Testing a somatization hypothesis to explain the Black–White depression paradox
Epidemiologic studies document a lower prevalence of major depression in Blacks than Whites in the United States. This is paradoxical from the perspective of social stress theory. A long-standing claim in the (clinical) literature is that Blacks express depression more somatically than Whites. If true, the diagnostic algorithm may undercount depression in Blacks, since the screening symptoms privilege the psychological rather than somatic dimensions of depression. We test hypotheses that (1) Blacks express depression more somatically than Whites which (2) reduces their likelihood of endorsing screening symptoms, thereby undercounting Blacks’ depression and explaining the Black–White depression paradox.
We use cross-sectional data collected in 1991–92 from the National Longitudinal Alcohol Epidemiologic Survey (n = 42,862) among Blacks and Whites endorsing at least one past-12-month depression symptom. We compare groups on depression somatization and test whether greater somatization in Blacks leads to lower endorsement of psychological screening symptoms, and therefore under-diagnosis.
Blacks have higher mean depression somatization scores than Whites (0.28, SE 0.04 vs. 0.15, SE 0.02), t(122) = − 2.15, p = 0.03. This difference is small and driven by Blacks’ higher endorsement of 1 somatic symptom (weight/appetite change) and Whites’ greater propensity to endorse psychological symptoms. However, Blacks have the same odds as Whites of endorsing screening symptoms, before and after adjusting for somatization.
We find minimal evidence that Blacks express depression more somatically than Whites. Furthermore, this small difference does not appear to inhibit endorsement of diagnostic depression screening symptoms among Blacks, and therefore does not resolve the Black–White depression paradox.
KeywordsMajor depressive disorder Race Somatization United States
The authors thank Sharon Schwartz for her insightful comments on this manuscript.
Compliance with ethical standards
Conflict of interest
On behalf of all authors, the corresponding author states that there is no conflict of interest.
- 12.Aneshensel CS (1999) Outcomes of the stress process. A handbook for the study of mental health: social contexts, theories, and systems. Cambridge University Press, Cambridge, pp 211–227Google Scholar
- 13.Aneshensel CS, Phelan JC (1999) The sociology of mental health: surveying the field. Handbook of the sociology of mental health. Plenum Publishers, New York, pp 3–18Google Scholar
- 15.Thoits PA (1999) Sociological approaches to mental health. A handbook for the study of mental health: social contexts, theories, and systems. Cambridge University Press, Cambridge, pp 121–138Google Scholar
- 16.Wheaton B (1999) The nature of stressors. A handbook for the study of mental health: social contexts, theories, and systems. Cambridge University Press, Cambridge, pp 176–197Google Scholar
- 19.Jordan WD (1968) White over Black: American attitudes toward the Negro, 1550–1812. The University of North Carolina Press, Chapel HillGoogle Scholar
- 22.Kochanek KD, Arias E, Anderson RN (2013) How did cause of death contribute to racial differences in life expectancy in the United States in 2010? NCHS data brief 125:1–8Google Scholar
- 23.Williams DR, Harris-Reid M (1999) Race and mental health: emerging patterns and promising approaches. In: Horwitz AV, Scheid TL (eds) a handbook for the study of mental health: social contexts, theories, and systems. Cambridge University Press, Cambridge, pp 295–314Google Scholar
- 33.Ryder AG, Yang J, Heine SJ (2002) Somatization vs. psychologization of emotional distress: A paradigmatic example for cultural psychopathology. Online Read Psychol Cult 10:3Google Scholar
- 38.Carter JH (1974) Recognizing psychiatric symptoms in black Americans. Geriatrics 29(11):95–99Google Scholar
- 40.Das AK, Olfson M, McCurtis HL, Weissman MM (2006) Depression in African Americans: breaking barriers to detection and treatment. J Fam Pract 55:30Google Scholar
- 45.National Institute on Alcohol Abuse and Alcoholism (1998) Drinking in the United States: main findings from the 1992 National Longitudinal Alcohol Epidemiologic Survey (NLAES). National Institute on Alcohol Abuse and Alcoholism, Washington D.C.Google Scholar
- 47.Grant BF, Dawson DA, Stinson FS et al (2003) The alcohol use disorder and associated disabilities interview schedule-IV (AUDADIS-IV): reliability of alcohol consumption, tobacco use, family history of depression and psychiatric diagnostic modules in a general population sample. Drug Alcohol Depend 71:7–16CrossRefGoogle Scholar
- 50.Grant BF, Hasin DS, Stinson FS et al (2005) Co-occurrence of 12-month mood and anxiety disorders and personality disorders in the US: results from the national epidemiologic survey on alcohol and related conditions. J Psychiatr Res 39:1–9. https://doi.org/10.1016/j.jpsychires.2004.05.004 CrossRefGoogle Scholar
- 51.Grant BF, Stinson FS, Hasin DS et al (2004) Immigration and lifetime prevalene of DSM-IV psychiatric disorders among Mexican Americans and non-Hispanic whites in the United States: results fromt he National Epidemiologic Survey on Alcohol and Related Conditions. JAMA Psychiatry 61:1226–1233Google Scholar
- 53.Link B, Dohrenwend BP (1980) Formulation of hypotheses about the true prevalence of demoralization in the United States. Mental illness in the United States: epidemiologic estimates. Praeger Publishers, New York, pp 114–132Google Scholar
- 58.Mouzon DM (2010) Can social relationships explain the race paradox in mental health?. Rutgers University Graduate School, New BrunswickGoogle Scholar
- 64.Gray BA, Keith VM (2003) The benefits and costs of social support for African American women. In and out of our right minds: the mental health of African American women. Columbia University Press, New York, pp 242–257Google Scholar
- 68.Jackson JS, Knight KM (2006) Race and self-regulatory health behaviors: the role of the stress response and the HPA axis in physical and mental health disparities. In: Schaie KW, Carstensen LL (eds) Social structures, aging, and self-regulation in the elderly. Springer, New York, pp 189–207Google Scholar
- 71.Neighbors HW, Trierweiler SJ, Munday C et al (1999) Psychiatric diagnosis of African Americans: diagnostic divergence in clinician-structured and semistructured interviewing conditions. J Natl Med Assoc 91:601–612Google Scholar