Cultural racism is a concept that has long eluded precise measurement. Unlike interpersonal discrimination, which individuals can report directly, cultural racism refers to the underlying ideologies, values, images and narratives that normalize racial hierarchy: derogatory media portrayals, exclusionary cultural norms, and the everyday symbols and assumptions that render inequality seemingly natural. Researchers have argued that this cultural layer is the soil in which structural and individual racism grow, yet its health consequences have remained understudied because of the difficulty of quantifying it. The new research, led by Oyomoare L. Osazuwa-Peters of Duke University School of Medicine together with colleagues including Nancy Krieger of Harvard T.H. Chan School of Public Health and Tyson Brown of Duke University, set out to close that gap with an empirically derived measure spanning all fifty states and the District of Columbia.

To construct the exposure, the team distilled seven state-level indicators into a single composite score they call the cultural racism factor. Drawing on prior theoretical work, the indicators captured multiple dimensions of the construct, including anti-Black sentiment in attitudes, disparate representation in positions of influence and media, and resource-related dimensions reflecting how cultural priorities are encoded in state-level conditions such as income inequality measured by the Gini coefficient, poverty rates, and population characteristics derived from US Census and American Community Survey data. The factor was validated using established psychometric techniques, including confirmatory factor analysis and reliability estimation, to ensure that the composite genuinely reflected a shared underlying dimension rather than a statistical artifact. The resulting measure and its indicator values have been made publicly available through Zenodo, allowing other researchers to scrutinize and reuse the instrument.

The outcome data came from an extraordinary source: the Behavioral Risk Factor Surveillance System, the Centers for Disease Control and Prevention’s massive annual telephone survey, covering the years 2018 through 2021. After linking each respondent to the cultural racism score of their state of residence, the analytical sample comprised 1,292,787 adults, weighted to be 52.2 percent women. Within this population, 19.5 percent reported a history of depression, and respondents averaged 4.3 days of poor mental health per month. Because the survey spans the onset of the COVID-19 pandemic, the study window also captures a period of documented deterioration in American mental health, which the authors contextualized against prior evidence of rising psychological distress between 1993 and 2020.

The statistical strategy was designed for rigor in the face of complex survey data. The researchers used modified Poisson regression, an approach well suited to estimating relative risks for binary outcomes such as depression history, along with models for the count of poor mental health days. Models adjusted for a battery of individual and state-level confounders, including age, sex, race and ethnicity, income, and other state characteristics, to reduce the likelihood that the association simply reflects broader regional differences in wealth, urbanicity, or health care access. Analyses followed established guidelines for reporting observational studies, and the authors pre-specified stratified analyses to examine whether associations varied across racial and ethnic groups, age strata, and sex.

The headline result is deceptively simple in its expression but profound in its implications. Each one standard deviation increase in the state-level cultural racism factor was associated with a 3 percent higher relative risk of reporting a history of depression overall, and a 3 percent increase in the number of poor mental health days. Three percent may sound modest, but applied across an entire population and a full standard deviation of variation in cultural racism between states, it translates into a substantial population burden, particularly given that tens of millions of adults experience depression and psychological distress each year.

The stratified results revealed far starker disparities. Among Native Hawaiian and Pacific Islander respondents, each standard deviation increase in cultural racism was associated with up to a 25 percent higher risk of depression, the largest effect observed for any group. Among Hispanic respondents, the association with poor mental health days reached as high as 14 percent per standard deviation. Associations were consistently strongest among racial minority groups, the populations most directly targeted by the ideologies and systems the factor is designed to capture, and among adults under 65 years of age. Notably, the associations did not differ significantly between men and women, suggesting that the corrosive influence of cultural racism on mental health operates across gender lines rather than being concentrated in one.

These findings align with a growing body of research on racism and health. Prior studies have linked police killings of Black Americans to spillover effects on the mental health of Black communities, shown that perceived discrimination is associated with worse psychiatric outcomes in meta-analyses, and demonstrated that structural racism, expressed through historic redlining and contemporary lending patterns, leaves measurable imprints on population health. A related 2025 study by several of the same investigators showed that a latent measure of cultural racism was associated with US mortality and life expectancy, extending the health consequences of cultural racism beyond mental health into physical health and survival. The new work complements this literature by demonstrating that the cultural dimension of racism is not merely a backdrop for more tangible forms of discrimination but carries its own detectable psychological toll.

The biological and social pathways plausibly connecting cultural racism to depression are multifaceted. Chronic exposure to devaluing cultural messages can function as a persistent psychosocial stressor, activating physiological stress responses, eroding self-concept, and fostering vigilance and alienation. Stereotype threat research has shown that merely confronting negative cultural portrayals can impair cognition and decision making, while studies of media representation demonstrate lasting effects on identity and wellbeing, particularly among young people from marginalized groups. Cultural racism may also operate indirectly by legitimizing inequitable policies, shaping where resources flow, and normalizing the social conditions, such as poverty, segregation, and reduced access to care, that are themselves robust predictors of mental illness.

The authors are careful to note that their observational design cannot prove causation, and that residual confounding by unmeasured state or individual characteristics remains possible. Self-reported depression history and mental health days, while validated and widely used, are imperfect measures. Yet the sheer scale of the sample, the psychometric grounding of the exposure measure, the consistency of associations across outcomes and subgroups, and the coherence with prior evidence collectively strengthen the case that cultural racism is a genuine determinant of mental health. The study’s data, drawn from publicly available CDC survey files and open repository sources, invite replication and extension by independent teams.

The implications reach well beyond academic debate. If the cultural climate of a state measurably shapes the psychological health of its residents, then interventions aimed solely at individual-level care are addressing symptoms rather than causes. The findings underscore, in the authors’ words, the need for further research and policy action: policies that address media representation, educational narratives, income inequality, and the cultural norms that sustain racial hierarchy may be mental health interventions in their own right. As the United States continues to grapple with rising rates of depression and psychological distress, this research adds a sobering dimension to the national conversation, suggesting that the stories a society tells about race, and the systems those stories sustain, are written not only into institutions but into the minds of the millions of people who live within them.

Subject of Research: Association of state-level cultural racism with depression and poor mental health days among US adults, 2018–2021

Article Title: Association of cultural racism with mental health outcomes among US adults during 2018–2021

Article References: Osazuwa-Peters, O. L., Wilkerson, J., Gupta, A., Wilson, L. E., Krieger, N., Brown, T., & Akinyemiju, T. (2026). Association of cultural racism with mental health outcomes among US adults during 2018–2021. Nature Mental Health. https://doi.org/10.1038/s44220-026-00728-z

Image Credits: AI Generated

DOI: 10.1038/s44220-026-00728-z

Keywords: cultural racism, mental health, depression, BRFSS, health disparities, structural racism, psychological distress, population health, racial inequities, public health, Association, cultural