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International Journal of Epidemiology 2007;36:758–760
Commentary: Race and mental health—more
questions than answers
David R Williams1,* and Tara R Earl2
1 May 2007
paradox. On almost every indicator of physical health status
African-Americans (or blacks) have higher rates of morbidity
and mortality than whites,1but, surprisingly, blacks have lower
rates of commonly occurring, mood, anxiety and substance
disorders than whites.2However, racial disparities in mental
health are complex with the pattern varying for different
indicators of mental health status. Compared with whites,
well being (e.g. life satisfaction and happiness),3and more
often than not, have higher rates of psychological distress.4
At the same time, blacks also report higher levels of flourishing
(high levels of psychological well-being and being free of
current mental disorders) than whites.5
The Prenatal Determinants of Schizophrenia (PDS) study
highlights an additional dimension of complexity by document-
ing a 3-fold elevated risk of schizophrenia in a California birth
cohort for African-Americans compared with whites.6There has
long been the suggestion that blacks have higher levels of
schizophrenia than whites but serious questions exist about the
accuracy of the available mental health data on this topic.
Studies of state psychiatric hospitals find that blacks are
on racial disparitiesin healthhasastriking
over-represented with schizophrenia,7but these facilities do not
provide a comprehensive coverage of schizophrenia cases.
Existing data from broad-based population studies also have
serious limitations. The Epidemiologic Catchment Area (ECA)
study found that while there was little racial variation in the
rates of most of the common mental disorders, blacks had rates
of schizophrenia that were slightly higher than those of whites,
a difference that was reduced to non-significance when
adjusted for socio-economic status (SES) and demographic
However, while the ECA study provided good
population-based data, the absence of clinical judgement
raised serious questions about the validity of the diagnoses
for psychoticdisorders. The National Comorbidity
Replication (NCS-R) sought to address some of the limitations
of the ECA study by having a clinical re-appraisal interview
in which clinicians used a structured diagnostic instrument to
re-interview respondents who had earlier completed a psychosis
screen. This study found higher rates of non-affective psychosis
in blacks compared with whites, but with the national estimate
extrapolations from a mere 73 clinical re-interviews, there
was inadequate statistical power to obtain a stable estimate.9
The PDS study avoids some of the limitations of prior
research and since it sampled persons with health insurance;
it likely excludes the extremes of SES. Accordingly, the racial
gap documented here is likely to be smaller than in the general
population. However, the PDS study does not rule out
longstanding concerns that the higher rate of schizophrenia
* Corresponding author. E-mail: email@example.com
1Harvard School of Public Health, 677 Huntington Avenue, Room 615,
Boston, MA 02115-6096, USA.
2Center for Multicultural Mental Health Research, Cambridge Health
Somerville, MA 02143.
INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
by guest on December 30, 2015