Do racial patterns in psychological distress shed light on the Black–White depression paradox? A systematic review

Purpose: Major epidemiologic studies in the US reveal a consistent “paradox” by which psychiatric outcomes such as major depressive disorder (MDD) are less prevalent among Blacks relative to Whites, despite greater exposure to social and economic stressors and worse physical health outcomes. A second paradox, which has received less attention and has never been systematically documented, is the discrepancy between these patterns and Black–White comparisons in psychological distress, which reveal consistently higher levels among Blacks. By systematically documenting the latter paradox, this paper seeks to inform efforts to explain the first paradox. Methods: We conduct a systematic review of the literature estimating the prevalence of MDD and levels of psychological distress in Blacks and Whites in the US. Results: The literature review yielded 34 articles reporting 54 relevant outcomes overall. Blacks have a lower prevalence of MDD in 8 of the 9 comparisons observed. In contrast, Blacks have higher levels of psychological distress (in terms of “high distress” and mean scores) than Whites in 42 of the 45 comparisons observed. Tests of statistical significance, where available, confirm this discrepant pattern. Conclusions: A systematic review of the epidemiologic evidence supports the existence of a “double paradox” by which Blacks’ lower prevalence of MDD relative to Whites’ is inconsistent with both the expectations of social stress theory and with the empirical evidence regarding psychological distress. Efforts to resolve the Black–White depression paradox should account for the discordant distress results, which seem to favor artifactual explanations.