Social Psychiatry and Psychiatric Epidemiology

, Volume 54, Issue 10, pp 1255–1263 | Cite as

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

  • David M. BarnesEmail author
  • Lisa M. Bates
Original Paper



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.


Major 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.


  1. 1.
    Brown TN (2003) Critical race theory speaks to the sociology of mental health: mental health problems produced by racial stratification. J Health Soc Behav 44:292–301PubMedGoogle Scholar
  2. 2.
    Earl T, Williams D, Anglade S (2011) An update on the mental health of Black Americans: puzzling dilemmas and needed research. J Black Psychol 37:485–498. CrossRefGoogle Scholar
  3. 3.
    Jackson JS, Knight KM, Rafferty JA (2010) Race and unhealthy behaviors: chronic stress, the HPA axis, and physical and mental health disparities over the life course. Am J Public Health 100:933–939PubMedPubMedCentralGoogle Scholar
  4. 4.
    Mezuk B, Abdou CM, Hudson D et al (2013) “White Box” epidemiology and the social neuroscience of health behaviors: the environmental affordances model. Soc Ment Health 3:79–95. CrossRefGoogle Scholar
  5. 5.
    Neighbors HW, Njai R, Jackson JS (2007) Race, ethnicity, John Henryism, and depressive symptoms: the national survey of American life adult reinterview. Res Hum Dev 4:71–87Google Scholar
  6. 6.
    Barnes DM, Bates LM (2017) Do racial patterns in psychological distress shed light on the Black–White depression paradox? A systematic review. Soc Psychiatry Psychiatr Epidemiol 52:913–928. CrossRefPubMedGoogle Scholar
  7. 7.
    Dressler WW, Oths KS, Gravlee CC (2005) Race and ethnicity in public health research: models to explain health disparities. Annu Rev Anthr 34:231–252Google Scholar
  8. 8.
    Horwitz AV (2002) Outcomes in the sociology of mental health: where have we been and where are we going? J Health Soc Behav 43:143–151PubMedGoogle Scholar
  9. 9.
    Pearlin LI, Meneghan EG, Lieberman MA, Mullan JT (1981) The stress process. J Health Soc Behav 22:337–356PubMedGoogle Scholar
  10. 10.
    Schwartz S, Meyer IH (2010) Mental health disparities research: the impact of within and between group analyses on tests of social stress hypotheses. Soc Sci Med 70:1111–1118PubMedGoogle Scholar
  11. 11.
    Turner RJ (2010) Health disparities and the stress hypothesis: a commentary on Schwartz and Meyer. Soc Sci Med 70:1119–1120PubMedGoogle Scholar
  12. 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. 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
  14. 14.
    Pearlin LI, Bierman A (2013) Current issues and future directions in research into the stress process. In: Aneshensel CS, Phelan JC, Bierman A (eds) Handbook of the sociology of mental health. Springer, Dordrecht, pp 325–340Google Scholar
  15. 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. 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
  17. 17.
    Platt JR (1964) Strong inference. Science 146:347–353PubMedGoogle Scholar
  18. 18.
    Muntaner C, Ng E, Vanroelen C et al (2013) Social stratification, social closure, and social class as determinants of mental health disparities. In: Aneshensel CS, Phelan JC, Bierman A (eds) Handbook of the sociology of mental health. Springer, Dordrecht, pp 205–227Google Scholar
  19. 19.
    Jordan WD (1968) White over Black: American attitudes toward the Negro, 1550–1812. The University of North Carolina Press, Chapel HillGoogle Scholar
  20. 20.
    Williams DR, Yu Y, Jackson JS, Anderson NB (1997) Racial differences in physical and mental health, socio-economic status, stress and discrimination. J Health Psychol 2:335–351Google Scholar
  21. 21.
    Williams DR, Jackson PB (2005) Social sources of racial disparities in health. Health Aff (Millwood) 24:325–334. CrossRefGoogle Scholar
  22. 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. 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
  24. 24.
    Simon GE, VonKorff M, Piccinelli M et al (1999) An international study of the relation between somatic symptoms and depression. N Engl J Med 341:1329–1335PubMedGoogle Scholar
  25. 25.
    Lehmann HE (1959) Psychiatric concepts of depression: nomenclature and classification. Can Psychiatr Assoc J 4:1–12PubMedGoogle Scholar
  26. 26.
    Cadoret RJ, Wilson D (1983) Somatization among depressed patients in industrialized nations. Am J Psychiatry 140:1103–1104PubMedGoogle Scholar
  27. 27.
    Carragher N, Adamson G, Bunting B, McCann S (2009) Subtypes of depression in a nationally representative sample. J Affect Disord 113:88–99. CrossRefPubMedGoogle Scholar
  28. 28.
    Kirmayer LJ, Robbins JM, Dworkind M, Yaffe MJ (1993) Somatization and the recognition of depression and anxiety in primary care. Am J Pyschiatry 150:734–741Google Scholar
  29. 29.
    Tsai J, Elhai JD, Pietrzak RH et al (2014) Comparing four competing models of depressive symptomatology: a confirmatory factor analytic study of 986,647 U.S. veterans. J Affect Disord 165:166–169. CrossRefPubMedGoogle Scholar
  30. 30.
    Schnittker J (2012) The proximity of common unhappiness and misery. Soc Ment Health 2:135–153. CrossRefGoogle Scholar
  31. 31.
    Kirmayer LJ, Young A (1998) Culture and somatization: clinical, epidemiological, and ethnographic perspectives. Psychosom Med 60:420–430PubMedGoogle Scholar
  32. 32.
    Kleinman AM (1977) Depression, somatization and the “new cross-cultural psychiatry”. Soc Sci Med 11:3–10PubMedGoogle Scholar
  33. 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
  34. 34.
    Tseng W-S, Hsu J (1970) Chinese culture, personality formation and mental illness. Int J Soc Psychiatry 16:5–14. CrossRefGoogle Scholar
  35. 35.
    Tylee A, Gandhi P (2005) The importance of somatic symptoms in depression in primary care. Prim Care Companion J Clin Psychiatry 7:167–176PubMedPubMedCentralGoogle Scholar
  36. 36.
    Yusim A, Anbarasan D, Hall B et al (2010) Sociocultural domains of depression among indigenous populations in Latin America. Int Rev Psychiatry 22:370–377. CrossRefPubMedGoogle Scholar
  37. 37.
    Prange AJ, Vitols MM (1962) Cultural aspects of the relatively low incidence of depression in southern Negroes. Int J Soc Psychiatry 8:104–112. CrossRefPubMedGoogle Scholar
  38. 38.
    Carter JH (1974) Recognizing psychiatric symptoms in black Americans. Geriatrics 29(11):95–99PubMedGoogle Scholar
  39. 39.
    Baker FM (2001) Diagnosing depression in African Americans. Community Ment Health J 37:31–38PubMedGoogle Scholar
  40. 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
  41. 41.
    Hunter LR, Schmidt NB (2010) Anxiety psychopathology in African American adults: literature review and development of an empirically informed sociocultural model. Psychol Bull 136:211–235. CrossRefPubMedGoogle Scholar
  42. 42.
    Karasz A (2005) Cultural differences in conceptual models of depression. Soc Sci Med 60:1625–1635. CrossRefGoogle Scholar
  43. 43.
    Breslau J, Javaras KN, Blacker D et al (2008) Differential item functioning between ethnic groups in the epidemiological assessment of depression. J Nerv Ment Dis 196:297–306PubMedPubMedCentralGoogle Scholar
  44. 44.
    Uebelacker LA, Strong D, Weinstock LM, Miller IW (2008) Use of item response theory to understand differential functioning of DSM-IV major depression symptoms by race, ethnicity and gender. Psychol Med 39:591. CrossRefPubMedGoogle Scholar
  45. 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
  46. 46.
    Chatterji S, Saunders JB, Vrasti R et al (1997) Reliability of the alcohol and drug modules of the alcohol use disorder and associated disabilities interview schedule—alcohol/drug-revised (AUDADIS-ADR): an international comparison. Drug Alcohol Depend 47:171–185PubMedGoogle Scholar
  47. 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 71:7–16PubMedGoogle Scholar
  48. 48.
    Grant BF, Stinson FS, Dawson DA et al (2004) Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry 61:807–816PubMedGoogle Scholar
  49. 49.
    Canino G, Bravo M, Ramirez R et al (1999) The Spanish alcohol use disorder and associated disabilities interview schedule (AUDADIS): reliability and concordance with clinical diagnoses in a Hispanic population. J Stud Alcohol 60:790–799PubMedGoogle Scholar
  50. 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. CrossRefPubMedGoogle Scholar
  51. 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
  52. 52.
    Hasin DS, Goodwin RD, Stinson FS, Grant BF (2005) Epidemiology of major depressive disorder: results from the National Epidemiologic Survey on Alcoholism and Related Conditions. Arch Gen Psychiatry 62:1097–1106PubMedGoogle Scholar
  53. 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
  54. 54.
    Coyne JC (1994) Self-reported distress: analog or ersatz depression? Psychol Bull 116:29–45PubMedGoogle Scholar
  55. 55.
    Dohrenwend BP, Shrout PE, Egri G, Mendelsohn FS (1980) Nonspecific psychological distress and other dimensions of psychopathology: measures for use in the general population. Arch Gen Psychiatry 37:1229PubMedGoogle Scholar
  56. 56.
    Breslau J, Aguilar-Gaxiola S, Kendler KS et al (2006) Specifying race-ethnic differences in risk for psychiatric disorder in a US national sample. Psychol Med 36:57–68Google Scholar
  57. 57.
    Williams DR, Gonzalez HM, Neighbors H et al (2007) Prevalence and distribution of major depressive disorder in African Americans, Caribbean blacks, and non-Hispanic whites: results from the National Survey of American Life. Arch Gen Psychiatry 64:305Google Scholar
  58. 58.
    Mouzon DM (2010) Can social relationships explain the race paradox in mental health?. Rutgers University Graduate School, New BrunswickGoogle Scholar
  59. 59.
    Bertera EM (2005) Mental health in U.S. adults: the role of positive social support and social negativity in personal relationships. J Soc Pers Relatsh 22:33–48. CrossRefGoogle Scholar
  60. 60.
    Chatters LM, Taylor RJ, Jackson JS, Lincoln KD (2008) Religious coping among African Americans, Caribbean Blacks and Non-Hispanic Whites. J Community Psychol 36:371–386. CrossRefPubMedPubMedCentralGoogle Scholar
  61. 61.
    Ellison CG, Boardman JD, Williams DR, Jackson JS (2001) Religious involvement, stress, and mental health: findings from the 1995 Detroit Area Study. Soc Forces 80:215–249Google Scholar
  62. 62.
    Fischer AR, Shaw CM (1999) African Americans’ mental health and perceptions of racist discrimination: the moderating effects of racial socialization experiences and self-esteem. J Couns Psychol 46:395Google Scholar
  63. 63.
    Hettler TR, Cohen LH (1998) Intrinsic religiousness as a stress-moderator for adult Protestant churchgoers. J Community Psychol 26:597–609Google Scholar
  64. 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
  65. 65.
    Hughes D, Rodriguez J, Smith EP et al (2006) Parents’ ethnic-racial socialization practices: a review of research and directions for future study. Dev Psychol 42:747–770. CrossRefGoogle Scholar
  66. 66.
    van Olphen J, Schulz A, Israel B et al (2003) Religious involvement, social support, and health among African-American women on the east side of Detroit. J Gen Intern Med 18:549–557PubMedPubMedCentralGoogle Scholar
  67. 67.
    Kiecolt K, Hughes M, Keith VM (2008) Race, social relationships, and mental health. Pers Relatsh 15:229–245Google Scholar
  68. 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
  69. 69.
    Keyes KM, Barnes DM, Bates LM (2011) Stress, coping, and depression: testing a new hypothesis in a prospectively studied general population sample of U.S.-born whites and blacks. Soc Sci Med 72:650–659PubMedGoogle Scholar
  70. 70.
    Mezuk B, Rafferty JA, Kershaw KN et al (2010) Reconsidering the role of social disadvantage in physical and mental health: stressful life events, health behaviors, race, and depression. Am J Epidemiol 172:1238–1249PubMedPubMedCentralGoogle Scholar
  71. 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 91:601–612PubMedPubMedCentralGoogle Scholar
  72. 72.
    Neighbors HW, Trierweiler SJ, Ford BC, Muroff JR (2003) Racial differences in DSM diagnosis using a semi-structured instrument: the importance of clinical judgment in the diagnosis of African Americans. J Health Soc Behav 44:237–256PubMedGoogle Scholar
  73. 73.
    Strakowski SM, Keck PE, Arnold LM et al (2003) Ethnicity and diagnoses in patients with affective disorders. J Clin Psychiatry 64:747–754PubMedGoogle Scholar
  74. 74.
    Kessler RC, McGonagle KA, Zhao S et al (1994) Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry 51:8–19Google Scholar
  75. 75.
    Ayanian JZ, Weissman JS, Chasan-Taber S, Epstein AM (1999) Quality of care by race and gender for congestiv heart failure and pneumonia. Med Care 37:1260–1269PubMedGoogle Scholar
  76. 76.
    Ayanian JZ, Cleary PD, Weissman JS, Epstein AM (1999) The effect of patients’ preferences on racial differences in access to renal transplantation. N Engl J Med 341:1661–1669PubMedGoogle Scholar
  77. 77.
    Bach PB, Cramer LD, Warren JL, Begg CB (1999) Racial differences in the treatment of early-stage lung cancer. N Engl J Med 341:1198–1205PubMedGoogle Scholar
  78. 78.
    Mayberry RM, Mili F, Ofili E (2000) Racial and ethnic differences in access to medical care. Med Care Res Rev 57:108–145PubMedGoogle Scholar
  79. 79.
    Michaud CM, McKenna MT, Begg S et al (2006) The burden of disease and injury in the United States 1996. Popul Health Metr 4:11PubMedPubMedCentralGoogle Scholar

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© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Epidemiology, College of Global Public HealthNew York UniversityNew YorkUSA
  2. 2.Department of Epidemiology, Mailman School of Public HealthColumbia UniversityNew YorkUSA

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