Reconsidering the Role of Social Disadvantage in Physical and Mental Health: Stressful Life Events, Health Behaviors, Race, and Depression
Briana Mezuk
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Jane A. Rafferty
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Kiarri N. Kershaw
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Darrell Hudson
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Cleopatra M. Abdou
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Hedwig Lee
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William W. Eaton
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James S. Jackson
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P.O. Box 980212,
Richmond, VA 23298 (
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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.
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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)