Does the Black-White mental health paradox persist across U.S. geographical regions?

Abstract

Purpose:

The “Black-White mental health paradox” refers to the epidemiological pattern whereby Black Americans experience similar, and often lower, rates of psychiatric disorders relative to their White counterparts despite their greater exposure to stressors and societal-level racism. The aim of this study is to examine the extent to which the Black-White mental health paradox is observed within four U.S. geographical regions: Midwest, Northeast, South, and West.

Methods:

A sample of Black and White Americans was drawn from the National Comorbidity Survey-Replication (NCS-R) and the National Survey of American Life (NSAL). Racial patterns of disorder were examined before and after adjusting for other sociodemographic characteristics (e.g., education, employment status, marital status, sex, age). Logistic regression analysis estimated relative odds of past-year mood, anxiety, substance use, and any disorder among Black and White adults within each region.

Results:

Evidence of the paradox was most prominent in the U.S. South region. Black Southerners experienced lower odds of mood, anxiety, and any disorders relative to their White Southern counterparts. Black individuals in the Northeast and West also had lower odds of any disorder vis-a-vis their White counterparts. By contrast, Black Americans in the Midwest experienced elevated odds of mood disorders compared to White Midwesterners; this racial pattern, however, dissipated after adjusting for sociodemographic characteristics (e.g., education, employment).

Conclusion:

Mental health intervention and prevention programs should address the elevated risk of mood disorder among Black Americans living in the Midwest, in part by ameliorating racial inequalities in access to education, employment, and other economic resources.

The “Black-White Mental Health Paradox” refers to epidemiological patterns indicating similar, and often lower, rates of most psychiatric disorders among Black Americans relative to their Non-Hispanic White counterparts (Erving et al., 2019; Kiecolt et al., 2008; Pamplin II and Bates, 2021; Thomas Tobin, 2021). This racial patterning of mental disorder is considered “paradoxical” because it defies the expectation set forth by social stress theory that individuals who are members of historically disadvantaged populations will experience greater exposure to social stress and, in turn, higher rates of mental disorder (Pearlin and Bierman, 2013; Turner, 2013). Several mechanisms underlying the paradox have been empirically tested, ranging from social support (Kiecolt et al., 2008; Mouzon, 2013, 2014, 2017), coping resources (Louie et al., 2022), and health behavior (Jackson et al., 2010) to, most recently, pharmaceutical side effects (Schnittker and Do, 2020), to name a few.

Another line of research explores the extent to which the paradox applies across psychiatric diagnoses beyond depression (Erving et al., 2019; Thomas Tobin et al., 2022) and to varying segments of the U.S. population, including distinctions by education (Barnes et al., 2013), gender (Erving et al., 2019) as well as age (Thomas Tobin et al., 2022). This work has identified some critical exceptions, namely higher risk of PTSD for Black women compared to White women (Erving et al., 2019), as well as higher risk for substance use disorder among Black men compared to White men in mid-life (i.e., ages 45–64 years of age) (Thomas Tobin et al., 2022). These exceptions, though few, beg the question of whether other exceptions to the paradox exist. The present study engages this query by focusing on another form of variation: U.S. regional context. Specifically, this study investigates the following research questions: Is there evidence of the “paradox” across U.S. geographical regions? Stated differently, do Black Americans have similar or lower rates of mental disorder compared to White Americans within all U.S. regions? In addition, do the same racial patterns persist across U.S. regions and across different mental disorder types (e.g., mood versus anxiety)?

Understanding the racial patterning of mental disorders in a regional context is critical for at least three reasons. First, such an investigation contributes nuance to the extant literature on the Black-White mental health paradox and can either confirm that the paradox holds across U.S. regions or identify important exceptions to the Black mental health advantage. Second, and relatedly, this research can provide insights on the “where” (i.e., region), “who” (e.g., specific racialized group), and “what” (e.g., a focus on substance abuse versus mood disorders) of targeted public health prevention and intervention efforts to reduce the personal suffering that accompany and economic costs of treating mental disorder in the U.S. population. Finally, examining racial patterns of mental disorder within regions has implications for a growing literature at the cross-section of structural racism, place-based, and ecosocial theories (Homan et al., 2021; Krieger, 2001). Taking region as the unit of analysis, the study results may begin to elucidate another complex means through which structural racism is inextricably linked to place.

1. Regional differences in mental disorder

As the distribution of physical health problems varies widely across U.S. geographical regions, it is likely that mental health outcomes do as well. However, knowledge of mental health variation across regions remains limited. Regarding physical health, the Southern region exhibits higher prevalence rates of obesity (CDC, 2023), diabetes (Zang et al., 2021), stroke (Howard and Howard, 2020), heart disease (Parcha et al., 2021), and COVID-related mortality (Stoto et al., 2022) compared to other parts of the country. Conversely, the Northwest and West consistently display the lowest rates of physical health issues (CDC, 2023; Parcha et al., 2021; Zang et al., 2021). These patterns highlight distinct health disparities along regional lines, with the South consistently experiencing the highest rates of physical health problems and the Northeast and West reporting the lowest rates.

Despite a clear physical health disadvantage in the U.S. South compared to other regions, some evidence points to similarity in mental disorder across regions. For instance, findings from the National Survey on Drug Use and Health indicated that prevalence of any past-year mental disorder was 19.00 % in the West, 18.54 % in the Midwest, 18.14 % in the South, and 17.95 % in the Northeast (Lipari et al., 2017). Similar rates of any mental disorder across regions, however, obscures nuances across disorder types (e.g., anxiety versus substance use disorders). A handful of epidemiological studies have either directly or indirectly reported regional distinctions in mental disorders. Nevertheless, region has rarely been the substantive focus of psychiatric epidemiological studies and is often leveraged as a control or covariate in regression models.

Despite this general dearth in the literature, an early study drew data from the Midlife in the United States Survey (MIDUS) to provide a sociocultural analysis of regional distinctions in psychological well-being (e.g., self-rated mental health, six-item scales of positive and negative affect) (Plaut et al., 2002). Their nuanced study findings revealed that self-reported mental health (i.e., rating one’s emotional or mental health on a five-point scale ranging from “poor” to “excellent”) was highest in Northeast states (e.g., Massachusetts, Connecticut) and lowest in Midwest states (e.g., Wisconsin, Michigan), with other regions falling in the middle. However, negative affect (e.g., feeling nervous or restless in the past 30 days) was most prominent in Southern states like Kentucky and Tennessee (Plaut et al., 2002). Though not explicitly focused on mental disorders, this study suggests potential nuances in regional patterns contingent upon the specific indicator of psychological well-being under investigation.

Moving beyond regional patterns of mental disorder, the racial patterning of mental disorders within regions is unclear due to little focus on this topic in the literature. Most of what we know about the racial patterning of mental health is from within (racial) group studies. As such, the next two sections focus on regional distinctions in mental health among Black Americans and White Americans, separately.

2. Region and mental disorder among Black Americans

In one of the first studies to explicitly examine regional differences in psychiatric disorder among Black Americans, Satcher and colleagues (2024) discovered that Black Americans in the South had relatively lower past-year rates of major depression and any anxiety disorder compared to their counterparts living in other regions. Other studies report similar patterns, though region was not the primary topic under investigation in their research (Broman et al., 2008; Himle et al., 2008, 2009; Williams et al., 2007). For instance, drawing data from the National Survey of American Life (NSAL), Williams and colleagues (2007) identified regional nuances in the lifetime prevalence of major depressive disorder (MDD). Specifically, African Americans in the South and West had lifetime MDD prevalence rates of 8 % and 7.8 %, respectively. On the other hand, African Americans in the Midwest and Northeast had lifetime MDD prevalence rates of 15.8 % and 14.5 %, respectively (see Table 4 of Williams et al., 2007). Covering anxiety disorders, Himle and colleagues (2009) found that across five anxiety disorders (i.e., generalized anxiety disorder, social anxiety disorder, post-traumatic stress disorder, panic disorder, agoraphobia without panic), Black Americans residing in the West and South tended to have relatively lower 12-month prevalence of anxiety disorders while Black individuals residing in the Midwest had relatively higher rates, with Northeasterners falling somewhere in the middle (see Table 1 in Himle et al., 2009). Regarding substance abuse and substance dependence, Black Southerners (9.6 %, 3.4 %) experienced the lowest prevalence while Black Northeasterners (15.9 %, 7.3 %) faced the highest prevalence (see Table 2 of Broman et al., 2008). In sum, Black people living in the South and West appear to have the lowest prevalence of mood and anxiety disorders relative to Black Americans living in other U.S. geographical regions. Regional variation in mental disorder among White Americans follows less consistent patterns.

Table 4.

Odds ratio from ordinal logistic regression for the midwest U.S. Region (N = 2858).

	Model 4A Past-year Mood Disorder	Model 4B Past-year Anxiety Disorder	Model 4C Past-year Substance Disorder	Model 4D Any Past-year Mental Disorder
Race (Ref.¼White)
Black	1.113 (.836,1.480)	.941 (.631,1.403)	1.044 (.536,2.036)	.908 (.666,1.239)
Education (Ref.=Less than High School)
High School Diploma	.753 (.468,1.210)	.798 (.573,1.112)	.721 (.274,1.895)	.679** (.524,.881)
Some College	.808 (.557,1.171)	.883 (.588,1.325)	.522 (.224,1.215)	.784 (.582,1.057)
College Graduate	.758 (.455,1.264)	.654* (.432,.991)	.593 (.296,1.185)	.675** (.512,.891)
Employment Status (Ref.=Employed)
Unemployed	1.103 (.541,2.248)	.681** (.521,.890)	.291* (.109,.776)	.761 (.505,1.148)
Not in Labor Force	2.155** (1.349,3.440)	1.072 (.731,1.572)	.805 (.315,2.055)	1.387 (.975,1.974)
Marital Status (Ref.= Married/Cohabiting)
Never Married	.910 (.623,1.331)	.781 (.518,1.178)	1.823** (1.302,2.553)	.867 (.683,1.102)
Divorced/Separated/Widowed	2.142** (1.399,3.280)	1.958***(1.499,2.558)	1.851* (1.052,3.256)	2.024*** (1.501,2.728)
Gender (Ref.=Male)
Female	1.371* (1.039,1.810)	1.331* (1.050,1.689)	.338** (.166,.689)	1.246* (1.024,1.515)
Age	.963*** (.952,.974)	.971*** (.961,.980)	.947*** (.933,.961)	.962*** (.955,.969)

Notes: 95 % confidence intervals in parentheses; Ref. = Reference category.

^*p < .05,

^**p < .01,

^***p < .001.

Source: National Survey of American Life and National Comorbidity Survey, Replication (2001–2003)

Table 1.

Distribution of mental health and sociodemographic characteristics by race and region.

	Northeast		Midwest		South		West
	Black	White	Black	White	Black	White	Black	White
N	594	1290	776	2082	2877	2028	337	1268
Past-year Disorders
Mood Disorder	7.61 %	8.88 %	10.62 %	7.69 % *	5.00 %	8.52 %*	8.38 %	8.69 %
Anxiety Disorder	12.47 %	13.30 %	13.19 %	12.24 %	9.24 %	12.44 % *	11.06 %	13.22 %
Substance Use Disorder	2.89 %	3.71 %	3.80 %	3.36 %	2.39 %	2.37 %	3.59 %	4.21 %
Any Disorder	18.20 %	20.52 %	19.78 %	18.07 %	13.60 %	17.32 % *	18.03 %	20.23 %
Education
Less than High School (Ref.)	.22	.13 *	.21	.12 *	.26	.16 *	.16	.09 *
High School Diploma	.34	.37	.35	.36	.38	.28 *	.35	.23 *
Some College	.28	.26	.27	.30	.23	.26	.31	.33
College Graduate	.17	.24	.16	.22	.12	.29 *	.19	.35 *
Employment Status
Employed (Ref.)	.65	.63	.62	.69 *	.68	.64	.65	.67
Unemployed	.10	.08	.12	.08 *	.09	.09	.08	.07
Not in Labor Force	.24	.29	.26	.22	.23	.26	.27	.26
Marital Status
Married/Cohabiting (Ref.)	.38	.57 *	.39	.60 *	.42	.63 *	.35	.55 *
Never Married	.34	.22 *	.35	.20 *	.32	.18*	.37	.24 *
Div/Sep/Widowed	.27	.21 *	.26	.19 *	.26	.19 *	.28	.21
Sex
Male (Ref.)	.45	.48	.42	.49	.45	.48	.47	.49
Female	.55	.52	.58	.51 *	.55	.52 *	.53	.51
Age [years] (SD)	42.58 (16.42)	47.25* (18.53)	41.62 (16.16)	45.98* (17.69)	41.81 (16.25)	46.83* (17.86)	43.51 (15.12)	45.19 (17.34)

^*Significant difference (p < .05) between Black and White respondents living within the same region.

Source: National Survey of American Life and National Comorbidity Survey, Replication (2001–2003)

Table 2.

Unadjusted odds ratio from ordinal logistic regression for racial patterns of mental disorder by region.

	Past-year Mood Disorder	Past-year Anxiety Disorder	Past-year Substance Disorder	Any Past-year Mental Disorder
Northeast Race (Ref.¼White)
Black	.845 (.553, 1.293)	.929 (.698, 1.235)	.772 (.335, 1.778)	.862 (.652, 1.140)
Midwest Race (Ref.¼White)
Black	1.427* (1.010, 1.853)	1.089 (.742, 1.599)	1.138 (.540, 2.400)	1.118 (.828, 1.510)
South Race (Ref.¼White)
Black	.565*** (.439, .729)	.716** (.576, .890)	1.008 (.594, 1.712)	.751** (.628, .898)
West Race (Ref.¼White)
Black	.962 (.532, 1.740)	.816 (.637, 1.046)	.847 (.252, 2.853)	.868 (.616, 1.223)

95 % confidence intervals in parentheses.

^*p < .05,

^**p < .01,

^***p < .001.

Source: National Survey of American Life and National Comorbidity Survey, Replication (2001–2003)

3. Region and mental disorder among White Americans

Among White Americans, regional patterns are contingent upon the specific disorder under consideration. Regarding lifetime MDD, White Americans in the South (14.7 %) and Midwest (18.7 %) had lower rates relative to those living in the West (20 %) and Northeast (23.9 %) (see Table 1 of Williams et al., 2007). Different regional patterns emerge for White Americans when considering past-year anxiety disorders. For instance, for social anxiety disorder and post-traumatic stress disorder, White Americans living in the West had the highest prevalence (compared to Whites living in other regions; Himle et al., 2009). On the other hand, White Southerners had the highest risk of generalized anxiety disorder and agoraphobia (relative to Whites in other regions; Himle et al., 2009). Moreover, Northeastern Whites had the highest prevalence of panic disorder (see Table 1 of Himle et al., 2009). Prevalence of psychiatric disorders among White respondents in the NSAL, however, reflect White Americans living in census tracts composed of at least 10 % African Americans (Heeringa et al., 2004; Jackson et al., 2004), preventing us from drawing firm conclusions regarding the generalizability of these findings to White Americans in the broader U.S. population.

4. Black-White differences in mental disorder for specific U.S. Regions

Though we know little about regional differences in mental disorders among Black and White Americans, we know even less about racial differences in mental disorder within specific regions because this is rarely a topic of investigation. A race-comparative approach is critical to understand how Black Americans fare relative to their more racially advantaged White counterparts in specific geographical contexts. Moreover, though prior research elucidates the gravity of Black-White physical health disparities within specific regions, a similar literature regarding mental health has not yet materialized.

Studies have reported psychiatric disorder prevalence rates for Black and White Americans across region (Williams et al., 2007; Himle et al., 2009), yet it has not been of substantive focus, resulting in complex findings for specific disorders. Regarding lifetime MDD, across all regions, White individuals had higher rates of lifetime MDD compared to Black respondents, with the most significant Black-White differential observed in the West and Northeast (Williams et al., 2007). For instance, Black individuals living in the West had a lifetime MDD prevalence of 7.8 % compared to 20 % for White individuals in the West (prevalence differential of 12.8 %). Nevertheless, a past-year estimate of mental disorder would be more appropriate to assess a “region effect” given that individuals could have potentially moved across regions over their lifetime. In addition, this pattern could differ when a broader array of mood disorders is considered.

Regarding specific past-year anxiety disorders, there appears to be an overall mental health advantage (i.e., lower risk of disorder) for Black Americans compared to White Americans living within the same regions. However, PTSD is an exception, revealing a more nuanced pattern. Approximately 4.05 % of Whites in the West had a PTSD diagnosis while 2.18 % of Blacks in the West had past-year PTSD, revealing a Black mental health advantage (Himle et al., 2009). On the other hand, Black Northeasterners (5.41 %) had higher risk of PTSD compared to their White counterparts (3.63 %) in the same region (see Table 1 of Himle et al., 2009). Less is clear regarding other disorder categories such as substance use.

5. Theoretical expectations at the intersection of region, race, and mental disorder

What sociohistorical, structural, or cultural forces might shape patterns of psychiatric disorder across U.S. regions as well as between Black and White residents of those regions? Here, we draw from work by Veazie et al. (2025), Homan et al. (2021), and others that bring to bear fundamental cause theory (Link and Phelan, 1995) and Krieger’s (2001) ecosocial theory to posit that state-level structural racism, uniquely manifested through a combination of historical, economic, demographic, and legislative factors, shapes observed Black-White differences in health across U.S. states. Although there is some variation in findings, the extant literature points to regional consistency in the relative extent of racial inequality in educational, economic, and carceral circumstances that can potentially shape health and well-being (Phelan and Link, 2015; Williams et al., 2016).

Using latent class analysis to develop three typologies of state-level structural racism across five domains, Veazie et al. (2025) demonstrate that many states in the Midwest region have the most severe structural racism in multiple domains (typology 3), highlighting significant Black-White disparities in employment, homeownership, incarceration, and income, and moderate disparities in education. In contrast, states in the South, some states in the Northeast and West have the lowest inequities across all five domains (typology 1), while some states in the West and Northeast have the largest educational inequities and relatively moderate inequities in other domains (typology 2). Homan and colleagues (2021) demonstrate a similar pattern, showing that structural racism (measured across educational, judicial, economic, political, and segregation domains) is highest in the Midwest and Northeast, and lowest in the South, consistent with other studies of state-level structural racism (Mesic et al., 2018; Muller and Wildeman, 2016). In general, we posit that these patterns may influence Black-White mental health patterns within states and, in turn, accumulate to have broader regional-level impacts.

Though the Black-White mental health paradox yields evidence of racial similarity or better mental health for Black Americans in the U.S. generally, regions characterized by heightened racial inequality may reveal evidence of Black mental health disadvantage. For instance, a sociohistorical perspective points to heightened racial segregation (Logan and Stults, 2022), terror-inducing “Sundown towns” (Loewen, 2005), insidious colorblind racism and class blindness (Gonzales et al., 2022), and social erasure (Gonzales et al., 2022; Halvorson and Reno, 2022) of Black Americans in the Midwest. Of the four U.S. regions, the Midwest also has the lowest proportional representation of Black American residents. Given their relative underrepresentation, racial isolation and a high degree of racism could leave Black Midwesterners with smaller networks of social support and other coping strategies that Black Americans in more diverse regions (e.g., the South) can leverage to a greater degree and efficiency.

Another approach to understanding regional differences in mental disorder is an emerging theoretical framework of regional personality (Plaut et al., 2002; Rentfrow et al., 2008; Rentfrow, 2010). This framework generally posits that the social and political character of a given region shape interpersonal and institutional relationships in ways that foster a largely consistent, unique regional personality. Rentfrow and colleagues (2013) explore this phenomenon and provide empirical evidence for a theoretical framework of regional personality, finding that Southern and Midwestern residents exhibit a regional personality cluster characterized by friendliness, conventionality, and agreeableness, while Northeastern residents exhibit a temperamental and uninhibited personality. In contrast, residents in the West and Eastern seaboard are characterized by a relaxed, creative, and open personality. The authors link these regional personality clusters to well-being and health behaviors indicators such that relaxed and creative Westerners have the best well-being relative to the other regional personalities, friendly and conventional Midwestern and Southern residents have the worst well-being and health behaviors, and temperamental and uninhibited Northeastern residents fall somewhere in the middle. In a more recent study, Ebert et al. (2022) echoed findings related to agreeableness and extraversion among Midwestern and Southern residents and report regional consistency in conscientiousness among Southern residents relative to residents in other regions. Interestingly, high emotional stability is regionally consistent for both Southerners and Westerners, while low emotional stability is consistent for residents in the Midwest and Northeast.

In sum, the present study fills a gap in the literature on the Black-White mental health paradox by examining the extent to which the mental health advantage of Black Americans vis-à-vis White Americans is observed across four U.S. geographical regions: Midwest, Northeast, South, and West. Prior literature suggests regional differences in racial inequality (driven by state-level differences in structural racism) and the potential of these differences to shape mental health outcomes (Homan, 2024; Homan et al., 2021). We draw on this framework that embeds structural racism in place and links it to mental health to posit that the Black-White mental health paradox may not be universal to all regions and psychiatric disorders. Accordingly, we consider the consistency of these patterns across multiple disorder categories (i.e., mood, anxiety, substance, any disorder) by relying on two national data sources that provide “gold standard” measures of psychiatric disorders. In addition to adding regional nuance to empirical research on the paradox, study findings may have important implications for intervention programs as well as the distribution of resources related to improving mental health at the regional level.

6. Methods

6.1. Sample

We leverage data from the National Comorbidity Survey-Replication (NCS-R) and the National Survey of American Life (NSAL), both of which are nationally representative psychiatric epidemiology surveys. These data are among the most comprehensive sources for investigating U.S. psychiatric epidemiological patterns for Black and White Americans. These data also contain sufficient sample sizes for an analysis of regional and racial differences in psychiatric disorder in a multivariate regression analysis. The NCS-R survey population included adults aged 18 and older residing in coterminous U.S. households (N = 9282). Interviews were conducted in English, lasted an average of 2 h, and had a 71 % response rate (Pennell et al., 2004). The NSAL sampled African Americans (n = 3570), Blacks of Caribbean descent (n = 1621) and non-Hispanic Whites (n = 891; Jackson et al., 2004). These samples were representative and reflect national distributions on sociodemographic variables such as gender, region, urbanicity, educational attainment, income, and marital status (Jackson et al., 2004). The response rate was 72 %. Eighty-six percent of interviews were conducted face-to-face with race/ethnicity matching of interviewers and respondents used a computer-assisted instrument. In alignment with prior research (Barnes et al., 2013; Erving et al., 2019), NCS-R and NSAL were merged to create a large, nationally representative sample of U.S.-born non-Hispanic African Americans (in NSAL, NCS-R) and White Americans (in NCS-R).

6.2. Measures

Psychiatric Disorders.

The World Mental Health Survey Initiative version of the WHO (World Health Organization) Composite International Diagnostic Interview (WMH-CIDI) was used to assess psychiatric disorders in the NSAL and NCS-R. WMH-CIDI assesses the most common and severe mental disorders using diagnostic criteria established by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association, 1994). Three measures of the most commonly diagnosed categories of psychiatric disorder are included in the analysis: any mood disorder (major depressive disorder, bipolar 1 and 2, dysthymia), any anxiety disorder (panic disorder, agoraphobia, social phobia, generalized anxiety disorder, post-traumatic stress disorder), and any substance use disorder (alcohol abuse, alcohol dependence, drug abuse, drug dependence). Risk for any mental disorder (a compilation of any mood disorder, any anxiety disorder, and substance disorder) was also assessed.

Key Independent Measures.

Race was self-reported and distinguished between non-Hispanic African Americans and non-Hispanic Whites. Based on U.S. Census regional specifications, current region of residence distinguished among four geographical areas: Northeast, Midwest, West, and South.¹

Sociodemographic Characteristics.

The present analyses controlled for multiple sociodemographic characteristics to determine whether any observed racial differences were attributable to socioeconomic inequalities (Erving et al., 2019; Gibbs et al., 2013). Two indicators of socioeconomic status were available across both data sources: Educational attainment (0 = less than high school [reference], 1 = high school education/some college, 2 = college degree) and employment status (0 = employed [reference], 1 = unemployed, 2 = not in the labor force). In alignment with previous literature on the paradox (Louie et al., 2022; Mouzon, 2013, 2014, 2017), we also adjusted for marital status (0 = married/cohabiting [reference], 1 = divorced/separated/widowed, 2 = never married), sex (0 = male [reference], (1) female), and age (continuous measure; range: 18–99 years) because these demographic characteristics could potentially be confounders (but not mediators) of the association between racial identity and mental disorder.

6.3. Analytic strategy

Analyses were conducted with STATA 17.0 (StataCorp, 2021). Due to the data’s complex sampling strategy, survey procedures were used to correct for unequal probabilities of selection, non-response, and design effects in the sample. The analysis included (1) descriptive statistics (i.e., means, frequencies) for key study measures by region and race, (2) a series of binary logistic regression models that assessed racial patterns for each disorder category (i.e., mood, anxiety, substance use) within each geographical region (i.e., Northeast, Midwest, West, South), before (Table 2) and after (Tables 3–6) adjusting for sociodemographic factors. We conducted complete case analysis. Thus, the sample for this study includes 4584 Black Americans and 6668 White Americans (total N = 11252).

Table 3.

Odds ratio from ordinal logistic regression for the northeast U.S. Region (N = 1884).

	Model 3A Past-year Mood Disorder	Model 3B Past-year Anxiety Disorder	Model 3C Past-year Substance Disorder	Model 3D Any Past-year Mental Disorder
Race (Ref.¼White)
Black	.706 (.479,1.041)	.812(.599,1.102)	.579 (.313,1.071)	.704* (.538,.920)
Education (Ref.=Less than High School)
High School Diploma	.473** (.291,.769)	1.059 (.710,1.580)	2.522 (.438,14.51)	1.146 (.806,1.629)
Some College	.693* (.482,.997)	1.081 (.724,1.614)	.825 (.210,3.243)	1.014 (.768,1.339)
College Graduate	.531* (.296,.953)	1.121 (.790,1.591)	.477 (.0665,3.416)	.857 (.555,1.323)
Employment Status (Ref.=Employed)
Unemployed	.668 (.331,1.345)	.435 (.163,1.162)	.755 (.224,2.549)	.584 (.290,1.174)
Not in Labor Force	2.516* (1.260,5.024)	1.776* (1.163,2.713)	1.252 (.367,4.269)	1.705* (1.058,2.749)
Marital Status (Ref.= Married/Cohabiting)
Never Married	1.010 (.455,2.242)	1.203 (.855,1.691)	2.006 (.998,4.032)	1.292 (.918,1.818)
Divorced/Separated/Widowed	1.436 (.765,2.696)	2.282*** (1.866,2.792)	3.830*** (1.945,7.543)	2.168*** (1.720,2.733)
Gender (Ref.¼Male)
Female	1.501** (1.183,1.904)	1.426 (.923,2.202)	.470*** (.340,.651)	1.267 (.871,1.844)
Age	.966*** (.951,.983)	.971*** (.963,.980)	.934*** (.920,.949)	.963*** (.953,.974)

Notes: 95 % confidence intervals in parentheses; Ref. = Reference category.

^*p < .05,

^**p < .01,

^***p < .001.

Source: National Survey of American Life and National Comorbidity Survey, Replication (2001–2003)

Table 6.

Odds ratio from ordinal logistic regression for the west U.S. Region (N = 1605).

	Model 6A Past-year Mood Disorder	Model 6B Past-year Anxiety Disorder	Model 6C Past-year Substance Disorder	Model 6D Any Past-year Mental Disorder
Race (Ref.=White)
Black	.752 (.420,1.348)	.732 (.518,1.036)	.623 (.193,2.014)	.707* (.506,.988)
Education (Ref.=Less than High School)
High School Diploma	.488 (.230,1.034)	.692 (.318,1.507)	.529 (.186,1.500)	.522* (.296,.920)
Some College	.349*** (.235,.519)	.660 (.339,1.287)	.328 (.107,1.005)	.401** (.224,.720)
College Graduate	.428** (.236,.774)	.754 (.455,1.249)	.104* (.0185,.578)	.403*** (.277,.585)
Employment Status (Ref.=Employed)
Unemployed	.677 (.151,3.043)	.720 (.378,1.371)	.293 (.0710,1.208)	.503 (.211,1.200)
Not in Labor Force	1.227 (.651,2.312)	1.406** (1.163,1.700)	.673 (.259,1.745)	1.248 (.878,1.772)
Marital Status (Ref.= Married/Cohabiting)
Never Married	1.042 (.425,2.555)	.833 (.562,1.235)	2.187 (.919,5.207)	.999 (.551,1.813)
Divorced/Separated/Widowed	1.981*(1.143,3.434)	1.726* (1.116,2.669)	.861 (.345,2.152)	1.679** (1.196,2.357)
Gender (Ref.=Male)
Female	2.026* (1.219,3.367)	1.796* (1.003,3.213)	.472 (.220,1.014)	1.538 (.956,2.474)
Age	.968** (.947,.990)	.975*** (.967,.983)	.967** (.948,.987)	.968*** (.959,.978)

Notes: 95 % confidence intervals in parentheses; Ref. = Reference category.

^*p < .05,

^**p < .01,

^***p < .001.

Source: National Survey of American Life and National Comorbidity Survey, Replication (2001–2003)

7. Results

7.1. Descriptive statistics

Table 1 presents prevalence rates for psychiatric disorders and descriptive statistics for sociodemographic characteristics by race and region. Results indicate there were no statistically significant differences in the prevalence of psychiatric disorders between Black Americans and White Americans living in the Northeast. For Midwestern residents, Black Americans had higher rates of past-year mood disorders (10.62 %) than their White counterparts (7.69 %). Among Southerners, Black Americans experienced a significantly lower prevalence of past-year mood disorders (5 % versus 8.52 %), anxiety disorders (9.24 % versus 12.44 %), and any psychiatric disorders (13.60 % vs. 17.32 %) compared to White Americans. Residents of the West region had similar rates of mood, anxiety, substance use, and any disorder across racial groups.

Regarding the sociodemographic controls, there were significant education differences in every region, with more Black people than White people reporting that they did not complete high school. Employment rates were comparable across racial groups in every region except the Midwest, where more White compared to Black individuals were employed. Across all regions, more White people were married compared to Black people. White people also tended to be older in most regions, except in the West where Black and White individuals had a comparable average age. Given substantial differences in the sociodemographic characteristics of Black and White Americans living in the same regions, there is a possibility that racial differences in psychiatric disorders within regions could be attenuated after adjustments for educational attainment, employment status, marital status, sex, and age. We test this hypothesis next.

Table 2 provides unadjusted odds ratios from ordinal logistic regressions for racial patterns of mental disorder by region which enable a comparison of the unadjusted risk of mental disorder between Black and White Americans before adjusting for sociodemographic characteristics. Consistent with the crude prevalence rates presented in Table 1, the unadjusted odds ratios show consistent evidence of the paradox in the Northeast, South, and West regions. While the Northeast and West show no significant differences in mental disorder between Black and White Americans, the odds ratios are all less than 1, indicating relatively lower risk for Black Americans. On one hand, the paradox is most pronounced in the South region, with odds ratios of .565 (p < .001), .716 (p < .01), and .751 (p < .01) for past-year mood disorder, anxiety disorder, and any mental disorder, respectively. On the other hand, Black Americans living in the Midwest have a 1.427 times greater risk (p < .05) of pastyear mood disorder relative to their White Midwestern counterparts. Though not reaching traditional significance levels, past-year anxiety (OR = 1.089), past-year substance use (OR = 1.138), and any past-year mental disorder (OR = 1.118) have odds ratios greater than 1 in the Midwest, indicating that Black Americans have slightly higher (but not statistically significant) risk compared to White Americans.

7.2. Racial patterns in the northeast region

Table 3 presents odds ratios from logistic regression models assessing Black-White differences in psychiatric disorders for the Northeast region. Models 3A, 3B, 3C, and 3D present results for past-year mood disorders, anxiety disorders, substance use disorders, and any disorders, respectively. Models 3A-3C indicate there were no significant differences in past-year mood disorder, anxiety disorder, and substance use disorder, respectively between Black and White Americans. Despite not being statistically significant at p < .05, the odds ratios suggest that compared to their White counterparts, Black Americans have 29.4 %, 18.8 %, and 42.1 % lower risk of past-year mood, anxiety, and substance use disorder, respectively. Model 3D shows that Black Americans had significantly lower odds of any past-year disorder (OR = .704, p < .05). Regarding controls, higher educational attainment is associated with lower risk for mood disorder and being out of the labor force is associated with greater risk of mental disorder relative to the employed. Divorced, separated, and widowed respondents experience greater risk of mental disorder compared to those who are married or cohabiting. Gender differences in mental disorder are consistent with the literature: higher risk of mood disorder among females and higher risk of substance disorder among males. Last, older age is associated with lower risk of mental disorder.

7.3. Racial patterns in the midwest region

Table 4 examined mental health patterns for the Midwest region. There were no observed Black-White differences in mood disorder (see Model 4A), yet the odds ratio suggests an 11 % higher risk of mood disorder for Black Midwesterners relative to White Midwesterners. This suggests that racial differences in sociodemographic characteristics partially accounted for the observed higher rate of any mood disorder for Black Americans compared to their White counterparts. Those with a high school diploma (OR = .473, p < .01), some college (OR = .693, p < .05), and college graduates (OR = .531, p < .05) had lower risk of pastyear mood disorder compared to those with less than a high school diploma. Not being in the labor force was associated with 2.516 greater odds (p < .05) of past-year mood disorder relative to the employed. Females had higher risk for any-past year mood disorder (OR = 1.501, p < .01) as well as younger respondents (OR = .966, p < .001). In essence, Black Americans’ relatively lower levels of educational attainment and employment along with their higher representation of females and being younger, on average, accounted for their higher rate of past-year mood disorder (compared to White Midwesterners) observed in the unadjusted prevalence rate.

To assess to extent to which economic factors mediate the association between race and any mood disorder, we conducted an ancillary formal mediation analysis (Hicks and Tingley, 2011; Imai et al., 2010). Results from the mediation analysis revealed that 23.3 % of the racial difference in any mood disorder in the Midwest was attributable to employment status and 21.4 % was attributable to educational attainment.

In the Midwest, there were no significant racial differences in pastyear anxiety disorder (Model 4B), past-year substance use disorder (Model 4C), or any past-year mental disorder (Model 4D). Though not reaching statistical significance, after adjustment for sociodemographic characteristics, Black Americans have slightly lower risk of past-year anxiety (OR = .941) and any past-year mental disorder (OR = .908), while past-year substance use disorder is slightly higher for Black Americans (OR = 1.044). The imprecision of these estimates (e.g., see the wide confidence intervals), however, prevent us from making definitive claims about these patterns.

Some sociodemographic characteristics were associated with mental disorders, and in expected ways based on prior literature. For instance, female respondents experienced greater odds of past-year anxiety disorders (OR = 1.331, p < .05) while males had higher risk for substance use disorders (OR = .338, p < .01). Married/cohabiting respondents were less likely to experience mental disorder relative to their divorced/ separated/widowed counterparts across all models. Unexpectedly, unemployed respondents had lower odds of past-year anxiety disorder (OR = .681, p < .01) and past-year substance disorder (OR = .291, p < .05) compared to those who were employed.

7.4. Racial patterns in the south region

Table 5 includes an analysis of the South region where a vastly different picture emerged. Black Southerners had lower odds of pastyear mood (OR = .453, p < .001), past-year anxiety disorder (OR = .563, p < .001), and any past-year disorder (OR = .571, p < .001) relative to White Southerners. The only outcome for which there was no significant racial difference was past-year substance use disorder (OR = .829), yet the odds ratio suggests a 17.1 % lower risk of substance use disorder for Black Americans after adjusting for sociodemographic factors.

Table 5.

Odds ratio from ordinal logistic regression for the south U.S. Region (N = 4905).

	Model 5A Past-year Mood Disorder	Model 5B Past-year Anxiety Disorder	Model 5C Past-year Substance Disorder	Model 5D Any Past-year Mental Disorder
Race (Ref.¼White)
Black	.453*** (.353,.582)	.563*** (.448,.709)	.829 (.477,1.440)	.571*** (.483,.674)
Education (Ref.¼Less than High School)
High School Diploma	1.104 (.691,1.763)	.582*** (.441,.768)	.478 (.221,1.035)	.746 (.539,1.032)
Some College	.976 (.631,1.510)	.618* (.419,.910)	.634 (.340,1.183)	.712 (.501,1.011)
College Graduate	.891 (.532,1.492)	.617* (.419,.909)	.527* (.312,.891)	.675* (.479,.951)
Employment Status (Ref.=Employed)
Unemployed	.604 (.282,1.291)	.522* (.290,.940)	.454 (.164,1.259)	.509* (.285,.907)
Not in Labor Force	2.392*** (1.702,3.362)	1.751*** (1.323,2.317)	1.950 (.680,5.590)	1.893*** (1.370,2.616)
Marital Status (Ref.¼ Married/Cohabiting)
Never Married	.902 (.567,1.435)	.801 (.577,1.113)	1.255 (.719,2.189)	.955 (.697,1.310)
Divorced/Separated/Widowed	2.309*** (1.651,3.231)	2.186*** (1.706,2.801)	2.014* (1.110,3.656)	2.262*** (1.769,2.892)
Gender (Ref.=Male)
Female	2.276*** (1.690,3.067)	2.261*** (1.834,2.789)	.528* (.324,.859)	1.971*** (1.643,2.365)
Age	.963*** (.953,.973)	.960*** (.952,.968)	.932*** (.915,.949)	.958*** (.950,.966)

Notes: 95 % confidence intervals in parentheses; Ref. = Reference category.

^*p < .05,

^**p < .01,

^***p < .001.

Source: National Survey of American Life and National Comorbidity Survey, Replication (2001–2003)

Sociodemographic factors were related to mental disorder and in the anticipated directions. That is, higher educational attainment, being employed, marriage/cohabiting, and being older were associated with lower risk for one or more mental disorder type. With Black Americans experiencing higher levels of sociodemographic disadvantage (i.e., lower educational attainment, lower marriage/cohabiting, and being younger) vis-à-vis their White counterparts living in the South, the mental health advantage of Black Southerners is a research finding to which we return in the discussion section.

7.5. Racial patterns in the west region

In the West, there were no significant differences in past-year mood (Model 6A), past-year anxiety (Model 6B), or past-year substance use (Model 6C) disorder between Black Americans and White Americans; nevertheless, the magnitude of the odds ratios indicate 24.8 %, 26.8 %, and 37.7 % lower risk for past-year mood, anxiety, and substance disorder, respectively, for Black Americans vis-a-via their White counterparts living in the West. Black Americans experienced a significantly lower risk for any past-year mental disorder (Model 6D; OR = .707, p < .05) compared to their White counterparts living in the West region. Higher educational attainment was associated with lower odds of pastyear mental disorder and divorced/separated/widowed respondents had higher risk of past-year mental disorder relative to their married/ cohabiting peers. Last, younger respondents had higher risk for a pastyear mental disorder. Interestingly, Black Americans experienced relatively lower educational attainment and lower rates of marriage/ cohabiting than White Americans, yet these sociodemographic disadvantages did not correspond with greater risk for any past-year mental disorder. In essence, the suppression of Black Americans’ lower risk for any past-year mental disorder compared to White Americans in the regression analysis suggests that the mental health advantage of Black Americans in the West would be even larger if they did not experience greater sociodemographic disadvantages (e.g., lower education and marriage/cohabiting).

8. Discussion

This study investigated whether there was evidence for the “Black-White mental health paradox” within the four U.S. regions. Large regional disparities in physical health between Black and White Americans provided impetus for examining whether similar disparities emerge for psychiatric disorders. Prior research also suggests regional distinctions in specific mental disorders (e.g., MDD, OCD) among Black and White Americans (Himle et al., 2008; Williams et al., 2018). Additionally, theories at the intersection of structural racism, place, and ecosocial theory imply that the paradox may not be relevant for all U.S. regions because of differential exposure to racial, economic, and social inequality for Black Americans residing in different regions (Homan et al., 2021; Veazie et al., 2025). Our results revealed nuances that have not been captured in prior literature on the Black-White mental health paradox.

First, evidence of the paradox was most pronounced in the South: before and after adjusting for sociodemographic factors, Black Americans living in the South had a lower risk for developing any mental disorder compared to their Southern White counterparts. Accordingly, there is a possibility that Black Southerners experience psychological “flourishing” (Keyes, 2009) despite social and economic disadvantage and disproportionately higher rates of physical health problems (Miller and Vasan, 2021). This is especially striking given the sociodemographic disadvantages of Southern Black Americans, yet also consistent with past research on the paradox (Erving et al., 2019; Thomas Tobin et al., 2022). Though beyond the scope of the current study, future research might disentangle these findings by use more advanced statistical modeling approaches to assess direct and indirect effects of factors like educational attainment, income, and other socioeconomic indicators on the mental health of Black Americans relative to their White counterparts (Pamplin II et al., 2023). One possibility is that there is a weaker linkage between socioeconomic disadvantage and mental health for Black Southerners relative to White Southerners (i.e., an effect modification model; Pamplin II et al., 2023). Relatedly, these findings beg the question: Are Southern Black Americans psychologically resilient amidst economic marginalization and other challenges relative to their White counterparts? Of this, there is growing evidence. Mason et al. (2020) explored racial differences in the mental health impacts of extreme weather (i.e., summer heat waves and extreme winter weather) among Knoxville, Tennessee residents and found that Whites reported significantly worse negative mental health impacts relative to Black and other non-White residents. In terms of this resilience relative to Black residents in other regions of the U.S., interestingly, Williams and colleagues (2018) found that ethnic identity markers such as feeling a sense of commitment and belonging within one’s ethnic group were more strongly endorsed among Black Americans living in the South compared to Black Americans living in other regions; thus, ethnic identity may be a protective mental health factor for Black Southerners.

Moreover, as the southern US remains the region with the highest proportion of Black Americans, there is growing evidence that this “critical mass” of Blackness, even within the structural disadvantages of US southern contexts, has positive impacts on various aspects of health and well-being. Pattillo’s (2021) examination of Black advantage demonstrates how Black racial homogeneity in neighborhoods and communities is associated with improved emotional well-being (Vogt Yuan, 2007), increased happiness (Okulicz-Kozaryn, 2019), less experienced discrimination (English et al., 2014), better overall mental health (White and Lawrence, 2019) and, for Black adolescents, less internalizing behavior (Hurd et al., 2013). Additionally, research suggests that the drivers of poor mental health for Black Southerners may vary across the rural-urban divide (Linn et al., 1989). Despite evidence of increased relative disadvantage regarding mental health care needs (Haynes et al., 2017), scholarship in rural sociology suggests the mental health advantage persists for rural Black Southerners in particular relative to both urban Black southerners and rural White southerners (Efird et al., 2023; Weaver et al., 2015). The mental health advantage of Black rural Southerners is striking, as research on physical health outcomes and mortality suggest a “southern rural health penalty” (Miller and Vasan, 2021). Nevertheless, the Black Southern mental health advantage persists in spite of heightened risk of poor physical health in the U.S. South more generally.

Second, we identified evidence of the paradox in the Northeast and West. Initially, there were no racial differences in the unadjusted prevalence rates. However, after adjustment for sociodemographic factors, Black Americans experienced lower risk of any past-year mental disorder. This pattern suggests that the mental health advantage of Black Americans in the Northeast and West would be even larger if they did not experience socioeconomic disadvantages (e.g., see Upenieks et al., 2023 for a similar argument).

Third, unadjusted prevalence rates indicated higher prevalence of mood disorder among Black Americans in the Midwest relative to White Midwesterners, and the higher risk for Black Americans was partially explained by both employment status and educational attainment. This implies that economic and educational disadvantage are key factors contributing to the nonparadoxical patterns observed for mood disorder for Black Americans in the Midwest. A closer look into the cultural and economic characteristics that make the Midwest known, for many, as “Two Middle Americas” and the impacts of declining labor union density in this region that directly impacts one of those Middle Americas may provide clues on this pattern (Mast et al., 2023; Sander, 2020). Black Americans were excluded from midwestern labor unions in the early 20th century, but their eventual inclusion and growth led to the Midwest having the highest Black American union membership, spurring the growth of the Black middle class in the region (Saunders, 2019). However, since the post-industrial era and anti-worker policies in the Midwest all but gutted labor unions in this region, employment struggles have been a formidable economic barrier for Black Americans in the Midwest (Sander, 2020; Wolfe et al., 2021). This, coupled with having some of the most segregated cities in the U.S. (Logan and Stults, 2022) and among the highest Black-to-White incarceration ratios (Muller, 2012; Enders et al., 2019), ripen contexts for educational disadvantage among Black Americans in the Midwest. In light of this, it comes as no surprise that Black Midwesterners are most likely to report being disillusioned regarding racial progress relative to Black Americans in other regions of the U.S. (Stewart, 2018).

Our study findings have implications for research on the Black-White mental health paradox, revealing that evidence of the “paradox” varies across regional contexts. These findings highlight the importance of examining specific locales as opposed to solely focusing on nationallevel estimates of psychiatric disorders. Such locale-specific nuances should be assessed with greater granularity in future research, for instance, focusing on specific states and metropolitan areas within states.

The findings should be considered in the context of the study limitations. First, U.S. regions are large and heterogeneous; thus, granular spatial measures are necessary to better understand additional nuances like smaller divisions within regions (e.g., the West being divided into “Mountain” and “Pacific”; e.g., see Plaut et al., 2002) as well as urban versus rural spaces and state-level distinctions (Lipari et al., 2017). Moreover, some individuals move to different regions across their life course for educational, professional, and/or familial reasons. For instance, a recent study demonstrated that movement across regions is a dynamic process that differentially impacts the mental health of African Americans who remained in the South compared to those who moved to other regions (Vu et al., 2024). Future research should capture the dynamism of regional movement regarding the Black-White mental health paradox. Second, there are ongoing conversations in the literature regarding the validity of DSM diagnostic measures to capture mental illness among Black Americans (Pamplin and Bates, 2021; Brown, 2003, 2008; Walton and Shepard Payne, 2016). Because the DSM nosology was established based on White populations, the possibility remains that our current diagnostic system is not attuned to culturally relevant manifestations of mental illness in diverse populations in general and among Black Americans specifically. For instance, race-based traumatic stress could operate in distinct ways for Black Americans that would not be captured by mainstream psychiatric diagnostic assessments (Bell et al., 2008). To address the “monocultural ethnocentrism” of current diagnostic categories, some scholars call for norming structured diagnostic tools for different racial and other culturally distinct groups (Bell et al., 2008, p.36). Alternatively, high levels of stigma in some African American communities may also stifle some respondents from reporting mental health challenges at all in the context of a survey (Campbell and Mowbray, 2016). Furthermore, other measures of mental illness such as personality disorders (Gibbs et al., 2013) and suicidal attempt or ideation (Joe et al., 2006) should be considered in future research. Third, the NCS-R and NSAL data were collected 20 years ago. Many societal-level changes have occurred over the past 20 years including the rise of technological innovations like social media and smart phones as well as important sociopolitical events such as the Black Lives Matter Movement, the Obama and Trump presidencies, and a global pandemic. These societal-level changes likely influenced mental health in nuanced ways that we were unable to capture in this study. Nevertheless, NCS-R and NSAL remain useful and authoritative “gold standard” psychiatric epidemiological surveys for questions pertaining to mental health among a nationally representative survey of U.S. Black and White adults (Chatters et al., 2023). Future research should assess these associations using more recently collected data to account for recent contemporary societal shifts and major sociopolitical events.

Despite these limitations, this study leverages nationally representative psychiatric epidemiological data to provide novel findings regarding the Black-White mental health paradox. Specifically, this study suggests that region is a critical socio-spatial demographic factor that should be considered when attempting to assess the magnitude of Black Americans’ mental health advantage vis-à-vis their White counterparts. Moreover, our findings suggest that evidence of the paradox is weak to non-existent in some regions (e.g., Midwest) and racial patterns are contingent upon the mental disorder type under investigation.

Data availability

The dataset is available to member institutions of the Inter-university Consortium for Political and Social Research, available on https://www.icpsr.umich.edu/web/ICPSR/studies/20240.