Structural Racism in Psychiatric Research Careers: Eradicating Barriers to a More Diverse Workforce
Publication: American Journal of Psychiatry
Abstract
Investigators from minoritized backgrounds are underrepresented in psychiatric research. That underrepresentation contributes to disparities in outcomes of access to mental health care. Drawing on lived experience, scholarly qualitative reports, and empirical data, the authors review how the underrepresentation of minoritized researchers arises from interlocking, self-reinforcing effects of structural biases in our research training and funding institutions. Minoritized researchers experience diminished early access to advanced training and opportunities, stereotype threats and microaggressions, isolation due to lack of peers and senior mentors, decreased access to early funding, and unique community and personal financial pressures. These represent structural racism—a system of institutional assumptions and practices that perpetuates race-based disparities, in spite of those institutions’ efforts to increase diversity and in contradiction to the values that academic leaders outwardly espouse. The authors further review potential approaches to reversing these structural biases, including undergraduate-focused research experiences, financial support for faculty who lead training/mentoring programs, targeted mentoring through scholarly societies, better use of federal diversity supplement funding, support for scientific reentry, cohort building, diversity efforts targeting senior leadership, and rigorous examination of hiring, compensation, and promotion practices. Several of these approaches have empirically proven best practices and models for dissemination. If implemented alongside outcome measurement, they have the potential to reverse decades of structural bias in psychiatry and psychiatric research.
U.S. psychiatry, like most medical specialties, has low representation of racial and ethnic minoritized groups (1). Minoritized groups comprise 32.6% of the general U.S. population but considerably smaller fractions of psychiatric residents (16.2%), faculty (8.7%), and practicing physicians (10.4%) (2). The lack of diversity in academic psychiatry is even more stark: White psychiatrists comprise the majority (77%) of department chairs, compared with 5% for Latinx, 8% for Asian, and 4% for Black psychiatrists (3). This distribution reflects similar gaps across specialties—surgery and internal medicine, for example, each with 8% minoritized faculty (3, 4). Black faculty representation is actually decreasing compared with other minoritized faculty (5), despite efforts toward increasing Black representation. We highlight here an important difference between “minority” and “minoritized.” Whether or not they are proportionally represented in the physician population, certain groups are minoritized in medicine and medical research: they are subject to negative stereotypes and barriers, detailed below, that actively reduce their participation and limit access to power and leadership opportunities. (See Box 1 for a brief glossary of related terms.)
BOX 1. Relevant terms and definitions
Cluster hiring: An emerging practice that involves hiring multiple minoritized faculty simultaneously, either into multiple departments or programs or a single integrated program or center. The simultaneous hiring is meant to enable mutual support and peer mentoring.
Generational wealth: Financial assets passed by one generation of a family to another, either overtly (e.g., inheritances and gifts) or implicitly (e.g., the use of a parent’s well-established credit to access loans at lower interest rates).
Hidden curriculum: Values and attitudes taught by an educational institution implicitly, as opposed to through explicit materials and instruction. A hidden curriculum teaches which activities, identities, or styles of self-expression are valued and devalued by a community or discipline. These values are implicitly conveyed based on what leaders, faculty, and trainees praise or avoid, often in informal settings outside the classroom or laboratory (81).
Higher-tier institutions: Institutions designated as research universities, with formal classification of tier based on number and/or types of doctoral degrees awarded, total research and development expenditures, and number of research staff employed by the university. The Carnegie Classification of Institutions of Higher Education is a common example.
Intersectionality: Some minoritized researchers identify with more than one minoritized or negatively stereotyped group. Multiple forms of minoritization can interact, with negative synergies. As described in the main text, female minoritized researchers face more barriers in establishing research careers than do male minoritized researchers, because they experience gender bias in addition to racism. Minoritized researchers who are from socioeconomically disadvantaged backgrounds or who have minoritized sexual/gender identities similarly may experience additional burdens.
Minoritized: Preferable term to “minority.” The term “minoritized” recognizes that the process of being treated as a minority (experiencing structural racism in the forms described in this Box) is an active social process, carried out by individuals who currently have social power.
Microaggression: A comment or action that subtly and often unconsciously expresses a biased attitude toward a member of a minoritized group. Although these comments are not intended to cause harm, minoritized researchers are frequently conscious of their minoritized status and the related stereotypes. The minor exclusionary effect of individual microaggressions can accumulate over time to cause significant emotional burden and self-doubt.
Representation gap: A situation in which the percentage of minoritized people in a given profession or setting is substantially lower than the percentage that would be expected given the general adult population and/or the local demographics.
Stereotype threat: A “socially premised psychological threat that arises when one is in a situation or doing something for which a negative stereotype about one’s group applies” (102). A trainee may fear fulfilling stereotypes about his or her minoritized group (e.g., lack of intelligence or work ethic), and through the effects of fear on performance, that fear may become a self-fulfilling prophecy.
Structural racism: “The totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, earnings, benefits, credit, media, health care, and criminal justice. These patterns and practices in turn reinforce discriminatory beliefs, values, and distribution of resources” (103).
Targeted mentoring: This refers to mentoring aimed at a particular population, such as minoritized researchers.
The underrepresentation of minoritized groups in psychiatry is compounded by persistent funding disparities (6–10). Even after controlling for a researcher’s publication record, training history, and previous grants, minoritized researchers remain less likely to receive grants from the National Institutes of Health (NIH) and other funding agencies (6, 8), even if they have received NIH support earlier in their training (11). This directly harms public health, as minoritized scientists are more likely to study topics that affect minoritized groups (7, 12–14). Minoritized groups have higher mental illness burdens and worse access to care (15, 16), and are less well served by current treatments (17), largely due to structural racism in psychiatric practice (15, 18). Thus, an underrepresentation of minoritized researchers directly limits the execution and dissemination of research that optimizes clinical outcomes for all people. This opposes our mission and values as physicians.
Closing the gap in representation of minoritized researchers requires understanding its causes. The gap exists not because of a lack of qualified minoritized researchers (19, 20), but as a consequence of a system operating as it was designed, with historical values and rules that create barriers limiting minoritized researchers’ success. At each stage of their careers, minoritized researchers face barriers rooted in structural racism—a system whereby policies, institutional practices, cultural representations, and other norms reinforce and perpetuate inequity (21). Structural racism is intimately linked to financial disadvantage, societal exclusion, and classism, which exacerbates the barriers to minoritized researcher participation in research. These barriers are not unique to our specialty, and because psychiatric research often involves nonpsychiatrists, overcoming them will be an interdisciplinary effort. That said, psychiatry’s specific history of racist practices (22, 23) may require psychiatry-specific solutions. Here, we describe those barriers, with empirical data where available, but also through synthesis of first-hand observations and experiences of the authors. These perspectives were solicited as part of an American Psychiatric Association Council on Research effort to understand and overcome structural racism in research (see the online supplement ). They span the experiences of physician scientists at various career stages from both minoritized and non-minoritized backgrounds. We then identify existing and new programs, from the national to the laboratory level, that might reverse structural racism. Many of those solutions place a burden on present-day leaders to spend resources on problems we did not intentionally create. That resource commitment is uncomfortable but necessary to achieve a truly equitable research workforce and the resulting equitable health outcomes (24). In many ways, it represents payback for burdens that our training and promotion systems have imposed on minoritized researchers for decades.
Structural Barriers to Equity, Diversity, and Inclusion in the Research Workforce
Lack of Access to Knowledge and Experience at Early Career Stages
Many minoritized researchers begin their careers with a technical disadvantage. Research design and execution requires skills beyond those comprising standard medical school and residency curricula. Those skills are infused into the environments of elite academic centers, where research core facilities and/or Clinical Translational Science Institutes have been established. Access to highly resourced institutions is guarded by admissions processes that rely heavily on test scores and personal interviews for evaluation of “fit” with the existing culture. Both processes can reduce the admission rate of otherwise qualified minoritized researcher trainees (25–27). In general labor market studies, résumés labeled with names associated with White applicants (e.g., Emily or Greg) are more likely to be selected for interviews and to be viewed favorably compared with the same résumés when labeled with names associated with Black applicants (e.g., Lakisha or Jamal) (28–30). This is true even within companies seeking to improve their diversity (31). This is an example of how structural biases against cultural practices, such as parents’ naming choices, can create bias against minoritized researchers. Those biases can deny minoritized researchers access to strong, well-connected mentors. Without that early access to mentors and technical support, prospective minoritized researchers may never have a chance to discover natural capabilities for research. Higher-tier research institutions are also more likely to support the type of training in advanced or emerging methods needed for an early-career researcher to prepare innovative funding proposals.
Financial Pressure
Success in research is correlated with the researcher’s economic background; tenure-track faculty are likely to have parents with high educational attainment and incomes (32). This creates an additional burden for minoritized researchers, because racist policies have produced structural race-based wealth inequalities in the United States. Minoritized researchers are less likely to be able to buffer the financial demands of a research career, particularly in its early stages. Immediately after residency, aspiring clinician-researchers must forgo attending-level salaries to spend years in fellowship training. After fellowship, researchers largely work in academic medical centers, where compensation is lower and subject to legislated salary caps. Nonclinician researchers face similar challenges through the extended postdoctoral process. Early professional success depends on networking—for example, through travel to conferences and meetings—and minoritized researcher trainees are more likely to come from financially disadvantaged backgrounds, with substantial prior educational debt (33–35). Compared with non-minoritized researchers, minoritized researchers are more likely to be the only members of their families with scientific or medical training and are more likely to be called upon to coordinate medical care for family members and/or to be responsible for caregiving and financially supporting extended family (33, 36). With little access to generational wealth as a safety net and fewer resources to buffer difficult funding environments, minoritized researchers may face financial pressures that lead to self-selection out of research careers (37).
Available supports do not mitigate these problems. Military medical scholarships require a 4-year graduation plan, which prevents minoritized researchers from participating in more intensive research training. Postgraduation military or other service obligations also tend to be incompatible with the necessary early steps in a research career. Combined M.D.-Ph.D. and D.O.-Ph.D. programs can provide the training foundation needed to sustain a research trajectory, but competitive applicants to combined degree programs usually have substantial undergraduate and/or postbaccalaureate research experiences. These experiences are more difficult to achieve at minority-serving institutions or without access to generational wealth. For instance, of 60 NIH-supported Medical Scientist Training programs, only three are at federally designated minority-serving institutions (in Arizona and Texas), and there are none at historically black medical schools. The NIH Loan Repayment Program (LRP) is specifically designed to support budding researchers, but minoritized researchers (and Black/Hispanic researchers in particular) have persistently lower award rates (the mean success rate is 53.5% for White applicants, compared with 37.2% for Black applicants) (38). There is a specific LRP for applicants from disadvantaged backgrounds; it receives 1.5% of the LRP applications, gives out 1.25% of the awards, and has a lower success rate than the LRP as a whole (38% vs. 51%) (38).
Misalignment With Funding Policies and Priorities
Minoritized researchers are more likely to have lived experience with health disparities and are more likely to pursue research on topics related to disparities (7). This increases the impact of their work but paradoxically can reduce their likelihood of securing research funding. For over a decade, federal funding for mental health research has emphasized the search for biological mechanisms. Mechanistic understanding of processes underlying health and disease is clearly needed, but its overprioritization by funding bodies may inadvertently harm the development and success of minoritized researchers. Further, mechanistic studies tend to require advanced resources (e.g., specialized equipment and laboratory assets) that are less accessible to minoritized researchers, as described above.
Insufficient institutional and mentoring support may also affect minoritized researchers’ funding. Health disparities research is often grounded in local communities that are not well served by academic medicine. In the authors’ experience, attempts to identify and address health disparities may trigger defensive and/or dismissive reactions from academic leaders that further limit the availability of institutional funding or other resources for early-career investigators. Indeed, a major factor shown to predict retention in research training is the degree of alignment in the topics of interest between mentor and trainee (39). Reaching this alignment may be more difficult for minoritized researchers (37), particularly if they choose understudied topics for their research focus. Lower degrees of alignment also may reduce minoritized researchers’ success rate in early career grant applications, as the mentor’s current funding and prior productivity are weighted heavily in the review of mentored early-career grants. On the other hand, minoritized researchers who perceive their institutions as aligned with their impact goals are more likely to remain in academia (20).
Social and Institutional Pressure
Minoritized researchers may also experience unique social and institutional pressures. Minoritized clinicians can be pressured to prioritize direct patient care over research activities, due to the shortage of non-minoritized psychiatrists and psychiatric clinics in minoritized communities (40). Minoritized researchers may often feel an additional responsibility to provide care to an ethnically congruent patient population, whether or not doing so promotes their professional and scientific goals. They may have accepted scholarships from sponsors who assumed that they would return to and care for a particular community, or they may face corresponding family/community expectations. Non-minoritized researchers generally do not face these expectations and may even inadvertently reinforce them, even as they seek to foster inclusion. For example, academic leaders may ask minoritized research faculty to spearhead community engagement initiatives (5, 40–44). Minoritized researchers, even early in their careers, often face differential expectations and are disproportionately asked to take on additional mentorship roles to provide guidance for minoritized trainees (5, 41–43). Beyond their usual clinical care duties, minoritized researchers may also be solicited in private requests from patients seeking an ethnically congruent clinician. Satisfying these pressures leaves less time for research.
Microaggressions
Microaggressions are the everyday slights, invalidations, and offensive subtle behaviors that people from minoritized backgrounds experience daily from generally well-intentioned individuals who are not aware they are acting in disempowering and demeaning ways (45, 46). The prominent Black psychiatrist Chester Pierce was the first to describe these covert acts as microaggressions (47). Throughout their careers, minoritized researchers may receive subtle messages that they do not belong because they do not “look like,” “sound like,” or “act like” a stereotypical White male scientist (44, 48–54). For instance, non-minoritized people often express genuine shock or amazement when a non-White person can communicate well, often followed by some variant of the sentiment “Oh wow, you are so articulate.” Black researchers, including some of the authors, have experienced being followed by security guards or being mistaken for nonacademic staff while at work (54).
A research career requires extraordinary persistence in the face of obstacles, rejections, and bad luck. Each microaggression plants an additional seed of doubt and lessens the chance that a minoritized researcher trainee will self-advocate for additional resources, protected time away from clinical duties, access to training opportunities, or any other factor needed for career success. Compounding the adverse effects of microaggressions, minoritized researchers who do self-advocate may be labeled as “loud,” “pushy,” or “entitled” for the same behaviors considered “proactive” and “independent” when used by their non-minoritized colleagues.
Stereotype Threat and Cohort Difficulties
A stereotype threat exists when a person from a background carrying a negative stereotype (e.g., “Black people are less smart than White people”) fears that they may conform to that stereotype (e.g., actually be less smart than their White colleagues) (55, 56). Stereotype threats are reinforced by the lack of a cohort of peers from similar minoritized backgrounds (57). White trainees see many examples of successful researchers who look like them and have a shared cultural understanding, whereas non-White trainees see few. Stereotype threats can also be reinforced by institutional policies and/or microaggressions. Minoritized researchers may face anxieties and uncertainties about success in isolation, with stereotype threats visibly reinforced by the lack of direct role models in the environments where they learn and work (44, 54, 58).
Intersections, Interactions, and Negatively Synergistic Effects on Minoritized Researcher Career Trajectories
The problems described above interact and self-reinforce (Figure 1). For instance, a desire to focus on academics without being distracted by stereotype threat and microaggressions may lead an aspiring minoritized researcher to train at a historically minority-serving institution. However, that decision may result in less exposure to advanced technology and well-networked mentors (59) and may lead the minoritized researcher to choose research topics with lower chances of early funding and publication success. Alternatively, a minoritized researcher who aims to mitigate those institutional disadvantages and undertakes training at a higher-tier research institution may, as a consequence, face more isolation. The interactions between these elements reflect biases embedded in the culture and processes of research institutions and are a symptom of structural racism (60). For example, institutional policies for review and evaluation of an investigator’s scientific productivity, allocation of internal research funding, and appropriateness for faculty promotion involve the application of performance criteria that reflect implicit assumptions about the researchers’ personal resources, non-work responsibilities, and past opportunities. The assumptions applied during these evaluations specifically disadvantage minoritized researchers and magnify the hurdles they face.
FIGURE 1. Self-reinforcing effects of structural racism leading to minoritized researcher underrepresentationa
aArrows denote factors that can strengthen or perpetuate each other. Multiple factors can self-reinforce, either within an individual or across academic generations (for example, lack of senior minoritized researchers diminishes early research access for junior minoritized researchers, which leads to lack of senior minoritized researchers in the subsequent generation). Thus, reversing inequities requires multiple simultaneous solutions.
A second source of negative synergies is intersectionality—the additional burden faced by minoritized researchers who hold more than one minoritized identity (61). For instance, as a result of gender bias (sexism/heterosexism) intersecting with structural racism, female minoritized researchers are less likely to obtain independent research funding after training than either male minoritized researchers or female non-minoritized researchers (11). Female minoritized researchers are vastly underrepresented in psychiatric leadership compared to their White and non-White male counterparts (5). Socioeconomic status, sexual/gender identity, disability, and illness all can be targets of bias and negative stereotypes (62). At the same time, not all intersections are equal. A minoritized sexual identity or disability is often invisible to colleagues, whereas gender and race usually are overt. The authors who hold intersectional identities have more often felt stereotyped and devalued because of our race than from any other factor.
Therefore, as a profession and scientific discipline, we need to remove barriers that negatively impact the trajectories of minoritized researchers, both to improve our diversity of scientific thought and because it is our ethical duty as physicians to do so (63).
Interventions to Expand Minoritized Researcher Participation and Visibility in Research
Multifactorial barriers with deep structural roots require multifactorial solutions (64–67). There are evidence-based approaches to reducing these barriers, and many are underutilized. We emphasize that reversing structural racism will require several, possibly all, of the below strategies to be applied in parallel. As noted above, both psychiatrists and nonpsychiatrists will need to be part of those efforts to ensure that we reach all aspects of the psychiatric research workforce. Because these structural factors self-reinforce, tackling any one in isolation is unlikely to produce large effects.
Comprehensive Early-Career Research Experiences
The first step to minoritized researcher success is self-identification as a researcher. Early success can have a positive snowball effect. Reversing structural disparities requires dedicated opportunities for minoritized researcher trainees at all levels, particularly opportunities for exposure to advanced research techniques at early training stages. There are dedicated funding streams to increase trainee diversity—for example, the National Science Foundation’s Research Experience for Undergraduates program and NIH’s Maximizing Access to Research Careers (MARC) and ENDURE programs. (See Box 2 for a list and brief descriptions of major research funding programs and initiatives.) All allow undergraduate students, especially those at resource-limited institutions, to have intensive mentored summer research experiences at major academic centers. Such experiences can be “auditions” leading to admission into an otherwise unreachable institution. These programs are underutilized in mental health research, despite the disproportionate impact of mental disorders on minoritized communities (15, 18). For example, none of the top 10 National Institute of Mental Health (NIMH) grantee institutions had an active MARC program as of 2019, the last year with data available during article preparation. Rather, these institutions focus on trainees further along the career development trajectories, when minoritized researchers are already underrepresented. The top 10 overall NIMH research grantees are also the top recipients of T32 grants (funding for Ph.D. students and postdoctoral research fellows) and R25 grants (intensive research experiences for residents). The challenge is that even if these advanced training programs place an emphasis on minoritized researcher recruitment, they can only support candidates who have already gained admission to a higher-tier institution—after the pipeline has already leaked.
BOX 2. Major research funding programs and initiatives
Building Infrastructure Leading to Diversity (BUILD) initiative: An NIH-funded initiative providing grants to undergraduate institutions to study innovative approaches to engaging and retaining students from diverse backgrounds in biomedical research. BUILD institutions must predominantly serve a minoritized population and have a relatively low level of NIH funding for biomedical research. The program partners these primary institutions with high-tier research-intensive institutions to create training opportunities.
Enhancing Neuroscience Diversity Through Undergraduate Research Education Experiences (ENDURE): NIH-funded initiative that provides individuals typically underrepresented in the field with training at the undergraduate level, so that they are prepared to enter and successfully complete neuroscience Ph.D. programs.
Faculty Institutional Recruitment for Sustainable Transformation (FIRST): Funded by the NIH Common Fund, the program aims to enhance and maintain cultures of inclusive excellence in the biomedical research community by facilitating institutions in their building a self-reinforcing community of scientists through recruitment of a critical mass of early-career faculty who have a demonstrated commitment to inclusive excellence.
Maximizing Access to Research Careers (MARC): A research training program supported by an NIH award to host institutions that grant baccalaureate degrees and are research intensive. MARC provides stipends, tuition and fees, and training-related expenses to support the transition of a diverse pool of undergraduate students to biomedical, research-focused higher degree programs.
Medical Scientist Training Programs: Dual-degree (M.D.-Ph.D. or D.O.-Ph.D.) programs offered by some medical schools and designed to streamline the student’s educational experience for fulfillment of both clinical and research doctoral degrees.
Meyerhoff Scholars Program: A program at the University of Maryland–Baltimore County that aims to increase diversity among future leaders in science, technology, engineering, and mathematics. This award is open to prospective undergraduate students of all backgrounds who plan to pursue doctoral studies in the sciences or engineering and who are interested in the advancement of minorities in those fields.
National Research Mentoring Network (NRMN): NRMN provides researchers across all career stages in the biomedical, behavioral, clinical, and social sciences with evidence-based mentorship and professional development programming that emphasizes the benefits and challenges of diversity, inclusivity, and culture. Common NRMN activities include intensive grant writing and peer mentoring programs.
NIH Loan Repayment Program (LRP): Established by Congress and designed to recruit and retain highly qualified health professionals into biomedical or biobehavioral research careers, the LRP repays up to $50,000 annually of a researcher's qualified educational debt in return for a commitment to engage in NIH mission-relevant research. To qualify for an LRP award, a person must be employed to conduct research at an institution for at least 20 hours per week.
National Science Foundation Research Experience for Undergraduates (REU): Small groups of undergraduates work in the research programs of the host institution at REU sites. Each student is associated with a specific research project and works closely with the faculty and other researchers. Students are granted stipends and, in many cases, assistance with housing and travel.
NIH Research Supplements to Promote Diversity in Health-Related Research: This funding mechanism is commonly referred to as a “Diversity Supplement.” Different subprograms within this larger initiative provide support for research experiences for individuals from diverse backgrounds throughout the continuum from high school to the faculty level. Funding is tied to and augments the original budget of a major research project award—hence the term “supplement.” The supplemental funding supports the participation of a specific named scholar in that research project, usually a scholar who can gain critical skills or exposure from participation.
Research Core (Facilities) and Clinical-Translational Science Institutes: Specialized laboratories or research facilities designed to offer various specialized services, training, equipment, consultation, and other types of resources to support researchers in an academic community. They are typically established with federal grant funding, managed by individuals with scientific expertise and experience, and are sustained through user fees and partnership with home institutions. They generally require substantial institutional investment, for example, from endowment, tuition, or overhead income.
UNITE Initiative: A trans-NIH initiative reporting directly to senior NIH leadership, focused on eliminating and reversing structural racism throughout the biomedical research process. Sub-initiatives include increasing support for health disparities research and research serving minoritized populations, increasing equity in research training and in the Intramural Research Program, and increasing the availability of data on minoritized researchers through existing NIH dashboard/outcomes systems. (UNITE is not an acronym.)
Undergraduate-focused training programs could be expanded by explicitly promoting, recognizing, and paying for the effort and resources needed to create and administer them. Application forms for federal grants to support training programs are particularly burdensome, so successful submission of a proposal requires substantial administrative support. Institutions committed to reversing inequities should internally fund such support and the time needed for a faculty leader to prepare an application. While federal funding agencies typically pay an additional sum to cover indirect costs associated with a research project (the expenses of doing business that are not included in the project’s budget but are necessary for the general operation of the institution and the conduct of activities it performs), many types of funding designated for establishing training programs come with a very low rate of payment for indirect costs. Junior and midlevel faculty members in academic departments should be incentivized to apply as program directors for training programs focused on undergraduate trainees, with departmental recognition (and credit toward promotion and tenure) for successful training program leadership on par with that received by lead investigators on research projects.
Additionally, undergraduate-focused programs work against most faculty members’ implicit incentives. Undergraduate students are not highly trained researchers. They contribute little to a lab’s productivity, and their presence may slow or otherwise require modifications to the usual course of interactions and procedures. This creates a disincentive for highly productive research faculty to participate in programs designed to expose and train undergraduate students. Those highly productive faculty, however, with their established networks, reputations, and professional connections, are the sponsors most likely to improve a minoritized researcher’s career trajectory. Aligning incentives may require formalizing expectations for all faculty to engage in such training programs as a criterion for tenure or promotion. Other financial mechanisms to defray the additional workload of training undergraduate students might also be useful to motivate participation by senior researchers.
A single summer experience may not be enough. The most successful training program for minoritized undergraduates is arguably the University of Maryland–Baltimore County’s Meyerhoff Scholars Program. This program at a predominantly White institution is the single largest source of Black M.D.-Ph.D. graduates (68). The Meyerhoff program’s success depends on a multicomponent model, including community building, financial support, technical training, sustained administrative support, and involvement of senior academic leaders (65, 66). The program has been replicated at two predominantly White institutions with support from the Howard Hughes Medical Institute (HHMI). Compared to students who were invited but did not participate, participants in the replication project were seven times more likely to earn a graduate degree (68). Cohort growth may be more rapid in new sites because training approaches have been optimized over decades (68). Similar to efforts to increase faculty diversity (see below), national funders could support institutions seeking to start integrated, multicomponent, undergraduate-focused minoritized researcher programs. For instance, prominent private foundations have joined HHMI in funding Meyerhoff replication attempts (69). These new programs draw from the insights of the NIH Building Infrastructure Leading to Diversity (BUILD) awards, which aim to discover mechanisms to build a diverse biomedical workforce by investing resources at undergraduate institutions serving a large portion of students from disadvantaged backgrounds (70). Such programs may be an opportunity for greater collaboration between undergraduate departments and medical school departments that have historically focused on graduate training. Critically, these programs likely need to replicate the full breadth of support offered by the Meyerhoff model, although the replication study suggests that quantitative variations (e.g., changes in level of financial support) can still work (68). Even with these variances, a program at the Meyerhoff scale is not cheap; the replication costs were at least $2 million per year per institution. However, there is no evidence that any single-component program has achieved the same results. It is also important to recognize that minority-serving and historically Black institutions have decades of experience preparing minoritized undergraduates for professional success. They could be valuable partners if approached with respect for what they have already achieved.
Targeted Mentoring
Minoritized researchers usually have not grown up around researchers. They do not know the many unwritten rules of academic success (50). They have less access to the networks that distribute opportunities and facilitate inter-institutional exchange. This challenge is compounded because minoritized researcher trainees tend to seek out other minoritized researchers as mentors (41–43). Each mentor’s energy is diffused, both by a larger number of mentees with greater needs and by their own ongoing struggle against structural inequity (54). To compensate, each minoritized researcher needs multiple strong mentors. Mentoring programs that link minoritized researchers with non-minoritized researchers could reverse that imbalance, if designed correctly. Strong, evidence-based mentoring improves grant success rates to above the national average (71). Weak mentoring, on the other hand, has no effect (67).
In psychiatric research, supplementary mentoring mainly occurs through professional societies. The most common version is conference-based, where trainees are briefly paired with mentors based on shared interests. Some groups, such as APA, the American College of Neuropsychopharmacology (ACNP), the College on Problems of Drug Dependence, and the Society of Biological Psychiatry (SOBP), have specialized research career development programming at their annual meetings and set aside mentoring/travel award slots for minoritized trainees. These programs can be enormously valuable to minoritized researchers, but that value depends on the assigned mentor. An engaged conference mentor can open up a new world of possibilities (as several of the authors can attest), while a less engaged mentor can reduce the experience to a single half-hour coffee meeting.
Three low-cost interventions could improve society-based mentoring. First is feedback and recognition. We know from medical education that performance improves when we provide specific, defined behaviors and ask participants to rate those behaviors (72). Conference mentoring programs should do the same—evaluating whether mentors engaged in specific useful behaviors (e.g., “introduced me to faculty I could not meet on my own,” “engaged with and gave me technical feedback on my research plan”), then giving mentors feedback about their performance. Mentors who are consistently rated as strong by their mentees should receive a named and highly visible award from the sponsoring organization. Best practices for mentoring minoritized researchers can be taken from the National Research Mentoring Network (NRMN), which trains research mentors to support trainees from diverse perspectives (73). There may be a need to explicitly work to make these programs visible and available to minoritized researchers. Unpublished internal data from ACNP and SOBP suggest that even with set-asides, minoritized researchers are accepted into society-based mentoring at less than half the rate of non-minoritized researchers.
A second potential intervention involves making society-based mentoring longitudinal—expecting mentor and mentee to document interactions at least three to four more times over a year. APA employs this approach in its Diversity Leadership and Minority Fellowship programs. APA sends regular reminders to ensure quarterly meetings, and asks mentor and mentee to submit discussion reports from these meetings. The demand on the mentor’s time is compensated by the mentor’s access to a “first look” at a stream of motivated trainees with demonstrated skill in self-marketing and persistence. Those trainees may become future collaborators or lab members. This approach could be replicated in more explicitly research-focused societies.
A third intervention involves preparing mentors for minoritized researchers. Minoritized researchers often have experienced trauma, whether through early-life adversity or frequent microaggressions (5, 44, 49, 51, 54, 74). They have faced friction/resistance throughout their journey. This often leaves them less able to present their work confidently or take on higher-risk projects. Mentors may carry unconscious biases or have difficulty adjusting to trainee needs. More supportive words and behaviors can be taught (50, 58), but mentors need best practices. It may be possible to scale up programs such as HHMI’s Gilliam Fellowships, which train faculty to be better mentors to minoritized students.
Greater Use of Diversity-Related Supplemental Grant Funding
The majority of mental health research is funded by NIH, which offers a powerful tool—dedicated funding for minoritized researchers. Most NIH research grants are eligible for supplemental awards (commonly referred to as “Diversity Supplements”). These supplements add a multiyear research experience for a minoritized researcher to an existing funded project (75–77). Funding decisions can be made in as little as 3 months from the date of application. These supplements can overcome minoritized researchers’ lack of access to resources and advanced training. Research project grants that are eligible for diversity supplements are disproportionately clustered at elite, high-prestige institutions (32) that offer career-boosting opportunities. Most research-intensive faculty will gladly accept the proposition if asked “Could I work in your lab for a year or more at no direct cost to you?” Further, while NIMH-specific data are not published, supplement awardees almost universally remain in research (64).
Nevertheless, diversity supplements are underutilized. There are usually fewer than 40 NIMH-funded diversity supplements active nationwide, across all minoritized researcher career stages (78). The number of awards is far smaller than the pool of eligible trainees. Underutilization of supplements may reflect a lack of awareness that the funding is available. Single-institution, non-peer-reviewed data suggest that many trainees and mentors are unaware of supplement mechanisms (79). There may also be structural barriers. A prospective supplement trainee must connect with a mentor who agrees to prepare and submit the application. Most potential mentors will be unfamiliar with the process, as will their grant administrators. If the trainee needs to move, there may be difficulties identifying a suitable mentor at a new institution due to the network disparities noted above. Microaggressions and other negative pressures may cause minoritized researchers to self-select away from applying. Research societies may be able to mitigate these pressures, for example, by sharing success stories or providing examples of successful applications as part of research mentorship programs. Similar approaches have been successful in advancing and retaining psychiatric researchers past a critical career phase, the transition from mentored awards to independent research (79). It will be easier to increase utilization once the barriers are more clearly defined. To that end, more data are needed describing minoritized researchers who were awarded supplements and describing those who were eligible but never applied.
Reentry and Practical Training
As noted above, minoritized researchers face greater financial pressures than non-minoritized researchers. They are less able to buffer sudden life events such as a family member’s illness (5). This can easily lead to research career interruption and/or apparent low productivity. Similarly, early-career competition often depends on differentiating oneself via advanced techniques or access to unique patient cohorts, but those are harder for minoritized researchers to access. Thus, a robust workforce plan must help minoritized researchers reenter research after interruptions. Mentoring programs could establish specific cohorts for reentering researchers. Some fraction of diversity supplements could be explicitly targeted for reentry, or (given the underutilization of these supplements) laboratories could explicitly advertise their interest in hosting reentering researchers. Ideally, the latter would be an organized effort by multiple labs at a single institution to create buffers against isolation. Programs that do not currently support research training, such as military medical scholarships, could support research relevant to their target populations as a means for reentry. There is precedent for such funding—NIH currently offers administrative supplements to support reentry, and military service is an eligible form of interruption (80). The ongoing movement toward “team science” may help support reentry; it can be easier for a researcher to restart a career when buoyed by the infrastructure of a larger team.
Cohort Building
Research training contains a “hidden curriculum”: what to say and not to say in a paper or grant, which rules are flexible and when, how to network effectively, and how to self-promote tactfully (81). These are learned behaviors—but they are easier to learn if one is White, male, or otherwise used to assuming that one belongs in a research community. Minoritized researchers instead start with years of messaging that they do not belong (50, 54, 58, 74). Isolation can be countered by building cohorts of minoritized researchers who can normalize experiences, share strategies, and provide mutual support. Participating in such programs can prevent loss of research interest (82), and, in general, feeling identified with a community is a powerful approach to mitigating the effects of structural racism (57). One promising approach to cohort building is cluster hiring, in which multiple minoritized researchers are hired simultaneously (83, 84). This reduces isolation, communicates institutional priorities, and can amplify the voice of minoritized faculty. An innovative NIH program, Faculty Institutional Recruitment for Sustainable Transformation (FIRST), is specifically funding and evaluating cluster hiring for diversity (85). At the same time, it will be years before every institution has a sufficient cohort of successful minoritized researchers to sustain a local community. National societies can fill this gap. There are successful cohort development and peer mentoring programs in basic neuroscience (64), and these models could be adapted to mental health research.
Cohort-building programs directed at minoritized researchers could have two additional effects. First, they could support the expansion of evidence-based services and research to majority-minority communities. These communities often have strong stigma and mistrust around mental health treatment and research (86, 87). That mistrust can be overcome if research is led by minoritized researchers. Program building is difficult, however, and access to peers who can share worked-out protocols and study designs could accelerate progress. Second, expanding peer mentoring for minoritized researchers could alleviate the mentoring burden on senior minoritized researcher faculty. Because there are so few minoritized researchers in high-visibility, successful positions, they receive requests for mentoring and advice from trainees across the country (88), even as they battle structural biases in their own institutions. This is sometimes called a “minority tax” (5, 40–43, 88, 89). Providing minoritized researchers with more mentors may diffuse this burden, especially if those mentors are non-minoritized researchers dedicated to championing diversity.
Building Diverse Leadership
The scarcity of minoritized researchers worsens at higher academic ranks. Senior minoritized researchers have faced all the barriers described above, in a climate that did not acknowledge that such barriers exist. They have worked harder than non-minoritized researcher faculty for each paper, grant, or award. This leads to minoritized researchers appearing less competitive in searches for chairs, center directors, and the like, which means that junior minoritized researchers have less access to adequately resourced senior leaders and mentors. These biases can be mitigated in leadership searches by using specific scoring rubrics, especially those that emphasize “distance traveled”—the amount achieved by a candidate given his or her starting point and access to resources. Viewed in this light, many senior minoritized researchers have outperformed their non-minoritized colleagues. It is critical to ensure that faculty on search committees understand the need for such rubrics and are committed from the beginning to hiring with an emphasis on equity (84). Similarly, when writing reference letters for tenure, hiring, or awards, researchers at all career levels should have a “distance traveled” framework in mind.
Increasing Equity in Publishing
The ultimate currency of research is the peer-reviewed article. The articles and topics that are showcased in high-impact journals, which shape many other aspects of funding and promotion, are determined in part by editors’ priorities. Editors-in-chief could strive to ensure that minoritized perspectives are present in deputy editors, editorial board members, people invited to write commentaries or review papers for “special issues” of their journals, people invited to guest-edit special issues of the journal, people invited to review papers, and artists or investigators invited to prepare journal cover art. Because many high-impact journals in psychiatry are sponsored by scholarly societies, those societies should include equity metrics as outcome measures when evaluating editors’ performance. All of the above comments about academic leadership would also apply to selection of editors-in-chief. Similarly, checklists exist to ensure that research appropriately considers and describes minoritized perspectives (90), and editors should be encouraged to adopt these.
Reducing Environmental Bias
Social media campaigns such as #BlackInTheIvory and #BlackInNeuro have made negative messaging and microaggressions more visible, but awareness alone is insufficient (58). Academic leaders must commit to ending structural racism. That begins with identifying and apologizing for times when we or our institutions have promulgated it. We then need to change our approach to recruitment and retention of minoritized researchers. Many departments have diversity, equity, and inclusion (DEI) efforts—often led by minoritized faculty who are asked to solve a problem they did not create. These efforts must include consultation with minoritized researchers, but the responsibility of transforming departments must be led by all faculty (41, 42). DEI work must be led by faculty with sufficient administrative authority to implement change. Individual principal investigators can take similar steps. We can seek out and take a “chance” on minoritized researchers for our open positions, especially candidates who have traveled a further scholarly distance than their non-minoritized colleagues. We can advocate for level playing fields in hiring committees, for example, by a scoring rubric defined in advance that deemphasizes score cutoffs and by interviewing candidates with defined questions that focus on job qualifications (not vague “fit”) (84). We can “signal boost” our minoritized researcher trainees and colleagues by publicizing their papers in our social media, taking care to cite them, actively inviting them to participate in review articles, and ensuring that they are visible in panels we organize. Major psychiatric research societies have already begun considering panel diversity as a factor in their conference programming. Citation diversity indices are emerging as a useful tool for self-reflection on implicit biases in publishing; they currently emphasize binary gender diversity but could broaden (91).
We can work to reduce disparities in our clinical services, as a signal that we value minoritized populations. We can similarly value and promote the funding of research directed at eliminating those disparities. We can explicitly recognize the value of the community-engaged research often conducted by minoritized scholars and/or at minority-serving institutions. Many of these principles, and particularly the concept that they must be deployed as an integrated, multifactor approach to structural racism, are captured in the NIH UNITE initiative (92, 93). UNITE includes specific dedicated funding for health disparities and equity research, funding opportunities for interventions on both health disparities and workforce disparities, and more detailed reporting of outcomes across new and existing programs. UNITE materials released to date (92, 94) describe many of the barriers covered above and some of the programs, such as FIRST, that may reverse them.
Finally, although hardest of all, we can pay our colleagues fairly. In most medical centers, research-oriented faculty have lower salaries than full-time clinicians, particularly clinicians in private practice. We expect that research will be its own reward, and that academic freedom makes up the difference. Unfortunately, this is often code for “We presume that your or your spouse’s family wealth will make up the difference.” Minoritized researchers are less likely to have that wealth, and even then, are offered lower salaries than their non-minoritized colleagues (4). If we are serious about equity, we will ensure that minoritized researchers are paid at or above the median of non-minoritized peers. There is a strong case for setting those salaries above non-minoritized researcher salaries, because minoritized faculty carry higher uncompensated service burdens (5, 41, 42). Major community tragedies often call for a departmental response, usually coordinated by minoritized faculty (5). That work strengthens an entire department, and we have benefited from DEI work completed even before we recognized its value. We can now “balance the books.”
All of these efforts, taken together, will send a clear message that minoritized researchers do belong, and have both the intellectual capability and emotional fortitude to lead psychiatric research. This leads, however, to a final and most critical point—our best intentions will not make this process anything but slow and emotionally challenging. Minoritized researchers often start from a position of being told for years that they cannot, should not, or do not deserve to succeed. We will need to be patient mentors who work through extra drafts, provide additional start-up space/funds, and actively urge minoritized researchers to apply for opportunities that even we are not sure they are “qualified” for. The reward will be a new crop of trainees with successes far beyond our expectations.
Outcome Evaluation
Just as in research, it is frustratingly easy to design a DEI program that has fundamental flaws. We can avoid that trap by measurement. Within our institutions and departments, what are the success rates for minoritized researcher faculty and trainees on K- and R-series grants, publications, and citations to those publications? Are our numbers of diversity-supplement trainees proportionate with the R01-equivalent direct costs flowing into our departments? Do minoritized researchers in our mentoring programs do better than their colleagues? What are the reasons that minoritized researchers are not accepted into the NIH Loan Repayment Program, and which programs can mitigate those? Which scholarly societies succeed in matriculating minoritized researchers into their mentorship programs? Do those programs lead to better funding and career outcomes for matriculants? Truly excellent institutions should publicly report these outcomes, just as we do our clinical results. Until minoritized and non-minoritized researcher outcomes are comparable, our investment is not finished.
This will require transparency from funding bodies, including NIH (e.g., through the UNITE Data Dashboard). There appear to be no public, regularly released data tracking the long-term outcomes of, for example, K- or R-series grant applicants who previously received diversity supplements. Outcomes of minoritized researchers who previously received training awards have only recently been released (11), and will need to be broken down to analyze outcomes of minoritized-researcher-targeted programs. Similarly, no scholarly society that runs a mentorship program currently collects data on long-term outcomes of program participants. Those metrics are critical to understand where investment is needed and which institutions may have ideas worth copying.
We also need those metrics to avoid “separate but equal” research streams. The more we create programs that support minoritized researchers, the greater the possibility that an individual minoritized researcher is funded primarily or exclusively through such programs. That would perpetuate the incorrect stereotype that minoritized researchers are not as talented or hard-working as their non-minoritized peers. The goal is a workforce that matches and understands the full population we serve, where researchers of all backgrounds are able to contribute to their full potential. Diversity metrics therefore need to explicitly track and optimize minoritized researcher success in all aspects of academic competition.
Conclusions
Minoritized researchers are underrepresented nationally, in psychiatry as in every medical specialty. Psychiatry also has a greater need to close that gap, because mental disorders have strong stigma and race-based disparities (95, 96). Greater minoritized researcher representation is necessary both from basic principles of justice and to eliminate those outcome disparities. It may also be necessary to ensure that research involves and serves the full range of patients. The authors’ lived experience shows that the problem is not a shortage of talent—there are many minoritized researchers who are prepared for research excellence. The representation gap arises from interlocking structural inequalities, grounded in racial biases endemic in academia and the broader U.S. culture.
The problem is tractable—with investment and effort. Leaders in psychiatry, from multiple minoritized identities, have laid out a blueprint for increasing diversity and inclusion in psychiatry and neuroscience (5). Further, there has been tremendous progress in building gender equity in science and medicine (though that work is far from over) (97–99). The same could be done for racial equity, and there may be shared lessons on how to promote system change. Perhaps the most obvious is that change attempts must be longitudinal, multifactorial, and promoted by leaders in academia, industry, and government. It is impossible to point to any single initiative as primarily responsible for positive trends in gender equality.
If we actively invest in minoritized researchers, the science and the art of psychiatry will benefit. That investment will include a stronger focus on minoritized researcher faculty recruitment and retention. Retention efforts must include promotion metrics that align with values essential to minoritized groups, not only values held by dominant groups. Our colleagues at historically Black colleges and universities and minority-serving institutions have deep experience in these spaces (100, 101). There is not a need to “reinvent the wheel,” but rather to learn from their expertise and proven success. We emphasize that such investment is not special treatment, favoritism, “reverse discrimination,” or any other disadvantaging of non-minoritized researchers. The uncomfortable reality is that non-minoritized researchers (including some of the authors) have benefited from structural biases. We have had less competition, been able to pay some junior personnel less than their due, and avoided our responsibilities toward diversity and equity. It is time to pay the debt we owe our minoritized researcher colleagues, by acknowledging and eliminating structural racism in research and research training.
Acknowledgments
This article was prepared with extensive support from APA’s Council on Research, and the authors particularly thank Dr. Diana Clarke for her assistance. John White and Erin Shaw, from Parthenon Management Group, provided unpublished data regarding minoritized researcher participants in the Society of Biological Psychiatry and American College of Neuropsychopharmacology mentorship programs, respectively.
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History
Received: 7 August 2022
Revision received: 6 December 2022
Revision received: 4 February 2023
Accepted: 22 February 2023
Published online: 19 April 2023
Published in print: September 01, 2023
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Competing Interests
Dr. Jordan has received funding from NIAAA, Yale University, and the private foundation FORE. Dr. Alpert has received research support from NIMH, honoraria from Belvoir Publishing and MGH Psychiatry Academy, and royalties from Cambridge University Press. Dr. Carpenter has clinical trial contracts (with Butler Hospital) with Affect Neuro, Janssen, Neuronetics, and Neurolief; she has received research equipment loans from Magstim, Neuronetics, and Nexstim; and she has served as a consultant for Affect Neuro, Janssen, Magnus Medical, Neuronetics, Neurolief, Otsuka, Sage Therapeutics, and Sunovion. Dr. Krystal has served as a consultant for Aptinyx, Biogen Idec MA, Bionomics, Boehringer Ingelheim, Epiodyne, EpiVario, Janssen Research and Development, Jazz Pharmaceuticals, Otsuka, Spring Care, and Sunovion; he has served on scientific advisory boards for Biohaven Pharmaceuticals, BioXcel Therapeutics, Cerevel Therapeutics, Delix Therapeutics, Eisai, EpiVario, Jazz Pharmaceuticals, Neumora Therapeutics, Neurocrine Biosciences, Novartis, PsychoGenics, Takeda, Tempero Bio, and Terran Biosciences; he is co-founder of Freedom Biosciences; he is a stockholder in Biohaven Pharmaceuticals, Freedom Biosciences, and Spring Health and holds stock options in Biohaven Pharmaceuticals Medical Sciences, Cartego Therapeutics, Damona Pharmaceuticals, Delix Therapeutics, EpiVario, Neumora Therapeutics, Rest Therapeutics, Tempero Bio, Terran Biosciences, and Tetricus; he serves as editor of Biological Psychiatry; he is involved in research studies for which medications are provided by AstraZeneca, Cerevel, and Novartis; and he is named on patents related to psychiatric treatment. Dr. Nemeroff has received research support from NIH; he has served as a consultant for AbbVie, ANeuroTech (division of Anima BV), BioXcel Therapeutics, Clexio, EMA Wellness, EmbarkNeuro, Engrail Therapeutics, Intra-Cellular Therapies, GoodCap Pharmaceuticals, Magstim, Ninnion Therapeutics, Pasithea Therapeutics, Sage, Senseye, Signant Health, Silo Pharma, SynapseBio, and Relmada Therapeutics; he has served on scientific advisory boards for ANeuroTech, the Anxiety and Depression Association of America (ADAA), the Brain and Behavior Research Foundation, Heading Health, the Laureate Institute for Brain Research, Pasithea Therapeutics, Sage, Signant Health, and Skyland Trail and on the boards of directors for ADAA, Gratitude America, and Lucy Scientific Discovery; he is a stockholder in Antares, Corcept Therapeutics, EMA Wellness, Naki Health, Relmada Therapeutics, and Seattle Genetics; and he is named on patents related to psychiatric treatment. The other authors report no financial relationships with commercial interests.
Funding Information
Dr. Widge and Dr. Wilson acknowledge financial support from the Minnesota’s Discovery, Research, and InnoVation Economy (MnDRIVE) initiative. Dr. Wilson acknowledges support from the NIH National Center for Advancing Translational Sciences (grant UL1TR002494).The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of NIH or any other funding body. The original article was prepared by an APA Component and approved by the Board of Trustees, and has been modified only as required by peer review.
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