Presented at Presented at Montana State Montana State

UniversityUniversity

February 10, 2012 February 10, 2012

Health Disparities and the Stress Hypothesis

R. Jay Turner, Ph.DVanderbilt University

Stress Process Model

Retrospective self-report, computer assisted personal interviews

DSM-IV CIDI diagnoses: major depression,

dysthymia, GAD, social phobia, panic disorder, alcohol abuse and dependence, drug abuse and dependence, PTSD, and antisocial personality disorder.

PLUS attention deficit and hyperactive disorder and Childhood conduct disorder from the Diagnostic Interview schedule.

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FIGURE 3 - DSM-IV Disorder Conditional Onset Risk by Cumulative Exposureto Adversities among Community-dwelling Young Adults

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Psychiatric Disorder: Whites Psychiatric Disorder: African Americans

TABLE 1. Mean Standardized Scores on Stress Measures by Gender, Race/Ethnicity and Socioeconomic Level Recent Life Events Total Stress Exposure Gender Male –.075*

(.967) .063* (1.013)

Female .092 (1.033)

–.077 (.980)

Race/Ethnicity White –.092**

(.945) –.236*** (.920)

African American .112 (1.053)

.286 (1.019)

Difference = .204 Difference = .522 Socioeconomic Level Upper –.115+

(.938) –.277*** (.894)

Middle .053 (.986)

.051 (.950)

Lower .063 (1.065)

.227 (1.083)

* p<.05; ** p<.01; *** p<.001 U-L difference = .178 U-L difference = .504 Note: Numbers in parentheses are standard errors.

Gender (Female=1) 1.570 *** 1.372 *** 1.613 *** 1.241 *** 1.533 *** 1.731 *** 1.533 ***(.285) (.277) (.277) (.261) (.282) (.272) (.265)

Race/Ethnicity (African-American=1) 1.020 ** .810 ** .559 ** .337 .751 * .626 * .171(.321) (.312) (.311) (.296) (.311) (.303) (.294)

SES -.579 *** -.546 *** -.407 *** -.394 * -.494 ** -.465 ** -.312 *(.163) (.158) (.158) (.149) (.158) (.153) (.148)

Recent Life Events (past 12 months) 1.075 *** .625 *** .502 *** .927 *** .744 *** .210(.138) (.162) (.140) (.147) (.139) (.157)

Lifetime Major Events .871 *** .583 **(.172) (.195)

Chronic Stressors 1.594 *** 1.339 ***(.146) (.151)

Lifetime Major Discrimination 1.158 *** -.852(.402) (.461)

Daily Discrimination 1.231 *** .783 ***(.159) (.167)

2.456 2.637 2.653 2.934 2.624 2.582 2.872

R2 .072 *** .131 *** .155 *** .223 *** .139 *** .185 *** .262 ***Adjusted R2 .069 .127 .150 .229 .134 .181 .255

I III

Table 3. Depressive Symptoms Regressed on Status Characteristics and Five Dimensions of Stress Exposure (N = 899; 493 non-Hispanic whites and 406 African-Americans)

VIIIV V VI

Table entities represent unstandardized regression coefficient (standard errors).

Numbers of subjects prior to weighting are 466 non-Hispanic whites and 433 African-Americans.*, **, ***: p < .05, .01, .001, respectively.

II

Constant

Life Stressors

Status Characteristics

TABLE 3. Depressive Symptomatology (CES-D) Regressed on Social Status and Stress Process Components: Toronto, 1990–1991

1 2 3 4 5 6 7 8 

Intercept 24.744*** 23.766*** 44.327*** 59.348*** 14.286** 30.444*** 23.123*** 47.003***(4.320) (4.199) (4.221) (4.226) (4.148) (4.488) (4.136) (4.584)

Female 2.643*** 2.149*** 2.226*** 2.234*** 2.096** 2.196*** 3.105*** 1.556**(.623) (.568) (.546) (.595) (.612) (.580) (.599) (.482)

Age –.739** –.701** –.597* –.598** –.592* –.728** –.619** –.447*(.237) (.227) (.228) (.210) (.228) (.233) (.230) (.189)

Age2 .008* .008** .006† .006* .006* .008* .006* .004†(.003) (.003) (.003) (.003) (.003) (.003) (.003) (.003)

Previously-married 3.342** 1.339 3.803*** 3.491*** 3.909*** 2.994** 1.324 1.733*(1.064) (1.004) (.978) (.866) (.994) (1.035) (.861) (.757)

Never-married 1.198 1.176 1.872** .647 1.891* 1.038 –.083 1.114†(.808) (.727) (.688) (.693) (.799) (.778) (.723) (.629)

SES –1.060** –.682* –.175 –.712** –.713* –1.417*** –.877** –.091(.299) (.294) (.267) (.266) (.294) (.280) (.283) (.251)

Stress 3.968*** 2.799***(.289) (.287)

Mastery –.767*** –.359***(.060) (.050)

Self Esteem –1.326*** –.683***(.081) (.079)

Emotional Reliance .543*** .302***(.071) (.051)

Assertion of Autonomy –.618*** –.250**(.105) (.076)

Social Support –2.829*** –.931**(.247) (.264)

R2 .104 .276 .258 .266 .143 .141 .182 .443 

† p <.10 *p < .05 **p < .01 ***p < .001Note: Unstandardized OLS regression coefficients; standard errors are in parentheses; data weighted to adjust for respondent selection bias; standard errors adjusted forclustered sampling design using Stata survey regression procedure. N = 1338.

 

 

 

 

• 1. To evaluate the stress hypothesis and assess the utility of an elaborated “stress process” model for explaining race and socioeconomic position (SES) differences in health and changes in health over time, where:

• a) health status is estimated in multiple ways that address the problem of misclassification.

• b) variations in stress exposure are estimated more comprehensively than in prior research.

• c) the direct, mediating and moderation effects of an extended array of social and personal coping resources and of contextual and cultural factors are examined in the context of a) and b) above.

•

• 2. To confirm and extend epidemiological estimates of race and SEP differences in the prevalence of health problems, variously and collectively defined, while addressing the misclassification problem.

• 3. To evaluate the interrelationships of differing dimensions of health, variously estimated, and their risk significance for one another, in cross section and over time.

• 4. To describe the distribution of each risk factor identified across race, SEP, age and gender while examining antecedent factors that put individuals and groups at differential risk for acquiring such risk factors.

• 5. To obtain and preserve samples to support subsequent studies (not here proposed) on gene-environment interactions relating to factors hypothesized to be of risk or protective significance.

•

Table 1. Co-occurrence of Lifetime DSM-IV Psychiatric and Substance Dependence Disorders (No Temporal Ordering)

     Substance Dependence c

  N % OR e 95% CI

Comorbid Depression (Across and/or Within Category)Pure Depression

185130

47.218.5

6.8*** 1.8*

4.7 - 10.01.1 - 3.0

         

Comorbid PTSD (Across and/or Within Category)Pure PTSD

14065

45.020.8

7.0***2.8**

4.6 - 10.7 1.4 - 5.5

         

Comorbid Anxiety Disorder a 75 41.5 5.0*** 2.9 - 8.5

Pure Anxiety Disorder 22 15.0 1.3 0.4 - 3.9

         

Comorbid Personality Disorder b 287 43.4 6.3*** 4.5 - 8.7

Pure Personality Disorder 179 16.4 1.5†

0.9 - 2.4

  

Table 2. Temporally Ordered Associations between Lifetime DSM-IV Psychiatric and Substance Dependence Disorders

     Substance Dependence b

  N % OR d 95% CI

         

Comorbid Depression 162

121

39.7 5.0*** 3.3 - 7.4

Pure Depression 12.6 1.1 0.6 - 2.0

         

Comorbid PTSD 76 44.0 6.7*** 3.9 - 11.3

Pure PTSD 43 20.0 3.0** 1.3 - 6.9

         

Comorbid Anxiety Disorder a 70 37.5 4.2*** 2.4 - 7.4

Pure Anxiety Disorder 20 10.5 0.6 0.1 - 2.9

Table 4. Effects of Stress Exposure on Associations between Lifetime DSM-IV Psychiatric and Substance Dependence Disorders

    

  Substance Dependence b

  Not Ordered Ordered

OR         

Comorbid Depression 2.4*** 1.5 - 3.8 1.5† 0.9 - 2.6

Pure Depression 1.2 0.6 - 2.2 0.7 0.3 - 1.4

         

Comorbid PTSD 1.7* 1.0 - 3.1 1.5 0.7 - 3.1

Pure PTSD 1.1 0.4 - 2.7 1.7 0.6 - 4.5

         

Comorbid Anxiety Disorder a 1.7 0.8 - 3.4 1.3 0.8 - 2.1

Pure Anxiety Disorder 1.3 0.4 - 4.1 0.8 0.1 - 3.6

  OR d 95% CI d 95% CI