Testing a somatization hypothesis to explain the Black-White depression paradox

Emergency hospital admissions for stress-related presentations among secondary school-aged minoritised young people in England

BACKGROUND

Minoritised young people face a double burden of discrimination through increased risk of stress and differential treatment access. However, acute care pathways for minoritised young people with urgent mental health needs are poorly understood.

AIMS

To explore variation in stress-related presentations (SRPs) to acute hospitals across racial-ethnic groups in England.

METHOD

We examined rates, distribution, duration and types of SRPs across racial-ethnic groups in a retrospective cohort of 11- to 15-year-olds with one or more emergency hospital admissions between April 2014 and March 2020. SRPs were defined as emergency admissions for potentially psychosomatic symptoms, self-harm and internalising, externalising and thought disorders.

RESULTS

White British (8-38 per 1000 births) and Mixed White-Black (9-42 per 1000 births) young people had highest rates of SRPs, whereas Black African (5-14 per 1000 births), Indian (6-19 per 1000 births) and White other (4-19 per 1000 births) young people had the lowest rates of SRPs. The proportion of readmissions were highest for Pakistani (47.7%), White British (41.4%) and Mixed White-Black (41.3%) groups. Black Other (36.4%) and White Other (35.8%) groups had the lowest proportions of readmissions. The proportion of admission durations ≥3 days was higher for Black Other (16.6%), Bangladeshi (16.3%), Asian Other (15.9%) and Black Caribbean (15.8%) groups than their White British (11.9%) and Indian (11.8%) peers. The type of SRPs varied across racial-ethnic groups.

CONCLUSIONS

Patterns of SRP admissions systematically differed across racial-ethnic groups, indicative of inequitable triage, assessment and treatment processes. These findings highlight the need for implementation of race equality frameworks to address structural racism in healthcare pathways.

Patient-Reported Racial and Ethnic Disparities in Patients With Ulcerative Colitis: Results From the National Health and Wellness Survey

Background

Ulcerative colitis (UC) is an inflammatory condition characterized by chronic, disabling gastrointestinal symptoms that can have detrimental effects on psychological, social, and professional quality of life. Few studies have examined patient-reported outcomes (PROs) and economic outcomes among individuals with varying UC severity and across different racial/ethnic groups.

Methods

This cross-sectional study assessed sociodemographic data, PROs, and economic outcomes for participants from the National Health and Wellness Survey (2018, 2019, and 2020) with UC. Multivariable analyses were used to assess the association of self-reported UC severity and race/ethnicity with health-related quality of life (HRQoL), work productivity and activity impairment (WPAI), healthcare resource utilization (HCRU), and medical costs.

Results

This study included 1500 participants with UC (1150 non-Hispanic White, 99 non-Hispanic Black, and 251 Hispanic). Moderate/severe disease was associated with significantly worse HRQoL and WPAI, greater HCRU, and higher direct medical costs than mild UC. Compared with non-Hispanic White participants, non-Hispanic Black participants reported better HRQoL, whereas Hispanic participants reported more HCRU and higher medical costs. Race/ethnicity significantly interacted with UC severity level in predicting labor force participation.

Conclusions

Participants with moderate/severe disease had worse outcomes than those with mild UC. Additionally, racial/ethnic differences were found in HRQoL, employment, WPAI, HCRU, and direct medical costs. Notably, Hispanic participants showed distinct patterns, particularly in how disease severity influenced employment outcomes. Further research is needed to better understand the differential burden among patients across racial/ethnic groups.

The Worst of Times: Depressive Symptoms Among Racialized Groups Living With Dementia and Cognitive Impairment During the COVID-19 Pandemic

Objective: To explore differences in depressive symptoms for older adults (Black, Latinx, and White) by cognitive status during the 2020 COVID-19 pandemic. Methods: Data from the Health and Retirement Study identified older adults as cognitively normal, cognitively impaired without dementia (CIND), and persons living with dementia (PLWD). Multiple linear regression analyses examined associations between cognitive status and depressive symptoms among these racialized groups. Results: Compared to the cognitively normal older adults racialized as Black, those with CIND reported higher depressive symptoms during the pandemic (overall and somatic) and PLWD had higher somatic symptoms (p < .01). Older adults racialized as White with CIND reported higher somatic (p < .01) symptoms compared to cognitively normal older adults racialized as White. Discussion: The COVID-19 pandemic was a challenging event among older adults racialized as Black with CIND and PLWD. Future studies should examine if these depressive symptoms persist over time.

Investigating a Paradox: Toward a Better Understanding of the Relationships Between Racial Group Membership, Stress, and Major Depressive Disorder

Epidemiologic studies in the United States routinely report a lower or equal prevalence of major depressive disorder (MDD) for Black people relative to White people. Within racial groups, individuals with greater life stressor exposure experience greater prevalence of MDD; however, between racial groups this pattern does not hold. Informed by theoretical and empirical literature seeking to explain this "Black-White depression paradox," we outline 2 proposed models for the relationships between racial group membership, life stressor exposure, and MDD: an effect modification model and an inconsistent mediator model. Either model could explain the paradoxical within- and between-racial group patterns of life stressor exposure and MDD. We empirically estimated associations under each of the proposed models using data from 26,960 self-identified Black and White participants in the National Epidemiologic Survey on Alcohol and Related Conditions III (United States, 2012-2013). Under the effect modification model, we estimated relative risk effect modification using parametric regression with a cross-product term, and under the inconsistent mediation model, we estimated interventional direct and indirect effects using targeted minimum loss-based estimation. We found evidence of inconsistent mediation (i.e., direct and indirect effects operating in opposite directions), suggesting a need for greater consideration of explanations for racial patterns in MDD that operate independent of life stressor exposure. This article is part of a Special Collection on Mental Health.

COVID-19: Factors Predicting Depressive Symptoms in People Aging With Long-Term Physical Disabilities

The mental health impact of the COVID-19 pandemic may be greater than that of the viral infection. This impact is likely greater for disadvantaged groups such as people with long-term physical disabilities (PwLTPD). This cross-sectional study used a multiple linear regression model to examine factors associated with depressive symptoms and to understand their relative importance during the onset of the COVID-19 pandemic. The model explained 58% of the variance in depressive symptoms. Anxiety was the most important predictor, accounting for 8% of variance. Higher levels of anxiety, loneliness, and financial stress; prior diagnosis of depression; and non-Black race predicted a higher level of depressive symptoms in PwLTPD during the onset of the COVID-19 pandemic. Occupational therapy practitioners should strategically acknowledge predictors of depression that cannot be modified and actively address those that can be modified through evidence-based interventions to improve depressive symptoms in PwLTPD.

Perceived racial discrimination, psychosomatic symptoms, and resilience among Black individuals in Canada: A moderated mediation model

OBJECTIVE

Although no study has explored psychosomatic symptoms in Black communities in Canada, several studies in the United States showed that psychological distress is often express as physical pain among African Americans. Using a cross-sectional design, the present study documents the frequency of psychosomatic symptoms and its association to racial discrimination, and resilience among Black individuals aged 15 to 40 in Canada.

METHOD

A total of 860 participants (M_age = 25.0 years, SD = 6.3), predominantly born in Canada (79.1%) and women (75.6%), completed the Symptom Checklist-90-Revised (somatization subscale), the Everyday Discrimination Scale, and the Resilience Scale-14.

RESULTS

Findings revealed that 81.7% of participants experienced psychosomatic symptoms, with higher prevalence among women (84.2%) compared to men (70.7%;), ꭓ² = 21.5, p < .001; participants aged 25 to 40 years old (93.7%) compared to those aged 15-24 years old (75.2%) (ꭓ² = 45.0, p < .001). Participants reporting greater racial discrimination had more psychosomatic symptoms (89.4%) compared to others (72.9%), ꭓ² = 39.2, p < .001). A moderated mediation model showed that everyday racial discrimination was positively associated with psychosomatic symptoms (B = 0.1, SE = 0.01, p < .001). The model showed that the association between racial discrimination and psychosomatic symptoms was partially mediated by resilience (B = -0.01, SE = 0.0, p < .01), and negatively moderated by gender (B = -0.04, SE = 0.01, p < .01). In other words, being a woman is associated with higher levels of psychosomatic symptoms among those who have experienced racial discrimination.

CONCLUSION

By highlighting the association between racial discrimination and psychosomatic symptoms and the role of resilience and gender in this relation, this article reveals important factors to integrate to improve healthcare services, prevention, and interventions among Black individuals with psychosomatic symptoms.

Distress tolerance: prospective associations with cognitive-behavioral therapy outcomes in adults with posttraumatic stress and substance use disorders

74Distress tolerance (DT; perceived or actual ability to tolerate aversive physical or emotional states) is related to both posttraumatic stress disorder (PTSD) symptoms and substance use disorders (SUD). This investigation evaluates self-report and behavioral measures of DT as potential predictors of PTSD and SUD cognitive-behavioral therapy outcomes. Participants included 41 treatment-seeking adults (53.7% women; 73.2% African American; Mage = 44.90, SD = 9.68) who met at least four symptoms of DSM-5 PTSD and DSM-IV substance dependence, assessed via structured interviews. At baseline (pre-treatment), participants completed the Distress Tolerance Scale (DTS), Mirror-Tracing Persistence Task (MTPT), Breath Holding task, and Paced Auditory Serial Addition Task. The Clinician-Administered PTSD Scale for DSM-5 severity scores and percent days of primary substance use, measured via Timeline Follow-back, were used as indicators of PTSD symptoms and substance use, respectively. Covariates included treatment condition, baseline PTSD symptom severity, and baseline substance use. Lower perceived DT at baseline (DTS total score) was associated with higher PTSD symptom severity at end-of-treatment. Lower behavioral DT at baseline (MTPT duration) was associated with higher substance use at the conclusion of treatment (i.e. proportion of number of use days to total number of days between two final treatment sessions).

Racial Variation in the Association Between Domains of Depressive Symptomatology and Functional Recovery in Stroke Survivors

OBJECTIVE

The purpose of the study was to investigate the relationships between various domains of depressive symptomatology and functional recovery in Black and White stroke survivors.

METHODS

Black (n = 181) and White (n = 797) stroke survivors from the Stroke Recovery in Underserved Population database were included. Four domains of depressive symptomatology (depressed affect, positive affect, somatic symptoms, interpersonal difficulties) were measured by the Center for Epidemiologic Studies Depression Scale at discharge; functional recovery was measured by the Functional Independence Measure at discharge and 3-month follow-up. Multivariable linear regression analyses examined the relation between race and functional recovery, and the association between depressive symptomatology and functional recovery by race.

RESULTS

Three-month functional recovery was greater among White stroke survivors than Black survivors. Affective symptoms of depression predicted poorer functional recovery of White survivors; whereas somatic symptoms predicted poorer functional recovery of Black survivors.

CONCLUSIONS

Domains of depressive symptomatology were differentially associated with poorer functional recovery in Black and White stroke survivors. Psychosocial interventions aimed at alleviating depressive symptomatology have the potential to improve functional recovery in Black and White stroke survivors and should be addressed in planning rehabilitation post-stroke.

Evaluating hypothesized explanations for the Black-white depression paradox: A critical review of the extant evidence

The Black-white Depression paradox, the lower prevalence of major depression among non-Hispanic Black (relative to non-Hispanic white) individuals despite their greater exposure to major life stressors, is a phenomenon that remains unexplained. Despite a decade plus of research, there is little clarity as to whether the paradoxical observations are an invalid finding, spuriously produced by selection bias, information bias, or confounding, or are a valid finding, representative of a true racial patterning of depression in the population. Though both artefactual and etiologic mechanisms have been tested, a lack of synthesis of the extant evidence has contributed towards an unclear picture of the validity of the paradox and produced challenges for researchers in determining which proposed mechanisms show promise, which have been debunked, and which require further study. The objective of this critical review is to assess the state of the literature regarding explanations for the Black-white depression paradox by examining some of the more prominent hypothesized explanatory mechanisms that have been proposed and assessing the state of the evidence in support of them. Included mechanisms were selected for their perceived dominance in the literature and the existence of at least one, direct empirical test using DSM major depression as the outcome. This review highlights the very limited evidence in support of any of the extant putative mechanisms, suggesting that investigators should redirect efforts towards identifying novel mechanisms, and/or empirically testing those which show promise but to date have been relatively understudied. We conclude with a discussion of the broader implications of the evidence for well-accepted social theories and raise questions regarding the use of DSM major depression to assess mental health burden in Black communities.

"What Doesn't Kill You, Makes You Stronger": Psychosocial Resources and the Mental Health of Black Older Adults

A robust body of research has shown that Black Americans are less likely than Whites to have psychiatric disorders despite the social and economic disadvantage and systemic racism that they face. This mental health paradox has been demonstrated across all ages of the life course, including older adulthood. One of the prevailing explanations for the lower prevalence of psychiatric disorders among Blacks pertains to the influence of psychosocial resources on mental health. Psychosocial resources can directly or indirectly support mental health through physiological and psychological pathways. They can also mitigate the adverse effects of social stressors of discrimination and other stressors on psychological distress and mental illness. Black older adults may particularly benefit from psychosocial resources because they have had a lifetime of experiencing and overcoming adversity. Although this cycle of stress adaptation can wear away at the physical body, it may facilitate mental health resilience. In this chapter, we review research on the relationship between psychosocial resources and mental health. The chapter begins with a brief review of the Black-White mental health paradox and the mechanisms through which psychosocial resources operate to influence mental health. We then review research on intrapersonal, interpersonal, and community-level psychosocial resources that are particularly salient for Black Americans. Throughout the chapter we highlight research specifically focused on Black older adults and discuss the cultural relevance of each resource to their mental health and psychological functioning.

Racial and Ethnic Disparities in Serious Psychological Distress Among Those With Alzheimer's Disease and Related Dementias

BACKGROUND

Alzheimer's disease and related dementias (ADRD) is a growing public health challenge. Prior research suggests that non-Hispanic whites (whites), non-Hispanic African Americans (African Americans), and Hispanics have differing risks for ADRD.

OBJECTIVE

To examine the existence of serious psychological distress (SPD) among whites, African Americans, and Hispanics; to calculate the predicted probability of ADRD in whites, African Americans, and Hispanics, and to decompose the differences among ADRD populations, quantifying the burden of higher SPD among African Americans and Hispanics, compared to whites.

DATA AND METHOD

The authors use nationally representative data from the Medical Expenditure Panel Survey (2007-2015) to estimate the association between ADRD and race, ethnicity, and SPD. Using Blinder-Oaxaca decomposition analysis, the authors estimate to what extent higher SPD among Hispanics and African Americans was associated with higher ADRD rates compared to whites.

RESULTS

After controlling for individuals' demographic and socioeconomic characteristics and co-existing medical conditions, the presence of SPD was still significantly associated with a higher likelihood of having ADRD. The model predicted significantly higher likelihood of having ADRD among African Americans (7.1%) and Hispanics (5.7%) compared to whites (4.5%). Higher rates of having SPD among African Americans explained 15% of white-black difference and 40% of the white-Hispanic difference in ADRD rates, respectively.

DISCUSSION AND CONCLUSION

Our findings suggest a significant relationship between SPD and ADRD and that the burden of SPD was greater among African Americans and Hispanics with ADRD. Efficient screening using self-reported SPD, compared to simply using diagnoses codes of mental illness, may be more helpful to reduce racial and ethnic disparities in ADRD.