4.68
Type
journal article
Language
en
Open access
Locations
  • American Journal of Psychiatry (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
National Institute of Mental Health (K23MH112841, K23MH128582)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Suicide and Self-Harm Studies
  • Social Sciences › Sociology and Political Science › Racial and Ethnic Identity Research
  • Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
Keywords
structural racism, youth suicide prevention, youth of color, socio-ecological model, access to mental health care, racial trauma, institutional racism, school-based suicide prevention, intersectionality, health disparities
MeSH terms
Systemic Racism, Suicide Prevention, Adolescent, Humans, Schools, United States, Racism, Protective Factors

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