Reconsidering the Role of Social Disadvantage in Physical and Mental Health: Stressful Life Events, Health Behaviors, Race, and Depression

American Journal of Epidemiology, Dec 2010

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.

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Reconsidering the Role of Social Disadvantage in Physical and Mental Health: Stressful Life Events, Health Behaviors, Race, and Depression

Briana Mezuk ) 0 1 Jane A. Rafferty 0 1 Kiarri N. Kershaw 0 1 Darrell Hudson 0 1 Cleopatra M. Abdou 0 1 Hedwig Lee 0 1 William W. Eaton 0 1 James S. Jackson 0 1 0 P.O. Box 980212, Richmond, VA 23298 ( 1 D o w n l o a d e d f r o m American Journal of Epidemiology The Author 2010. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: . 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 (b: 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. adaptation, psychological; depression; health behavior; health status disparities; minority health; stress, psychological Abbreviations: CI, confidence interval; OR, odds ratio; PHB, poor health behaviors; SEP, socioeconomic position. - 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 (1014). Additionally, health behaviors, both enhancing (e.g., physical activity) (14, 15) and deleterious (e.g., smoking, high-fat diets), are similarly associated with SEP and race (5, 16, 17). 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 (18). 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 (19 21), despite evidence that blacks report higher levels of psychological distress (22). 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 (23); however, validation studies have indicated that survey assessments perform equally well for whites and blacks (23, 24), 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 (25). One of the authors (J. S.) has put forth a testable, theoryderived model that accounts for this counterintuitive patterning of social disadvantage and mental and physical health burden across blacks and whites (26). 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 (27); and 3) the specific set of stress-responsive behaviors engaged in is shaped by the characteristics of the environment (28). 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 (26). These behaviors act on common biologic structures and processes associated with pleasure and reward systems (2932), consistent with the hypothesis that these behaviors alleviate, or interrupt, the physiological and psychological consequences of stress. Recently, Jackson et al. (33) reported t (...truncated)


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Briana Mezuk, Jane A. Rafferty, Kiarri N. Kershaw, Darrell Hudson, Cleopatra M. Abdou, Hedwig Lee, William W. Eaton, James S. Jackson. Reconsidering the Role of Social Disadvantage in Physical and Mental Health: Stressful Life Events, Health Behaviors, Race, and Depression, American Journal of Epidemiology, 2010, pp. 1238-1249, 172/11, DOI: 10.1093/aje/kwq283