Distinguishing distress from disorder: Black-white patterns in the determinants of and links between depressive symptoms and major depression

Background: Black Americans experience higher levels of psychological distress but similar or lower rates of psychiatric disorders than Whites. This study aimed to clarify discordant distress-disorder patterns by distinguishing the sociodemographic and psychosocial risks (e.g. socioeconomic status, stress exposure) associated with distress and disorder among Blacks and Whites and by evaluating the distress-disorder linkage within and across racial groups. Methods: Secondary analysis of the Nashville Stress and Health Study (n=1,246), a cross-sectional community epidemiologic survey of Blacks and Whites in Nashville, Tennessee, was used to assess distress (CES-D depressive symptoms scale) and major depressive disorder (MDD; based on the CIDI). Race-stratified models assessed correlates of each outcome and the distress-disorder association among racial groups; interactions considered potential moderating effects of SES and stress exposure on this association within each group. Results: Distress and disorder were differentially shaped by risk factors and varied by race. Increases in distress were associated with greater disorder risk among both racial groups. However, a significant interaction between distress and stress exposure indicated that odds of "chronic" MDD (lifetime and past-year prevalence) depends on level of stress exposure for Blacks only. Conclusions: This study informs the "race paradox in mental health" by demonstrating that distress and disorder have etiologies that vary within and across racial groups, and the distress-disorder association depends on stress exposure among Black Americans. This has implications for public health practice, as pinpointing the protective mechanisms underlying Blacks' low disorder rates despite elevated risk exposure may inform more effective avenues of intervention.