The Role of Social Disadvantage in Physical and Mental Health
The Role of Social Disadvantage in Physical and Mental Health
Prevalence of depression is associated inversely with some indicators of socioeconomic position, and the stress of social disadvantage is hypothesized to mediate this relation. Relative to whites, blacks have a higher burden of most physical health conditions but, unexpectedly, a lower burden of depression. This study evaluated an etiologic model that integrates mental and physical health to account for this counterintuitive patterning. The Baltimore Epidemiologic Catchment Area Study (Maryland, 1993–2004) was used to evaluate the interaction between stress and poor health behaviors (smoking, alcohol use, poor diet, and obesity) and risk of depression 12 years later for 341 blacks and 601 whites. At baseline, blacks engaged in more poor health behaviors and had a lower prevalence of depression compared with whites (5.9% vs. 9.2%). The interaction between health behaviors and stress was nonsignificant for whites (odds ratio (OR = 1.04, 95% confidence interval: 0.98, 1.11); for blacks, the interaction term was significant and negative (β: −0.18, P < 0.014). For blacks, the association between median stress and depression was stronger for those who engaged in zero (OR = 1.34) relative to 1 (OR = 1.12) and ≥2 (OR = 0.94) poor health behaviors. Findings are consistent with the proposed model of mental and physical health disparities.
It is established that socioeconomic position (SEP), whether indexed by wealth, income, or education, is associated with racial categorization in the United States. These inequalities in socioeconomic resources are associated with widespread disparities in burden of health conditions, including heart disease, cancer, and diabetes. The precise mechanisms that produce these pervasive disparities have yet to be established, but social disadvantage, as indexed by black race, SEP, and their confluence, is considered a major factor in the perpetuation of health disparities. Indeed, the literature is replete with studies illustrating that social disadvantage, including marginalization through racial residential segregation and discrimination, is linked to poor physical health. Low SEP is associated with greater stress exposure over the life course, including witnessing or being a victim of violence and limited access to health care. Consistent with the racial patterning of SEP, blacks live in more disorganized and dangerous neighborhoods and face more traumatic life events and chronic stressors than whites do. Additionally, health behaviors, both enhancing (e.g., physical activity) and deleterious (e.g., smoking, high-fat diets), are similarly associated with SEP and race.
It is expected that blacks would experience higher rates of psychiatric disorders, particularly conditions associated with exposure to stress, such as major depression, given the evidence linking social disadvantage to poor physical health. Findings from epidemiologic surveys, however, consistently indicate that, compared with whites, blacks report similar or, in some cases, lower rates of lifetime mental disorders, even after accounting for the effects of SEP, despite evidence that blacks report higher levels of psychological distress. These findings seem counterintuitive, and researchers have sought explanations for why blacks experience lower levels of mental disorders than whites do, despite greater social disadvantage. It has been suggested that this patterning is due to misreporting bias; however, validation studies have indicated that survey assessments perform equally well for whites and blacks, and the consistency of this patterning across different instruments and study populations calls this argument into question. It has also been suggested that this patterning is due to greater utilization of positive coping strategies (e.g., religiosity, social support) among blacks, but such explanatory models are poorly specified and only weakly supported by empirical research.
One of the authors (J. S.) has put forth a testable, theory-derived model that accounts for this counterintuitive patterning of social disadvantage and mental and physical health burden across blacks and whites. The model rests on 3 empirical observations: 1) exposure to stressors is associated with risk of both physical and mental health problems through physiologic pathways; 2) when faced with exogenous stressors, individuals engage in coping behaviors to mitigate the psychological stress experience; and 3) the specific set of stress-responsive behaviors engaged in is shaped by the characteristics of the environment. This model posits that individuals who are exposed to chronic stress and live in poor environments will be more likely to engage in poor health behaviors (PHB), such as smoking, alcohol use, drug use, and overeating, because they are the most environmentally accessible coping strategies for socially disadvantaged groups. These behaviors act on common biologic structures and processes associated with pleasure and reward systems, consistent with the hypothesis that these behaviors alleviate, or interrupt, the physiological and psychological consequences of stress.
Recently, Jackson et al. reported that the relation between stressful events and depression risk was moderated by PHB among blacks, such that, at higher levels of stress, blacks who engaged in more PHB were less likely than those who engaged in fewer PHB to meet Diagnostic and Statistical Manual of Mental Disorders criteria for depression 3 years later. This same interaction between PHB and stress was not significant for whites. These initial results suggest that engaging in PHB can be conceptualized as stress-coping strategies and may explain the counterintuitive patterning of a lower burden of stress-related psychopathology, but a higher burden of behaviorally mediated physical health conditions, among blacks relative to whites.
The purpose of this study was to evaluate the association of race, stress, and PHB with risk of depression and chronic health conditions among whites and blacks over a 12-year period in the Baltimore Epidemiologic Catchment Area Study. Consistent with the etiologic model of the counterintuitive racial disparities in depressive disorders and physical health described above, it is predicted that blacks who engage in more PHB will have a lower risk of depression but a higher risk of physical health disorders at follow-up than those who engage in fewer of these behaviors.
Abstract and Introduction
Abstract
Prevalence of depression is associated inversely with some indicators of socioeconomic position, and the stress of social disadvantage is hypothesized to mediate this relation. Relative to whites, blacks have a higher burden of most physical health conditions but, unexpectedly, a lower burden of depression. This study evaluated an etiologic model that integrates mental and physical health to account for this counterintuitive patterning. The Baltimore Epidemiologic Catchment Area Study (Maryland, 1993–2004) was used to evaluate the interaction between stress and poor health behaviors (smoking, alcohol use, poor diet, and obesity) and risk of depression 12 years later for 341 blacks and 601 whites. At baseline, blacks engaged in more poor health behaviors and had a lower prevalence of depression compared with whites (5.9% vs. 9.2%). The interaction between health behaviors and stress was nonsignificant for whites (odds ratio (OR = 1.04, 95% confidence interval: 0.98, 1.11); for blacks, the interaction term was significant and negative (β: −0.18, P < 0.014). For blacks, the association between median stress and depression was stronger for those who engaged in zero (OR = 1.34) relative to 1 (OR = 1.12) and ≥2 (OR = 0.94) poor health behaviors. Findings are consistent with the proposed model of mental and physical health disparities.
Introduction
It is established that socioeconomic position (SEP), whether indexed by wealth, income, or education, is associated with racial categorization in the United States. These inequalities in socioeconomic resources are associated with widespread disparities in burden of health conditions, including heart disease, cancer, and diabetes. The precise mechanisms that produce these pervasive disparities have yet to be established, but social disadvantage, as indexed by black race, SEP, and their confluence, is considered a major factor in the perpetuation of health disparities. Indeed, the literature is replete with studies illustrating that social disadvantage, including marginalization through racial residential segregation and discrimination, is linked to poor physical health. Low SEP is associated with greater stress exposure over the life course, including witnessing or being a victim of violence and limited access to health care. Consistent with the racial patterning of SEP, blacks live in more disorganized and dangerous neighborhoods and face more traumatic life events and chronic stressors than whites do. Additionally, health behaviors, both enhancing (e.g., physical activity) and deleterious (e.g., smoking, high-fat diets), are similarly associated with SEP and race.
It is expected that blacks would experience higher rates of psychiatric disorders, particularly conditions associated with exposure to stress, such as major depression, given the evidence linking social disadvantage to poor physical health. Findings from epidemiologic surveys, however, consistently indicate that, compared with whites, blacks report similar or, in some cases, lower rates of lifetime mental disorders, even after accounting for the effects of SEP, despite evidence that blacks report higher levels of psychological distress. These findings seem counterintuitive, and researchers have sought explanations for why blacks experience lower levels of mental disorders than whites do, despite greater social disadvantage. It has been suggested that this patterning is due to misreporting bias; however, validation studies have indicated that survey assessments perform equally well for whites and blacks, and the consistency of this patterning across different instruments and study populations calls this argument into question. It has also been suggested that this patterning is due to greater utilization of positive coping strategies (e.g., religiosity, social support) among blacks, but such explanatory models are poorly specified and only weakly supported by empirical research.
One of the authors (J. S.) has put forth a testable, theory-derived model that accounts for this counterintuitive patterning of social disadvantage and mental and physical health burden across blacks and whites. The model rests on 3 empirical observations: 1) exposure to stressors is associated with risk of both physical and mental health problems through physiologic pathways; 2) when faced with exogenous stressors, individuals engage in coping behaviors to mitigate the psychological stress experience; and 3) the specific set of stress-responsive behaviors engaged in is shaped by the characteristics of the environment. This model posits that individuals who are exposed to chronic stress and live in poor environments will be more likely to engage in poor health behaviors (PHB), such as smoking, alcohol use, drug use, and overeating, because they are the most environmentally accessible coping strategies for socially disadvantaged groups. These behaviors act on common biologic structures and processes associated with pleasure and reward systems, consistent with the hypothesis that these behaviors alleviate, or interrupt, the physiological and psychological consequences of stress.
Recently, Jackson et al. reported that the relation between stressful events and depression risk was moderated by PHB among blacks, such that, at higher levels of stress, blacks who engaged in more PHB were less likely than those who engaged in fewer PHB to meet Diagnostic and Statistical Manual of Mental Disorders criteria for depression 3 years later. This same interaction between PHB and stress was not significant for whites. These initial results suggest that engaging in PHB can be conceptualized as stress-coping strategies and may explain the counterintuitive patterning of a lower burden of stress-related psychopathology, but a higher burden of behaviorally mediated physical health conditions, among blacks relative to whites.
The purpose of this study was to evaluate the association of race, stress, and PHB with risk of depression and chronic health conditions among whites and blacks over a 12-year period in the Baltimore Epidemiologic Catchment Area Study. Consistent with the etiologic model of the counterintuitive racial disparities in depressive disorders and physical health described above, it is predicted that blacks who engage in more PHB will have a lower risk of depression but a higher risk of physical health disorders at follow-up than those who engage in fewer of these behaviors.
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