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© 2004 American Public Health Association
RESEARCH AND PRACTICE |
Joyce T. Bromberger is with the University of Pittsburgh Graduate School of Public Health, Department of Epidemiology, and the University of Pittsburgh Medical School, Department of Psychiatry, Pittsburgh, Pa. Sioban Harlow is with the Department of Epidemiology, University of Michigan, Ann Arbor. Nancy Avis is with the Wake Forest University School of Medicine, Winston-Salem, NC. Howard M. Kravitz is with the Departments of Psychiatry and Preventive Medicine, Rush University Medical Center, Chicago, Ill. Adriana Cordal is with the University of Medicine and Dentistry of New Jersey, Newark.
Correspondence: Requests for reprints should be sent to Joyce T. Bromberger, PhD, University of Pittsburgh, 3811 O’Hara St, Pittsburgh, PA 15213 (e-mail: brombergerjt{at}upmc.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSReferences |
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Objectives. We examined racial/ethnic differences in significant depressive symptoms among middle-aged women before and after adjustment for socioeconomic, health-related, and psychosocial characteristics.
Methods. Racial/ethnic differences in unadjusted and adjusted prevalence of significant depressive symptoms (score 
16 on the Center for Epidemiologic Studies Depression [CES-D] Scale) were assessed with univariate and multiple logistic regressions.
Results. Twenty-four percent of the sample had a CES-D score of 16 or higher. Unadjusted prevalence varied by race/ethnicity (P < .0001). After adjustment for covariates, racial/ethnic differences overall were no longer significant.
Conclusions. Hispanic and African American women had the highest odds, and Chinese and Japanese women had the lowest odds, for a CES-D score of 16 or higher. This variation is in part because of health-related and psychosocial factors that are linked to socioeconomic status.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSReferences |
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Recent epidemiological data show that 22% of middle-aged women report clinically significant depressive symptoms1 and that women who have had previous depressive episodes are vulnerable to recurrences during the midlife years.2,3 Thus, although first-onset major depressive episodes decrease after 45 years of age,4 both major depression and elevated depressive symptoms are a significant problem for middle-aged women.
Studies of women during midlife have shown that low socioeconomic status (SES), financial strain, physical inactivity, low social support, stress, and poor physical health are each correlated with depressive symptoms.5–10 These studies were limited by relatively small samples sizes (i.e., about 300 women or fewer),7,10 wide age ranges,8,10 or limited control of confounding factors.6–10 None of these studies included all relevant socioeconomic, health-related, and psychosocial factors in a single study, and only 1 study included a substantial sample of minority women.7 Inclusion of minority racial/ethnic groups in many community studies of depression also is limited. Available data suggest that rates of clinical depression and elevated depressive symptoms vary among racial/ethnic groups, but not consistently.11–17
The Study of Women’s Health Across the Nation (SWAN)—a longitudinal, multiethnic, multisite community-based study—evaluated 3302 women aged 42 to 52 years who were approaching or experiencing menopause. One of SWAN’s goals was to increase understanding of the risk factors for significant depressive symptoms among middle-aged women and whether the prevalence of these symptoms varies by race/ethnicity. There is growing evidence that multiple factors have a joint role in health and well-being.18 Moreover, it is well documented that low SES is associated with poor health, stressful events, and inadequate social resources.19,20 These factors may mediate the relationship between low SES and elevated depressive symptoms.
We used cross-sectional data from the SWAN baseline visit to (1) evaluate the prevalence of significant depressive symptoms, which is defined as a score of 16 or higher on the Center of Epidemiological Studies Depression Scale (CES-D),21 among African American, White, Chinese, Hispanic, and Japanese women, (2) assess the effect of socioeconomic, health-related, and psychosocial factors on observed differences in these prevalences, and (3) identify the associations between socioeconomic, health-related, and psychosocial factors and significant depressive symptoms among middle-aged women. To our knowledge, this is the first community study that examined depressive symptoms among a large multiethnic group of middle-aged women and that concurrently evaluated the associations between socioeconomic, health-related, and psychosocial factors and depressive symptoms.
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METHODS |
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Participants
We used data from the baseline evaluations of the women who participated in SWAN, a study designed to document changes in women’s physical and mental health as they age and transition through menopause. The study’s design has been described elsewhere.22 Briefly, a screening survey was conducted between November 1995 and October 1997 to assess eligibility for enrollment in the cohort study and to collect health, reproductive, demographic, and lifestyle data. The women were randomly selected at 7 sites across the United States from a variety of lists, including a large managed health care plan, community census, utility households, and registered voters or by random-digit dialing. Eligibility criteria for inclusion in the screening survey included being aged 40 to 55 years, self-designation as a member of 1 of the site’s targeted racial/ethnic groups, residence in the site’s geographic area, use of English or 1 of the other selected languages (Spanish, Japanese, and Cantonese), and ability to give verbal consent to participate.
Approximately 450 women were recruited for the longitudinal cohort at each of the 7 clinical sites. In addition to White women, each site recruited women from 1 specified minority group (African Americans in Pittsburgh, Pa, Boston, Mass, Ann Arbor, Mich, and Chicago, Ill; Japanese in Los Angeles; Chinese in the San Francisco, Calif, East Bay region; and Hispanic women in Newark, NJ). To be eligible for the longitudinal cohort, women had to be aged 42 to 52 years, have an intact uterus and have had at least 1 menstrual period in the previous 3 months, not have used reproductive hormones in the previous 3 months, and have self-identified with 1 of the site’s designated racial/ethnic groups. Of the 16 065 women who participated in the screening survey, 3302 enrolled in the longitudinal cohort. Of these, 287 (8.7%) were excluded from our analysis because of missing data.
Assessments
The assessment protocol was the same across the 7 clinical sites. The baseline visit included interviewer-administered and self-administered questionnaires and measurements of height and weight.
Depressive symptoms were assessed during the baseline interview with the Center for Epidemiologic Studies Depression (CES-D) Scale, a 20-item measure that asks about the frequency of being bothered by depressive symptoms during the previous week on a scale of 0 (rarely) to 3 (most or all of the time).21 The measure includes items such as "I felt sad," "I felt lonely," and "my sleep was restless." This scale was developed to screen for clinical depression in community samples, and a score of 16 or higher identifies potential clinical depression.23,24 Community studies have demonstrated that about 65% of those who have a score 16 or higher meet the criteria for major depression.23 We dichotomized the CES-D scores and used this cutpoint to define our depressive symptoms outcome (yes/no), recognizing that we were not describing major depression. Many studies have demonstrated the measure’s validity and high internal consistency and its test-retest reliability among diverse racial/ethnic populations, including African Americans, Chinese, Japanese, and Hispanics.25–30 The CES-D and the other instruments used in our study were translated into Cantonese, Japanese, and Spanish and were offered in either English or the participant’s native language.
Primary race/ethnicity was self-identified as Black or African American, non-Hispanic White, Chinese or Chinese American, Japanese or Japanese American, or Hispanic (Cuban American, Dominican, Puerto Rican, South American, or Spanish). By design, only women who self-identified in particular categories were included in the cohort. The categories were Black (African American, i.e., African origin or descent), Chinese or Chinese American, Japanese or Japanese American, White/non-Hispanic White (European descent), and Hispanic. The latter category of women was composed of 38.9% South Americans, Spanish, or other; 19.8% Puerto Ricans; 16.4% Cubans; 14.9% Dominicans; and 9.9% Central Americans. Because of the small numbers in many of these groups, we combined them into 1 category.
Data were collected on demographic, socioeconomic, health-related, and psychosocial factors (Table 1
). The SES variables included age, educational attainment, level of difficulty paying for basic necessities,31 employment status, and marital status. The numbers of women who had less than a high school education, had a very hard time paying for basic necessities, and were single or widowed among the Hispanic, Chinese, or Japanese groups were small. Therefore, for the multivariable analyses, levels of these variables were combined as high school or less versus post–high school, somewhat hard or very hard time paying for basic necessities versus not very hard time, and unmarried versus married.
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Perceived health was a single question and was self-rated on a 5-category scale (excellent to poor) that was extracted from the Medical Outcome Study (MOS) 36-item short-form health survey (SF-36).31 In the multivariable analyses, excellent, very good, and good were combined and were compared with fair or poor. Symptom data were obtained from a checklist of symptoms commonly included in studies of menopause.32–34 Women were asked how frequently they had experienced each of 6 somatic and 3 vasomotor symptoms in the previous 2 weeks (not at all, 1–5 days, 6–8 days, 9–13 days, and every day). We defined presence of a symptom as reported occurrence for at least 6 days. Menstrual cycle pattern in the past 12 months was categorized as regular if women reported no change in the previous year in predictability of menses onset and irregular if menses had become less predictable. For a list of 23 illnesses/conditions, presence of the condition was defined as ever having been told by a health care professional that the participant had the condition. We included those for which the prevalence was at least 5%: anemia, high blood pressure/hypertension, migraine, and arthritis/osteoarthritis.
Psychosocial variables included social support, which was assessed with 4 items from the MOS Social Support Survey35 that question how often each of 4 kinds of support was available, if needed. The total score was dichotomized into high and low support. Also included was the 4-item Perceived Stress Scale36 and a checklist of stressful life events. We used the cumulative number of events identified as "very stressful."
Statistical Analysis
In our initial analyses, we used contingency tables to examine the relationships between race/ethnicity and a CES-D score of 16 or higher and each of the other variables and to examine the relationship between each independent variable and a CES-D score of 16 or higher. We used the Cronbach 
to determine internal consistency of the CES-D for each racial/ethnic group. A series of logistic regressions were used to model the association between a CES-D score of 16 or higher and the 3 domains of predictors (demographic and socioeconomic, health-related, and psychosocial factors). Site and race/ethnicity were forced into all models because of the sampling design of the study and so that we could examine factors that might explain differences in prevalence among the 5 racial/ethnic groups. Age also was included as a covariate in all analyses. The base model included site, race/ethnicity, and age. Three additional logistic regression models were then constructed by adding a set of variables to the base model: first the SES variables, then the health-related variables, and finally the psychosocial variables. Stepwise selection (a modification of forward selection where all variables included in the model are reevaluated at each step) was used for each model except for the base model. Multivariable analyses for each racial/ethnic group and for the full sample were conducted with stepwise selection from the entire set of candidate predictors (those variables significant at P < .05 in the 3 separate models). All results are shown as odds ratios with associated 95% confidence intervals. We used SAS37 and S-Plus38 software to conduct the analyses.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSReferences |
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Of the 3015 women who were not missing data on any of the variables, 1449 were White, 831 were African American, 249 were Hispanic, 224 were Chinese, and 262 were Japanese (Table 1
). The Hispanic group had the highest, and the Japanese group had the lowest, percentages of women who had low SES: 45% versus 0.8% had less than a high school education, and 26.3% versus 2.8% had a very hard time paying for basic necessities. Among the other groups, 1.3% of White women, 4.9% of African American women, and 12.7% of Chinese women had less than a high school education, and 5.4%, 11.8%, and 5.7%, respectively, had a very hard time paying for basic necessities. Except for age, all the socioeconomic, health-related, and psychosocial characteristics varied significantly among the racial/ethnic groups. The percentages of women who had less favorable health-related characteristics also varied by race/ethnicity (Table 1).
Overall, 24.1% of the sample had a CES-D score of 16 or higher (Table 1). Internal consistency of the CES-D items was very high overall (standardized = 0.90) and for each racial/ethnic group (standardized range = 0.88–0.90). Prevalence of CES-D scores of 16 or higher was highest among Hispanic women (43%) and lowest among Chinese (14.3%) and Japanese (14.1%) women (Table 2). Prevalence was associated with younger age, lower levels of education, and more difficulty paying for basic necessities. All health-related variables and all psychosocial variables were significantly associated with CES-D scores of 16 or higher in the expected directions: higher rates among women who had poor/fair perceived health, lower social support, or more stress.
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Results from the logistic regression models of separate domains of predictors, all of which were adjusted for site and age, are shown in Table 3
. In the base model, compared with White women, African American and Hispanic women had higher odds, and Chinese women had lower odds, for having CES-D scores of 16 or higher (Table 3). The addition of SES to the model attenuated the effect of race/ethnicity (P = .09). Of the 8 health-related variables we examined, all except high blood pressure were independently associated with CES-D scores of 16 or higher; however, race/ethnicity remained significant (P = .03), with the pattern of odds ratios similar to those in the base model. Compared with White women, there was no difference in the odds for CES-D scores of 16 or higher among African American women; however, among Hispanic women, the odds remained significantly elevated, and among Chinese women, the odds remained reduced. In the psychosocial model, low social support, perceived stress, and the presence of distressing life events increased the odds for having a CES-D score of 16 or higher. Notably, in this model, the overall effect of race/ethnicity remained significant (P = .04), with higher odds among Hispanic women compared with White women.
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Separate analyses stratified by race/ethnicity showed that high stress and low social support were significant predictors of CES-D scores of 16 or higher among all the groups (Table 4
). However, there was considerable variation in the other predictors across the ethnic groups. Low education was a significant predictor only for White women, whose odds for a high CES-D score increased almost 50%. Four health factors were each associated with the doubling of odds for high CES-D scores among the Hispanic women, the only group for whom having arthritis/osteoarthritis and reporting irregular menstrual cycles increased the odds. Being unmarried only increased the odds for high CES-D scores (nearly tripling them) among the Chinese and Japanese women.
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In the final multivariable regression model for the full sample, which included significant variables from each domain, neither ethnicity nor SES (with the exception of education) were significant, although the odds for Hispanic and Chinese women remained elevated and reduced, respectively (Table 4
). In contrast, reporting fair/poor perceived health, 1 or more physical symptoms, vasomotor symptoms, anemia, low social support, 1 or more very stressful events, and high perceived stress each independently increased the odds significantly for CES-D scores of 16 or higher relative to their respective comparison groups. Also of interest, menstrual cycle irregularity in the year before study entry was a marginally significant predictor, although the magnitude of the effect was smaller than that of other factors. |
DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSReferences |
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Prevalence of CES-D scores of 16 or higher among a large multiethnic sample of middle-aged women (aged 42 to 52 years) varied among the racial/ethnic groups. Importantly, the significance of the association between race/ethnicity overall and CES-D scores of 16 or higher was attenuated after we adjusted for SES, although the odds ratios remained lower for Chinese women compared with White women.
The crude prevalence of CES-D scores of 16 or higher was highest among African American and Hispanic women and lowest among Chinese and Japanese women. These relative frequencies are similar to those reported in some, but not all,14,15,26,39 studies that have examined racial/ethnic differences in the prevalence of depression across a wide range of age groups. These studies used varying constructs of depression, including Diagnostic and Statistical Manual of Mental Disorders, Third Edition,40 or Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,41 major depression and depressive symptoms.11,12,42 In the only other study of middle-aged women that included a substantial number of African American women, Freeman et al.7 reported that African American women had significantly higher mean CES-D scores (16.4) than did White women(13.3).
Chinese women compared with White women in Oakland, Calif, were approximately 40% to 50% less likely to have significant depressive symptoms. Such differences between Chinese and White women are not inconsistent with the literature. In a community study of 1747 Chinese Americans in Los Angeles, Calif,43 a structured diagnostic interview indicated that 6.9% had a lifetime history of a major depressive episode, which was more than 50% lower than the lifetime prevalence reported by the National Comorbidity Survey for the US population. The differences in symptom reports between White women and Chinese women may reflect culture-specific concepts of mental disorder. It has been suggested that Asian cultures tend to somatize psychological distress as part of cultural norms and the stigma attached to emotional illness.44,45 On the other hand, the CES-D has frequently been used to assess depressive symptom levels among Chinese people both in the US and in China, and it shows good internal consistency.46
The high prevalence of significant depressive symptoms among Hispanic women is consistent with other studies.11,13,14 However, the prevalence observed among Hispanic women in our study was particularly high, with 43% scoring 16 or higher on the CES-D. Our results indicate that the high prevalence may have been caused by the high percentage of women who had low SES (45% had less than a high school education) and who had health problems (27.5% with fair/poor perceived health).
Previous research has shown that SES indicators, such as education, income, and marital status, are associated with depressive symptoms11,26,47,48 and, in some cases, may explain racial/ethnic differences in rates of depression. In our study, financial strain, not working, being unmarried, and younger age all were significantly associated with significant depressive symptoms when no other covariates were included. When we controlled for these variables, the odds for these symptoms were greatly reduced among both African American and Hispanic women.
In all separate racial/ethnic analyses, with the exception of education and marital status, SES indicators dropped out of the model; however, there was a differential effect of specific health-related and psychosocial factors on CES-D scores of 16 or higher. For example, health was a particularly important predictor among the Hispanic women. For them, vasomotor symptoms, physical symptoms, fair/poor perceived health, osteoarthritis, and irregular menstrual cycles each independently increased the odds for a CES-D score of 16 or higher by two- to threefold.
The final multivariable model showed that higher odds for CES-D scores of 16 or higher were associated with younger age, compromised health, low social support, greater perceived stress, and experiencing more stressful events. Most notably, when the health-related and psychosocial variables were included in a model with the SES indicators, with the exception of education, the latter were no longer statistically significant. This suggests that the SES indicators are associated with significant depressive symptoms through their association with health-related and psychosocial factors that may mediate the SES–depression relationship. In our data and in the extant literature, economic hardship was associated with stress, poor health, and inadequate social resources.19,20 Low SES may lead to decreased probability of seeking health care or less access to health care, which may lead to more physical illness or impairment and, thus, to more depressive symptoms. Because of the cross-sectional nature of the data, we cannot exclude the alternative explanation that poor health leads to less ability to work, lower income, more financial strain, and ultimately lower SES, although Lynch et al.19 did not find evidence of this alternative reverse causation.
Our results show the strong association between health-related and psychosocial factors and significant depressive symptoms among middle-aged women, irrespective of their race/ethnicity. These data are important for several reasons. They highlight the independent associations of physical health and stress with significant depressive symptoms among middle-aged women, and they indicate that these types of factors may be more important than gross indicators of SES. Race/ethnicity may be an important risk marker for depression in midlife precisely because many racial/ethnic groups have higher rates of conditions and stresses that are associated with risk for depression.
There are several limitations to our study. Because our analyses were based on cross-sectional data, it was not possible to determine whether the various factors examined were antecedents, correlates, or consequences of depression. It also should be noted that we were not measuring clinical depression. However, elevated depressive symptoms have the potential to affect functioning,49–51 and subsyndromal depression is associated with an increased risk for future major depression.52,53 Although these data included a wide range of predictors, some variables associated with depression and differentially distributed among racial/ethnic groups were not included (e.g., substance abuse, history of sexual abuse).
We also recognize that our broad racial/ethnic groups were not homogeneous and included both different specific groups of women, such as Puerto Ricans and South Americans in the Hispanic group, and a mixture of women who had different degrees of acculturation. Having only 1 of the 3 minority groups at only 1 site may limit the generalizability of the findings. However, the White women at each of these 3 sites had significantly higher educational levels than the sites’ minority women, which indicates that there are consistent White–racial/ethnic differences within sites. Finally, the results of the separate multivariable analyses of the Chinese and Japanese women may have been limited by the small numbers of women in some categories, such as those who had vasomotor symptoms and high blood pressure.
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CONCLUSIONS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSReferences |
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Although there has long been an interest in the prevalence and the characteristics of depression among middle-aged women, few studies have included the breadth and depth of potentially important risk factors in as large and diverse a community-based sample of middle-aged women as SWAN has. We found that approximately one quarter of middle-aged women may have potentially significant depressive symptoms, that the variation in the prevalence of these symptoms by race/ethnicity is largely because of SES, and that health-related factors and stress together may be the correlates of SES that are associated with the emergence of significant depressive symptoms.
Because of the longitudinal design of SWAN, which includes annual assessments similar to that of the baseline, we plan to develop more refined models of the associations among race/ethnicity, SES, physical health, and the psychological and social aspects of women and their life circumstances. Moreover, we will be able to integrate the influence of hormonal and psychosocial changes during the menopausal transition with these data.
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Acknowledgments |
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The Study of Women’s Health Across the Nation (SWAN) was funded by the National Institute on Aging, the National Institute of Nursing Research, and the National Institute of Health Office of Research on Women’s Health. The institutions which participated in SWAN were the University of Michigan, Ann Arbor (NR04061 and AG12495); Massachusetts General Hospital, Boston (AG12531); Rush University, Chicago, Ill (AG12505); the University of California, Davis (AG12554); the University of California, Los Angeles (AG12539); the University of Medicine and Dentistry, New Jersey Medical School, Newark (AG12535); the University of Pittsburgh, Pittsburgh, PA (AG12546); and New England Research Institutes, Watertown, MA (AG12553).
We thank the study staff at each site and all the women who participated in SWAN.
Human Participant Protection
Institutional review board approval was obtained at each study site.
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Footnotes |
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Contributors
All the authors contributed to the formulation of hypotheses and the review and interpretation of analyses, and they participated in the writing of the article. J. T. Bromberger helped design the study, planned the analyses, and wrote the overall initial draft and the final article. S. Harlow, N. Avis, and H. M. Kravitz edited revisions of the article.
Accepted for publication December 9, 2003.
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References |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSReferences |
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