Psychosis and the Burden of Inequality

This week, Mad in America examines three articles around discrimination and psychosis. The first explores human rights violations, coercion, structural discrimination, and social exclusion against people that experience psychosis. The second finds that minority identity, police violence, experiencing discrimination, and childhood adversity are linked to increased odds of psychosis. The third reports that trauma, stigma, and structural disadvantage shape women’s recovery from psychosis.

Coercion and Human Rights Violations Remain Widespread for People that Experience Psychosis

A new systematic literature review and narrative synthesis published in The Lancet Psychiatry reports people that experience psychosis are routinely exposed to coercion and human rights violations despite international human rights standards. This research, led by Piers Gooding from La Trobe University in Australia, also finds that structural discrimination and social exclusion are common. The authors recommend integrating mental health into universal health coverage as well as legal reforms to bring mental health laws in line with the UN Convention on the Rights of Persons with Disabilities (CRPD).

The goal of this study was to examine how mental health policy, legal systems, and social conditions affect the rights of people that experience psychosis. While this research investigated psychosis and human rights worldwide, the authors focused on low- and middle-income countries in particular.

The authors performed an international literature review of studies published in English that investigated psychosis along with human rights, coercion, discrimination, community inclusion, or healthcare. Studies were excluded if they were not related to psychosis. Commentaries, editorials, book chapters, conference papers, interventions focused solely on stigma reduction, peer support research, and randomized controlled trials that did not focus on social determinants of psychosis were also excluded. In total, the authors used data from 352 papers published between January 1, 1990 and August 7, 2025.

Coercion and human rights violations were common in the literature. Involuntary hospitalization, forced drugging, physical and mechanical restraint, seclusion, shackling, involuntary confinement within homes and communities, and institutional abuses were all listed as human rights abuses in the current work. Involuntary hospitalization and forced drugging were more common in high- and middle-income countries, while shackling, detention in prayer camps, and involuntary confinement in homes and communities were more common in low-income countries.

People that experience psychosis faced more police violence and the authors note that every country included in the current review had police forces that were ill-equipped to respond to mental health issues. Demographics such as gender, cultural background, race, class, etc. also significantly affected rates of experiencing coercion, with minorities at greater risk. While there is some debate around whether psychiatric coercion should be stopped or minimized, experts generally agree that it is harmful.

People that experience psychosis face discrimination throughout many life domains. Healthcare workers often dismiss physical complaints and illnesses as psychological in this population, leading to worse healthcare and higher rates of mortality. This group is more likely than other people with a mental health diagnosis to be involuntarily detained, drugged, and stripped of their ability to make their own healthcare decisions. People that experience psychosis also face discrimination in employment, education, housing, and social inclusion. The authors note that while discrimination is a serious issues for everyone that experiences psychosis, minorities that experience psychosis experience the most discrimination.

One significant barrier to recovery is social exclusion. The authors emphasize that recovery is more than simple symptom reduction. Sustained recovery often relies on meaningful social relationships, stable housing, and stable employment. Unfortunately, people that experience psychosis often face discrimination and social exclusion. This can result in a cycle of social disadvantage worsening their mental state, and their worsening mental state resulting in more social disadvantage.

The authors recommend integrating mental healthcare into universal healthcare models and reforming laws around mental health to better reflect the principals of the CRPD. This would involve expanding supported decision-making, reducing coercive practices, increasing investment in community services, and involving people with lived experience of psychosis in policy decisions and mental healthcare systems.

This research had several limitations. The included studies varied significantly in methodology, populations, legal contexts, and outcomes measures. The findings have limited generalizability across the many mental health systems included in the current work. The focus and low- and middle-income countries further reduces generalizability to high income countries. The authors only included studies published in English, meaning they likely missed insights from non-English language sources.

Discrimination, Police Violence, and Childhood Adversity Increase Psychosis Risk

A new study published in Schizophrenia Bulletin finds that identifying as black, indigenous or a person of color (BIPOC) was linked to higher rates of experiencing psychosis. This study, led by Jacqueline I Cosse from New York University, also finds increased rates of psychosis for people that have experienced police violence, higher rates of discrimination, childhood abuse, and bullying.

The goal of the current work was to test the social defeat hypothesis in the United States. This hypothesis suggests that chronic exclusion, discrimination, marginalization, and oppression increases the likelihood of psychotic experiences. The authors also sought to expand the social defeat hypothesis by including structural racism and police violence as contributors to psychosis as these realities are particularly relevant in the US.

The authors used data from the US National Survey of Poly-Victimization and Mental Health, a self-report survey that collected data from 1,555 US adults between the ages of 18 to 29 with greater representation from marginalized groups such as BIPOC and LGBTQ individuals. This research measured the links between self-reported psychotic experiences over the past 12 months and indicators of social defeat and marginalization, including race, everyday discrimination, police violence, childhood abuse, bullying, substance use, education, income, urbanicity, gender, and sexual orientation.

BIPOC participants had a 60% higher likelihood of reporting a psychotic experience during the last 12 months compared to white participants. Those that reported high rates of child abuse were a 116% increased odds of psychosis. Psychotic experiences were also more likely to be reported by participants that experienced high rates of bullying during their childhood (89% increased odds), those that had experienced police violence in the past year (52%), and those that reported higher amounts of perceived discrimination (177%).

This study had several main limitations. The design of the study means the data cannot speak to causes. This means that while certain factors were linked to psychotic experiences, the authors can not definitively say that they caused these experiences. The variables were measured at a single point in time and the authors were not able to determine if factors preceded the reported psychotic experiences. The self-report nature of the survey means the data was susceptible to misremembering and misreporting. The sample of participants came from the US and the survey was only offered in English, limiting generalizability of the findings.

Trauma, Stigma, and Structural Disadvantage Shape Women’s Recovery from Psychosis

A new study published in Culture, Medicine, and Psychiatry finds that women’s recovery from psychosis is shaped by trauma, stigma, structural disadvantage, and gender-specific experiences such as social expectations. This research, led by Chizara Lock from the University of Birmingham in the UK, concludes that mental health services need to adopt trauma-informed care models and gender-sensitive approaches that recognize the influence of women’s social roles, lived experiences, and systemic inequalities on recovery from psychosis.

This study sought to examine the barriers faced by women recovering from psychosis, with special attention given to how both biological sex and socially constructed gender roles influence these barriers. The authors used interview data from a previous study that investigated women’s lived experience of first-episode psychosis. Participants were recruited from early intervention services in England. In total, the authors examined interview data from 31 participants and identified common themes in these women’s lived experience of psychosis. The authors identified four major themes involving barriers to recovery from psychosis.

(1) Identity and diminished self-esteem involved women reporting significant changes in their identity following experiences of psychosis. One participant said “I think once you’ve experienced psychosis, you can’t be the same person ever again.” Participants reported struggling with their expected social roles such as being a mother, which often reinforced their sense of inadequacy and losing their previous identity.

Many lost trust in themselves which effected their ability to perform daily tasks and lowered their self-esteem. Participants also struggled with weight gain from antipsychotic use. This intensified self-esteem issues due to societal expectations around femininity and thinness and made many participants feel further alienated from their pre-psychosis selves.

(2) The influence of past experiences included participants linking their experience of psychosis to earlier traumas. Many spoke of child abuse, domestic violence, sexual assault, and traumatic childbirth as causes of their psychosis. For example, one participant linked her experience of an abusive relationship to her psychosis, saying “I just completely had this big meltdown and decided that everybody, if they were a man, had an axe under their coat and that they were chasing me round with axes.”

Participants believed recovery was harmed when mental health services focused on symptoms of psychosis rather than underlying traumatic experiences. These unresolved traumas could act as significant barriers to recovery. Participants also reported ups and downs in their recovery journeys and feelings of stagnation as negatively affecting their recovery.

(3) Social imaginings of psychosis and stigma dealt with discrimination and loss of support due to people’s biased attitudes towards those that experience psychosis. Stigma resulted in many participants losing close relationships with friends and family. Participants reported prejudice in healthcare with one saying “Once somebody figures out that you’ve got a problem like that [psychosis], that’s when they stop taking you seriously.” Some also felt that media depictions of people with psychosis limited their ability to find employment, form social connections, and access healthcare.

(4) Socioeconomic and structural barriers included poverty, unemployment, insecure housing, and limited support from health and social services. These factors led some participants to lose their sense of agency and hope, significantly complicating the recovery process.

This study had several limitations. The interviews were collected during a previous study, so barriers to recovery were not explicitly explored. All the participants came from England and most were white, significantly limiting generalizability to other populations. The study did not examine the influence of drugs, therapy, or other interventions on recovery. The interviews were conducted years after the participants’ first-episode psychosis and could have been susceptible to misremembering.

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Cosse, J. I., Amos, B. J., Prout, L., Downey, D. L., Kim, S., Secaira, S., Fedina, L., & DeVylder, J. E. (2025). Social defeat and psychosis in the United States: A replication and critical reconceptualization. Schizophrenia Bulletin, 52(2). (Link)

Gooding, P., Kumar, S., Encalada, A. V., Juan, N. V., Chen, B., Dutta, J., Toncón-Chaparro, L., & Pathare, S. (2026). Psychosis, human rights, and legal frameworks: Global perspectives, with a focus on low-income and middle-income countries. The Lancet Psychiatry. (Link)

Lock, C., Lavis, A., Pendrous, R., & Greenfield, S. (2026). Exploring barriers to recovery amongst women with psychosis: A qualitative secondary analysis. Culture, Medicine, and Psychiatry, 50(2). (Link)