Race, Socioeconomic Position, and Physical Health: A Descriptive Analysis.

A substantial and long-standing body of research supports the widely held conclusion that socioeconomic position (SEP) is a primary determinant of physical health risk. However, supporting evidence derives almost entirely from studies of dominantly white populations, and more recent research suggests that this relationship may vary across race-ethnicity. This article considers the extent to which such evidence applies to African Americans. It does so by examining the within-race relationships between SEP and physical health utilizing alternative research definitions of health and a nearly exhaustive array of measures of SEP. The results offer minimal support for SEP as a fundamental cause of disease among African Americans. They do not challenge the widely held view that health differences are rooted in the fundamental conditions of social context and experience. Rather, they indicate that these conditions tend to be defined more by being black than by being of lower SEP.

Childhood adversity and adult health: Evaluating intervening mechanisms.

Substantial evidence has accumulated supporting a causal link between childhood adversity and risk for poor health years and even decades later. One interpretation of this evidence is that this linkage arises largely or exclusively from a process of biological embedding that is not modifiable by subsequent social context or experience - implying childhood as perhaps the only point at which intervention efforts are likely to be effective. This paper considers the extent to which this long-term association arises from intervening differences in social context and/or environmental experiences - a finding that would suggest that post-childhood prevention efforts may also be effective. Based on the argument that the selected research definition of adult health status may have implications for the early adversity-adult health linkage, we use a representative community sample of black and white adults (N = 1252) to evaluate this relationship across three health indices: doctor diagnosed illnesses, self-rated health, and allostatic load. Results generally indicate that observed relationships between childhood adversity and dimensions of adult health status were totally or almost totally accounted for by variations in adult socioeconomic position (SEP) and adult stress exposure. One exception is the childhood SEP-allostatic load association, for which a statistically significant relationship remained in the context of adult stress and SEP. This lone finding supports a conclusion that the impact of childhood adversity is not always redeemable by subsequent experience. However, in general, analyses suggest the likely utility of interventions beyond childhood aimed at reducing exposure to social stress and improving social and economic standing. Whatever the effects on adult health that derive from biological embedding, they appear to be primarily indirect effects through adult social context and exposure.

Physical disability and depression: clarifying racial/ethnic contrasts.

OBJECTIVE: This study assesses racial/ethnic disparities in depressive symptoms among persons who are physically disabled and evaluates the extent to which variation in stress exposure, coping resources, and feelings of shame associated with disability account for observed differences. METHOD: Data are drawn from a Miami-Dade County study that oversampled persons with physical disabilities. The sample used in this study includes individuals of Cuban and other Hispanic heritage, African Americans, and non-Hispanic Whites who identify as physically disabled (N = 550). RESULTS: Cubans and other Hispanics report higher levels of depressive symptoms. This elevation in risk is largely explained by variations in stress exposure, available coping resources, and shame. Findings also suggest that feelings of shame may condition the relationships between both stress exposure and coping resources and depressive symptomatology. DISCUSSION: Findings demonstrate racial/ethnic differences in depressive symptoms among persons with physical disabilities and highlight the importance of stress exposure, coping resources, and shame for understanding these differences.

Childhood exposure to adversity and risk of substance-use disorder in two American Indian populations: the meditational role of early substance-use initiation.

OBJECTIVE: We examined the relationship of childhood exposure to adversity and risk of substance-use disorder in two culturally distinct American Indian reservation communities, exploring both the role of early initiation of substance use in mediating this relationship and variation in risk across types of adversity exposure. METHOD: The American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project provided data from 2,927 American Indians on the occurrence and age at onset of adversities, substance use, and substance-use-disorder symptoms. RESULTS: The risk of substance-use disorder associated with early adversity was explained partially by early initiation of substance use. Three types of adversity (major childhood events, traumas, and witnessed violence) were associated with early onset of substance use and increased risk of substance-use disorder. Gender and tribe were also related to variation in both early substance use and substance-use disorder. CONCLUSIONS: Early exposure to adverse events was associated with early substance use and the subsequent development of substance-use disorders among American Indians. public health initiatives targeting substance use and substance-use disorders in American Indian communities should include efforts to help children in these communities cope with adversities they encounter.

Physical disability and suicidal ideation: a community-based study of risk/protective factors for suicidal thoughts.

Although the significance of poor physical health for suicide risk is well established, the potential relevance of physical disability, as distinct from diseases and traumas that give rise to disability, has received little attention. Prior evidence suggests the possible utility of the stress process theoretical model for understanding variations in risk for suicide ideation and the contribution of physical disability to such risk. In this article, we examine the independent and joint explanatory significance of physical disability and components of the stress process model for risk of suicide ideation. Data from an ethnically diverse and representative sample of disabled and nondisabled adults (n = 1,768) reveal that physical disability is associated with a greater risk of lifetime suicidal ideation.

Social anxiety disorder as a risk factor for alcohol use disorders: a prospective examination of parental and peer influences.

Elucidation of mechanisms underlying the high rates of alcohol use disorder (AUD) remains a pressing clinical and research concern. Despite data indicating that social anxiety disorder (SAD) may be a psychological vulnerability that increases AUD risk, no known prospective research has examined underlying mechanisms. Given the nature of SAD, social support and peer alcohol use may be implicated. The present study set out to clarify the SAD-AUD link in several ways using a prospective dataset comprised of 1803 (47% female) young adults at T1, 1431 of whom were assessed again approximately 3 years later. First, stringent criteria were used to directly test whether SAD was a risk for AUD. Second, we examined whether social support and peer alcohol use moderated the prospective SAD-AUD link. Structured diagnostic interviews were conducted to assess DSM-IV Axis I disorders, negative life events, social support, and peer alcohol use. Among men, Time 1 (T1) SAD was not significantly related to Time 2 (T2) AUD. Yet, among women, T1 SAD was related to T2 AUD. Further, T1 SAD was the only internalizing disorder to significantly predict T2 AUD after controlling for relevant variables (e.g., T1 depression, other anxiety, alcohol and marijuana use disorders). The SAD-AUD relation demonstrated directional specificity. Family cohesion and adverse family relations significantly moderated this relation. Findings highlight the important role of SAD and familial support in the onset of AUD among women.

Physical limitations and depressive symptoms: exploring the nature of the association.

OBJECTIVES: Although evidence suggests that physical disability and depression may be reciprocally related, questions of causality versus spuriousness and the direction of causality remain to be confidently answered. This study considered the hypothesis of reciprocal influence; the possibility of spuriousness in relation to pain, stress, and lifetime major depression; and the possible mediating effects of pain and social stress. METHODS: We analyzed data from a two-wave panel study of Miami-Dade County residents (n = 1,455) that included a substantial oversampling of individuals reporting a physical disability. RESULTS: Results indicated that, although prior levels of physical limitations predicted changes in depressive symptoms, there was no evidence of the reverse association. Results also indicated that part of the association between prior physical limitations and changes in depressive symptoms was explained by intervening level of pain and, to a lesser extent, by the day-to-day experience of discrimination. DISCUSSION: Much of whatever causation may be involved in the linkage between physical limitations and depressive symptomatology flows from limitations to depression rather than in the reverse direction. Results also make clear that this linkage is not an artifact of shared associations with pain, social stress, or lifetime major depression.

Major life events: their personal meaning, resolution, and mental health significance.

Researchers have employed varying strategies in an effort to better understand variation in responses to stress. This article argues that crisis theory makes a useful contribution to these efforts, particularly when studying variable response to major life events that are of high threat potential. Regression analyses of depressive symptomatology, mastery, and self-esteem in a community sample of adults (n = 1,542) provide preliminary support for the central tenets of crisis theory that specify the conditions under which experienced events are minimally and maximally hazardous. The results also offer mixed support for the proposition that successfully resolved crises can even yield emotional and coping benefits. Longitudinal models and further development of survey-based measures for distinguishing the occurrence of a crisis and assessing the adequacy of its resolution are needed to more thoroughly test crisis theory.

Cumulative lifetime adversities and alcohol dependence in adolescence and young adulthood.

OBJECTIVE: Negative life events have been implicated in the development of alcohol dependence. This paper tests whether cumulative exposure to such stressors significantly predicts risk of DSM-IV alcohol dependence disorder in young adults. We also provide descriptive data that characterizes the patterns of cumulative exposure to such events and rates of alcohol dependence across gender, race/ethnic, and socioeconomic groups. METHOD: Members of a representative urban community sample of 1786 young adults in South Florida were interviewed retrospectively using the Composite International Diagnostic Interview, and a lifetime checklist of 41 major adverse life events. The conditional risk of first onset of alcohol dependence disorder was estimated in relationship to a measure of lifetime cumulative adversity using discrete-time event history analysis. RESULTS: Event history analysis suggested that lifetime stress exposure exhibits a pattern of association with alcohol dependence that is consistent with a cumulative impact interpretation. Both recent events and events more distant in time were significantly and independently associated with such risk. Although these results contribute toward an understanding of variations in alcohol dependence across individuals, they do not assist in the understanding of observed ethnic group differences in such dependence.

The relationship of cumulative and proximal adversity to onset of substance dependence symptoms in two American Indian communities.

The proximal and distal effects of adversity on the onset of symptoms of substance dependence during adolescence were explored in two culturally distinct American Indian (AI) reservation communities (Northern Plains and Southwest). Data (N=3084) were from the American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project (AI-SUPERPFP). The age-related risk of symptom onset increased gradually from age 11 through age 16, remained relatively high through age 18, then declined rapidly. Both tribe and gender were related to onset of dependence symptoms; men and Northern Plains tribal members were at greatest risk and Southwest women were at particularly low risk of symptom onset across adolescence. For all tribe and gender groups, both proximal and cumulative distal experiences of adversity were associated with substantially increased risk of symptom onset. The relationship of adversity to onset of substance dependence symptoms remained strong when previous symptoms of psychiatric disorder and childhood conduct problems were considered. These findings suggest that efforts to help children and adolescents in AI communities develop constructive mechanisms for coping with adversity may be especially valuable in substance dependence prevention.

The social antecedents of anger proneness in young adulthood.

Anger has been shown to be an important factor in occupational maladjustment, family conflict, physical and sexual assault, criminal behavior and substance abuse. It has also been linked with such adverse health outcomes as hypertension, heart disease, and cancer. Focusing on anger proneness, conceptualized as a relatively enduring propensity to experience and express anger; this article examines both early and recent antecedent factors that predict and may condition levels of anger proneness. The roles of both prospectively and retrospectively assessed factors are considered. Data from an ethnically diverse and representative sample of young adults reveals clear gender differences and, at least for short-tempered anger; decreasing levels of anger with increasing socioeconomic status. Prior exposure to violent events, prior exposure to other forms of social stress, and certain personal attributes were found to be significant antecedents of both hostility and short-tempered forms of anger proneness.

Hispanic drug abuse in an evolving cultural context: an agenda for research.

Drug abuse in the U.S. Hispanic population appears to be in a dynamic state of acceleration, although there are differences in drug use patterns between U.S.-born and foreign-born Hispanics, and across Hispanic subgroups (i.e., Mexican, Cuban, Puerto Rican, and Central or South American). An understanding of the consequences of cultural adjustments for drug use is needed to effectively anticipate the scope and dimensions of illicit drug use in the largest, rapidly growing, minority group in the U.S. This paper provides an epidemiologic overview of current Hispanic drug use, summarizes research on the relationship between culture change and drug use, organized according to individual, social (i.e., family and peer group), and community level influences on drug use, and offers a systematic agenda for future research.

Family structure and substance use problems in adolescence and early adulthood: examining explanations for the relationship.

AIMS: Our study has two goals: to evaluate variation in symptoms of substance abuse/dependence by family structure and to examine several potential explanations for this association, including differences in socio-economic status, social support, social stress and perceived approval and use of substances by family and friends. DESIGN: Ordinary least squares (OLS) regression is used to examine the association between family type and problematic substance use and to assess the hypothesized mediators. SETTING: Data were collected between 1998 and 2000 as part of a study of the prevalence and social distributions of psychiatric and substance use disorders. The study involved face-to-face interviews with a representative sample of young adults in a South Florida community. PARTICIPANTS: Respondents (n = 1760) were between 18 and 23 years of age. Approximately 25% were of Cuban origin, 25% other Caribbean basin Hispanic, 25% African American and 25% non-Hispanic white. MEASUREMENTS: Four family types are examined: mother-father families, single-parent families, single-parent families that include other adult relative(s) and stepfamilies. Problematic substance use is measured by a set of 22 substance abuse/dependence symptoms. FINDINGS: Controlling for race-ethnicity and gender, respondents from single-parent families report a significantly higher level of problematic substance use than those from mother-father families. Although nearly all explanations receive support, we find the strongest evidence for differential association with deviant peers and exposure to stress. CONCLUSIONS: Our findings suggest that--rather than representing a unique and independent predictor of substance use problems--family structure can be viewed as a marker of the unequal distribution of factors influencing the risk of problematic substance use.

Stress burden, drug dependence and the nativity paradox among U.S. Hispanics.

It seems well established that exposure to social stress, including acculturation stress, increases risk for psychiatric and substance problems, and that the disadvantaged experience higher levels of such exposure. Such evidence points to the expectation that immigrant minority groups must be at elevated risk relative to their native-born counterparts. That the opposite appears to be true for various immigrant groups within the U.S. constitutes what has been referred to as the nativity health paradox. This paper examines the association between nativity and drug dependence among the distinctive and understudied Hispanic population of South Florida and attempts to evaluate competing explanations for the apparent advantage of immigrant populations. Based on data on a representative sample young adults of Cuban and other Hispanic backgrounds (n=888), we found the paradox to be limited to women and confirmed the finding of prior research that acculturation plays a major role in explaining this difference in risk. We also found cumulative exposure to major and potentially traumatic events to be lower rather than higher among immigrants, to be a strong predictor of drug dependence and to contribute importantly toward accounting for observed nativity differences among women. Taken together, cumulative stress exposure and degree of acculturation explained 40% of the nativity difference. Finally, our results suggest that social support matters for risk primarily because such support more effectively acts to reduce exposure to social stress among foreign-born young Hispanic women.

Family structure and mental health: the mediating effects of socioeconomic status, family process, and social stress.

Although numerous studies reveal differences in mental health by the structure of one's family of origin, there remains debate regarding the processes generating these patterns. Using a sample of young adults (19-21 years) in Miami-Dade County in Florida, this study examines the explanatory significance of three presumed correlates of family type: socioeconomic status, family processes, and level of social stress. Consistent with prior research, our results reveal higher levels of depressive symptoms among those from stepfamilies, single parent families, and single parent families with other relatives present, compared with mother-father families. All three presumed correlates make significant independent contributions to the prediction of depressive symptomatology. Substantial mediating effects also are observed for all three explanatory dimensions. Collectively, they completely or largely explain observed family type variations in mental health risk.

Understanding variations in exposure to social stress.

Although exposure to stress is a central component of the stress process paradigm, little research has explicitly sought to identify antecedents of stress exposure. Based on a probability sample of 1393 adults aged 18-55 residing in Toronto, Canada, this research examines the effects of social status, past adversity, social and personal resources and history of mental disorder on recent exposure to stress. Consistent with earlier findings, results indicate that younger adults, divorced individuals and those with lower socioeconomic status, experience greater levels of social stress. Although respondent's history of major depressive disorder was related to all types of stress exposure, past cumulative adversity was the most powerful predictor of both total current stress (operant burden) and the subsequent onset of life events, independent of other antecedents. Findings suggest that the onset of chronic stress is more affected by personal characteristics, such as emotional reliance and disorder history, than is onset of life events. Implications of these findings are discussed.

Anxiety and risk for substance dependence among late adolescents/young adults.

This study examined the relation between comorbid and pure (non-comorbid) anxiety disorders and both substance dependence and substance use problems in a community sample of 1747 young adults ages 18-23 years. Results indicate that collectively anxiety disorders, both pure and comorbid with other psychiatric diagnoses, are predictive of substance dependence. When temporal order was controlled, anxiety disorders generally preceded the onset of substance dependence. However in analyses in which PTSD was excluded, anxiety disorders were no longer predictive of substance dependence, suggesting that the increased risk associated with anxiety disorders is largely if not wholly attributable to PTSD. Finally, comorbid and pure anxiety disorders were found to be predictive of the number of alcohol and drug use problems.

Personal resources and depression in the transition to adulthood: ethnic comparisons.

Based on a representative sample of 1,803 South Florida young adults, we examine the extent to which personal attributes mediate or moderate the ethnicity-depression relationship and condition the effects of social stress on depression. Our sample contains nearly equal proportions of African American, Cuban American, "other" Hispanic, and non-Hispanic white respondents. Findings suggest that there are ethnic variations in four of the five personal resources considered. Additionally, when accounting for ethnic differences in response tendencies and in the confounding of personal resources with depression, there is strong evidence for both direct and stress-buffering effects of personal resources. Although naïve comparisons of within group findings imply a number of ethnic variations in those effects, few statistically significant differences are observed. It is suggested that ethnic similarities outweigh differences, at least with respect to the mental health significance of the personal resources considered. Overall, the results highlight some of the complexities inherent in making multi-ethnic comparisons.

Stress burden and the lifetime incidence of psychiatric disorder in young adults: racial and ethnic contrasts.

BACKGROUND: With the exception of studies of individual traumatic events, the significance of stress exposure in psychiatric disorder previously has not been effectively examined. OBJECTIVE: To address the hypothesis that accumulated adversity represents an important risk factor for the subsequent onset of depressive and anxiety disorders. DESIGN: A community-based study of psychiatric and substance use disorders among a large, ethnically diverse cohort representative of young adults in South Florida. Adversity was estimated with a count of major and potentially traumatic events experienced during one's lifetime and prior to the onset of disorder. SETTING: Most interviews took place in the homes of participants, with 30% conducted by telephone. PARTICIPANTS: We obtained a random sample of individuals aged 18 to 23 years from a previously studied representative sample of young adolescents. Because participants in the prior study were predominantly boys, a supplementary sample of girls was randomly obtained from the early-adolescence school class rosters. A total of 1803 interviews were completed, representing a success rate of 70.1%. MAIN OUTCOME MEASURES: Depressive and anxiety disorders were assessed through computer-assisted personal interviews using the DSM-IV version of the Michigan Composite International Diagnostic Interview. RESULTS: Level of lifetime exposure to adversity was found to be associated with an increased risk of subsequent onset of depressive and/or anxiety disorder. This association remained clearly observable when childhood conduct disorder, attention-deficit/hyperactivity disorder, prior substance dependence, and posttraumatic stress disorder were held constant and when the possibility of state dependence effects was considered. CONCLUSION: Evidence suggests that high levels of lifetime exposure to adversity are causally implicated in the onset of depressive and anxiety disorders.