Title: Depression and Distress in Blacks and Whites in the US
Description: This dissertation tested a methodological explanation for a double paradox in psychiatric epidemiology: a lower prevalence of major depression in Blacks than Whites in the US, coupled with equal and higher levels of psychological distress in Blacks. The first paradox is a lower prevalence of major depression in Blacks than Whites. The second paradox is the discordant results from comparing Blacks and Whites on depression and distress. These are paradoxes from the vantage points of, respectively, dominant theory and conceptual and empirical understandings of the relationship between disorder and distress. The idea that Blacks in the US express depression and distress more somatically than Whites has been in the literature for decades. If true, it could explain the double paradox. A formal diagnosis of major depression requires endorsing a screening symptom, either sad mood or anhedonia, which are both psychological rather than somatic symptoms. To the extent Blacks express depression more somatically than Whites, depression could be disproportionately undercounted in Blacks due to a lower likelihood of Blacks endorsing a screening symptom, adjusting for underlying levels of depression.

Measures of distress share symptom content with the diagnostic criteria for depression but typically do not require endorsing screening symptoms. Thus, if Blacks do somatize depression and distress more somatically than Whites, the depression algorithm may produce a greater undercount of depression in Blacks than Whites, whereas a similar undercount would not occur with distress measures. Accordingly, both paradoxes could be explained. This dissertation has three main parts. In part one, the double paradox is documented in a systematic literature review. Using data from two nationally representative household samples, parts two and three test whether Blacks express depression and distress, respectively, more somatically than Whites, whether this accounts for a lower likelihood of Blacks endorsing a screening symptom, and if (part two only) this explains the Black White depression paradox. The systematic review provides robust evidence of the double paradox. Parts two and three reveal slightly higher levels, respectively, of depression and distress somatization in Blacks than Whites.

However, the underlying structure of these small differences provides no evidence of a broad somatization hypothesis in Blacks. Moreover, no evidence is found that the somatization difference inhibits Blacks' endorsement of screening symptoms. One unexpected finding points to subsequent steps to take towards resolving the double paradox.