As a social epidemiologist in training, I thought about how social stressors affected the mental health of adults in Puerto Rico (PR). It is well documented that residents of PR have been burdened by the mental health outcomes caused by environmental, economic, and socio-political stressors in the last decade (Lafarga Previdi & Vélez Vega, 2020). While figuring out what my master’s thesis would be, I struggled with identifying literature that examined the impact of discrimination on mental health in the archipelago. With discrimination often considered a taboo topic and the rise of mental health issues in PR, it is essential to recognize its impact. By doing so, we can foster conversations about developing and implementing targeted public health strategies to reduce its effects on health and overall well-being. 

The American Psychological Association (APA) defines discrimination as the “unfair and prejudicial treatment of people and groups based on specific characteristics” (APA, 2019). Now, the manifestation of that unfair treatment is what scholars describe as perceived discrimination (Pascoe & Richman, 2009). Perceived discrimination (PD) may be a chronic stressor, leading to physiological and psychological changes and health complications. A study conducted by Dong et al. (2023) found that discrimination as a chronic stressor has been associated with adverse clinical outcomes through the activation of the inflammation response (Figure 1). Prior research shows that minority groups and marginalized communities are more discriminated against (Ward et al., 2019; Ajrouch et al., 2010). Furthermore, individuals who suffer from discrimination have a higher risk of suicide ideation, substance use, physical inactivity, and sleep problems, which can lead to the development of diabetes, hypertension, obesity, and depression symptoms (Gonzales et al., 2021; Martos-Méndez et al., 2020; Molina et al., 2018; Pascoe & Richman, 2009). 

Note. The authors’ conceptual model explains the association between discrimination and clinical outcomes through the brain-gut-microbiome system. Adapted from “How Discrimination Gets Under the Skin: Biological Determinants of Discrimination Associated With Dysregulation of the Brain-Gut Microbiome System and Psychological Symptoms,” by T. S. Dong, G. C. Gee, H. Beltran-Sanchez, M. Wang, V. Osadchiy, L. A. Kilpatrick, Z. Chen, V. Subramanyam, Y. Zhang, Y. Guo, J. S. Labus, B. Naliboff, S. Cole, X. Zhang, E. A. Mayer, & A. Gupta, 2023, Biological Psychiatry, 94(3), 203–214. (https://doi.org/10.1016/j.biopsych.2022.10.011)

Perceived Discrimination and Depression Symptoms in the United States and Puerto Rico

The Survey on Racism, Discrimination, and Health by the Kaiser Family Foundation, which surveyed 5,073 adults in the United States, found that half (50%) of Hispanics reported experiencing discrimination at least a few times in the past year (Artiga et al., 2023). When asked if  “people act as if they think you are not smart” or “you are criticized for speaking a language other than English in public,” one in three (33%) Hispanics reported experiencing the former, while three in ten (28%) reported the latter (Figure 2). Moreover, Hispanics who experienced at least one form of discrimination in their daily life said that their race or ethnicity was a reason for these events to occur (Artiga et al., 2023). When exploring overall PD patterns among Puerto Ricans, high levels have also been found. A cross-sectional study that examined the prevalence of lifetime PD among Puerto Rican adults in Boston found that 37% of adults aged 45-75 years had experienced it at least once (Todorova et al., 2010). Additionally, the authors found a positive association between perceived discrimination and depression symptoms, perceived stress, and medical conditions. 

However, no studies have documented the impact of PD among young Puerto Rican
adults at the moment this article was written.

Note. Experiences of discrimination in the United States among minority groups. Adapted from “Survey on Racism, Discrimination, and Health—Findings,” by S. Artiga, L. Hamel, A. Gonzalez-Barrera, A. Montero, L. Hill, M. Presiado, A. Kirzinger, & L. L. Published, 2023, KFF. (https://www.kff.org/report-section/survey-on-racism-discrimination-and-health-findings/). 

Depression is one of the most commonly diagnosed mental health conditions among adults in the United States (Terlizzi & Zablotsky, 2024). In the last five years, global reports have documented an ongoing rise in depression across populations (Santomauro et al., 2021). Symptoms of depression may be divided into two categories: physical and behavioral (National Institute of Mental Health, 2024). Physical symptoms may include difficulty concentrating, remembering, or making decisions; fatigue, lack of energy, or feeling slowed down; and changes in appetite or unplanned weight. Similarly, behavioral symptoms include loss of interest or pleasure in hobbies and activities, thoughts of death or suicide or suicide attempts, and increased anger or irritability (National Institute of Mental Health, 2024). 

In 2019, the National Center for Health Statistics developed the National Health Interview Survey (NHIS), sampling 31,997 US adults, which showed that the proportion of adults experiencing symptoms of depression in the past two weeks was highest (21%) among those aged 18-29 years (Villarroel & Terlizzi, 2020). In PR, a community sample of 1,497 young adults from the Puerto Rico Young Adults’ Stress, Contextual, Behavioral & Cardiometabolic Risk (PR-OUTLOOK) study concluded that 60% of individuals reported depression symptoms (López-Cepero et al., 2023), almost 40% more than in the US. Previous studies conducted on other Latino adults, African-American women, and Korean young adults have associated perceived discrimination with elevated depression symptoms (Kim et al., 2019; Ward et al., 2019; Ajrouch et al., 2010). With the high prevalence of depression symptoms among young adults residing in PR and the lack of data on PD in the archipelago, it is imperative to examine how the number of PD experiences exacerbates depression symptoms in this population. 

Exploring the association between perceived discrimination and depressive symptoms: Findings from PR-OUTLOOK

A cross-sectional analysis of baseline data from the PR-OUTLOOK study from September 2020 through November 2023 was conducted under the mentorship of Dr. Cynthia M. Pérez-Cardona and Dr. Claudia P. Amaya-Ardilla. The participants were young adults aged 18-29 residing in PR. The study aimed to 1) describe the proportion of perceived discrimination and depression symptoms and 2) examine the association of perceived discrimination and depression symptoms among young adults in PR. Key findings revealed that over half (55%) of young adults reported four or more discriminatory experiences in the last 12 months, and almost 60% had elevated depression symptoms (data to be published).

Similarly, 63% of participants who had four or more discriminatory experiences reported being a sexual minority and having vaped. Individuals having four or more discriminatory experiences were significantly more likely to have elevated depression symptoms compared to those not having discriminatory experiences. To our knowledge, this is the first study to examine the association between perceived discrimination and depression symptoms among young adults in Puerto Rico. 

Conclusions

With this article, I hope to accentuate the need for open-ended conversations about the impact of discrimination on our health. Discrimination can have detrimental effects on both our physical and mental well-being, and it is important to raise awareness, reduce stigma, and challenge the systemic structures that perpetrate prejudice. As a born and raised Puerto Rican woman and scientist, I’ve seen firsthand how the mental health of young adults is hindered and continues to be debilitated. Understanding the impact of social stressors, such as discrimination, on depression symptoms helps develop targeted interventions against them. Depression is a public health issue with its rising prevalence both globally and in the United States, affecting morbidity and mortality rates among adults. To address this issue, multi-sectoral stakeholders must turn actionable plans into policies that promote overall well-being for communities, especially those from underserved backgrounds. 

Regarding young adults in PR, our findings align with prior studies on perceived discrimination as a social stressor associated with depression symptoms (Ward et al., 2019; Ajrouch et al., 2010; Kim et al., 2019). Further studies are needed to better understand the sources of discrimination and the mechanisms through which this form of stress acts (Ajrouch et al., 2010). Transitioning from adolescence to young adulthood is a critical developmental period in which the greater demands of society provide limited space for failure and growth (Stroud et al., 2015). Public health interventions centering on positive coping strategies should be tailored to young adults in PR to mitigate the burden of depression symptoms associated with perceived discrimination. 

References

1. Lafarga Previdi, I., & Vélez Vega, C. M. (2020). Health Disparities Research Framework Adaptation to Reflect Puerto Rico’s Socio-Cultural Context. International Journal of Environmental Research and Public Health, 17(22), 8544. https://doi.org/10.3390/ijerph17228544
2. Discrimination: What it is and how to cope. (2019). Https://Www.Apa.Org. Retrieved August 17, 2023, from https://www.apa.org/topics/racism-bias-discrimination/types-stress
3. Pascoe, E. A., & Smart Richman, L. (2009). Perceived discrimination and health: A meta-analytic review. Psychological Bulletin, 135(4), 531–554. https://doi.org/10.1037/a0016059
4. Dong, T. S., Gee, G. C., Beltran-Sanchez, H., Wang, M., Osadchiy, V., Kilpatrick, L. A., Chen, Z., Subramanyam, V., Zhang, Y., Guo, Y., Labus, J. S., Naliboff, B., Cole, S., Zhang, X., Mayer, E. A., & Gupta, A. (2023). How Discrimination Gets Under the Skin: Biological Determinants of Discrimination Associated With Dysregulation of the Brain-Gut Microbiome System and Psychological Symptoms. Biological Psychiatry, 94(3), 203–214. https://doi.org/10.1016/j.biopsych.2022.10.011
5. Ward, J. B., Feinstein, L., Vines, A. I., Robinson, W. R., Haan, M. N., & Aiello, A. E. (2019). Perceived discrimination and depressive symptoms among US Latinos: The modifying role of educational attainment. Ethnicity & Health, 24(3), 271–286. https://doi.org/10.1080/13557858.2017.1315378
6. Ajrouch, K. J., Reisine, S., Lim, S., Sohn, W., & Ismail, A. (2010). Perceived everyday discrimination and psychological distress: Does social support matter? Ethnicity & Health, 15(4), 417–434. https://doi.org/10.1080/13557858.2010.484050
7. Gonzales, K. L., Jiang, L., Garcia-Alexander, G., Jacob, M. M., Chang, J., Williams, D. R., Bullock, A., & Manson, S. M. (2021). Perceived Discrimination, Retention, and Diabetes Risk Among American Indians and Alaska Natives in a Diabetes Lifestyle Intervention. Journal of Aging and Health, 33(7-8 Suppl), 18S-30S. https://doi.org/10.1177/08982643211013188
8. Martos-Méndez, M. J., García-Cid, A., Gómez-Jacinto, L., & Hombrados-Mendieta, I. (2020). Perceived Discrimination, Psychological Distress and Cardiovascular Risk in Migrants in Spain. International Journal of Environmental Research and Public Health, 17(12), 4601. https://doi.org/10.3390/ijerph17124601
9. Molina, K. M., Estrella, M. L., Rivera-Olmedo, N., Frisard, C., Lemon, S., & Rosal, M. C. (2018). It Weigh(t)s On You: Everyday Discrimination and Adiposity among Latinos. Obesity (Silver Spring, Md.), 26(9), 1474–1480. https://doi.org/10.1002/oby.22248
10. Artiga, S., Hamel, L., Gonzalez-Barrera, A., Montero, A., Hill, L., Presiado, M., Kirzinger, A., & Published, L. L. (2023). Survey on Racism, Discrimination, and Health—Findings—10257. KFF. https://www.kff.org/report-section/survey-on-racism-discrimination-and-health-findings/
11. Todorova, I. L. G., Falcón, L., Lincoln, A. K., & Price, L. L. (2010). Perceived discrimination, psychological distress, and health. Sociology of Health & Illness, 32(6), 843–861. https://doi.org/10.1111/j.1467-9566.2010.01257.x
12. Terlizzi, E. P., & Zablotsky, B. (2024). Symptoms of Anxiety and Depression Among Adults: United States, 2019 and 2022. National health statistics reports, (213), CS353885. https://doi.org/10.15620/cdc/64018 
13. Santomauro, D. F., Herrera, A. M. M., Shadid, J., Zheng, P., Ashbaugh, C., Pigott, D. M., Abbafati, C., Adolph, C., Amlag, J. O., Aravkin, A. Y., Bang-Jensen, B. L., Bertolacci, G. J., Bloom, S. S., Castellano, R., Castro, E., Chakrabarti, S., Chattopadhyay, J., Cogen, R. M., Collins, J. K., … Ferrari, A. J. (2021). Global prevalence and burden of depressive and anxiety disorders in 204 countries and territories in 2020 due to the COVID-19 pandemic. The Lancet, 398(10312), 1700–1712. https://doi.org/10.1016/S0140-6736(21)02143-7
14. National Institute of Mental Health. (2024). Depression. Retrieved May 8, 2024, from https://www.nimh.nih.gov/health/topics/depression
15. Villarroel, M. A., & Terlizzi, E. P. (2020). Symptoms of Depression Among Adults: United States, 2019. NCHS Data Brief, 379, 1–8.
16. López-Cepero, A. A., Spruill, T., Suglia, S. F., Lewis, T. T., Mazzitelli, N., Pérez, C. M., & Rosal, M. C. (2023). Shift-and-persist strategies as a potential protective factor against symptoms of psychological distress among young adults in Puerto Rico. Social Psychiatry and Psychiatric Epidemiology: The International Journal for Research in Social and Genetic Epidemiology and Mental Health Services, No Pagination Specified-No Pagination Specified. https://doi.org/10.1007/s00127-023-02601-1
17. Kim, K., Jung, S. J., Cho, S. M. J., Park, J. H., & Kim, H. C. (2019). Perceived Discrimination, Depression, and the Role of Perceived Social Support as an Effect Modifier in Korean Young Adults. Journal of Preventive Medicine and Public Health = Yebang Uihakhoe Chi, 52(6), 366–376. https://doi.org/10.3961/jpmph.19.114
18. Stroud, C., Walker, L. R., Davis, M., & Irwin, C. E. (2015). Investing in the health and well-being of young adults. The Journal of Adolescent Health: Official Publication of the Society for Adolescent Medicine, 56(2), 127–129. https://doi.org/10.1016/j.jadohealth.2014.11.012