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. Author manuscript; available in PMC: 2014 Dec 1.
Published in final edited form as: Med Care. 2013 Dec;51(12):1114–1123. doi: 10.1097/MLR.0000000000000007

Prevalence, Risk, and Correlates of Posttraumatic Stress Disorder across Ethnic and Racial Minority Groups in the U.S

Margarita Alegría 1, Lisa R Fortuna 2, Julia Y Lin 3, L Frances Norris 4, Shan Gao 5, David T Takeuchi 6, James S Jackson 7, Patrick E Shrout 8, Anne Valentine 9
PMCID: PMC3922129  NIHMSID: NIHMS542329  PMID: 24226308

Abstract

Objectives

We assess whether posttraumatic stress disorder (PTSD) varies in prevalence, diagnostic criteria endorsement, and type and frequency of traumatic events (PTEs) among a nationally representative U.S. sample of 5071 non-Latino whites, 3264 Latinos, 2178 Asians, 4249 African Americans, and 1476 Afro-Caribbeans.

Methods

PTSD and other psychiatric disorders were evaluated using the World Mental Health-Composite International Diagnostic Interview (WMH-CIDI) in a national household sample that oversampled ethnic/racial minorities (n=16,238) but was weighted to produce results representative of the general population.

Results

Asians have lower prevalence rates of probable lifetime PTSD while African Americans have higher rates as compared to non-Latino whites, even after adjusting for type and number of exposures to traumatic events, and for sociodemographic, clinical and social support factors. Afro-Caribbeans and Latinos seem to demonstrate similar risk to non-Latino whites, adjusting for these same covariates. Higher rates of probable PTSD exhibited by African Americans and lower rates for Asians, as compared to non-Latino whites, do not appear related to differential symptom endorsement, differences in risk or protective factors or differences in types and frequencies of PTEs across groups.

Conclusions

There appears to be marked differences in conditional risk of probable PTSD across ethnic/racial groups. Questions remain about what explains risk of probable PTSD. Several factors that might account for these differences are discussed as well as the clinical implications of our findings. Uncertainty of the PTSD diagnostic assessment for Latinos and Asians requires further evaluation.

Keywords: Posttraumatic Stress Disorders across racial and ethnic minority groups, diagnosis

INTRODUCTION

Lifetime prevalence rates of posttraumatic stress disorder (PTSD) in the U.S. population range between 6.8 and 12.3 percent,1 with several studies reporting marked ethnic/racial differences.2–4 Some evidence points to higher rates of lifetime prevalence of PTSD among African Americans (8.7%) compared to non-Latino whites (7.4%) or Asians (4.0%).5 Other findings suggest either no difference in prevalence rates between African Americans, Latinos and non-Latino whites7 or only a weak link between race/ethnicity and risk of PTSD.8

Even when ethnic/racial differences in PTSD are found, they are not well understood. While African Americans report lower rates of exposure to traumatic events than non-Latino whites, their risk of developing PTSD following trauma exposure is higher after adjusting for gender, age and type of exposure.5 Conditional risks for PTSD are also reported as higher among Latinos than non-Latino whites,6 while Asians report lower risk for PTSD after exposure. Prevalence rates could also vary among ethnic/racial groups that experience traumatic events but fail to report intense fear, helplessness or horror. Differential receipt of social support from family or friends, a buffer for developing PTSD,12 can also vary across race/ethnicity. Additionally, there is evidence that less acculturated individuals report higher levels of PTSD symptoms13,14 than more acculturated individuals. As a result, inconsistent findings may result from differences in the type and frequency of traumatic exposure,9 differences in underlying risk (e.g., childhood psychiatric illness),5 or protective factors (e.g., higher education,5 nativity13,14 or greater social support),10 and/or differential reactions to traumatic events, as ascertained by symptom endorsement.11

Reconciling disparate findings is challenging as most prevalence studies use regional rather than national samples, employ varied methods and adjust for diverse risks and protective factors. To date, Roberts and colleagues’ study 5 is the only one using a nationally representative sample. We build upon this work using the Collaborative Psychiatric Epidemiology Surveys (CPES) to test: 1) whether there are differences in risk and protective factors as well as in PTSD prevalence across major ethnic/racial groups; 2) if so, whether these differences appear associated with variations in type of trauma or in patterns of symptom endorsement; and 3) whether these differences remain when adjusted for sociodemographic factors (education, nativity), clinical factors (psychiatric illnesses), support factors (family and friend support), type and number of traumatic exposures, and for variations in symptom endorsement.

METHODS

Data

We used the CPES pooled dataset of the National Latino and Asian American Study (NLAAS),15 the National Comorbidity Survey Replication (NCS-R)16 and the National Survey of American Life (NSAL).17 The studies, conducted between 2001 and 2003, all share a common sampling strategy,18 allowing the data to be treated as coming from a single, nationally-representative study.19 The sampling weights are inversely proportional to the selection probabilities and are used in survey analysis for population level inferences. The data represent residents (≥18 years) in the non-institutionalized population of the contiguous U.S. It includes 5,071 non-Latino whites, 3,264 Latinos, 2,178 Asians, 4,249 African Americans, and 1,476 Afro-Caribbeans (16,238 total sample). The standard errors of the estimates take into account the complex sample design. The sample was drawn as household clusters and weighted to represent the nation, thus the precision of prevalence estimates is less than that generated by simple random sampling. One way to appreciate these design effects is to calculate the effective sample size (of independent observations) that would give the same precision for estimating lifetime PTSD prevalence rates. These are 2,775 for non-Latino whites, 2,917 for Latinos, 899 for Asians, 3,491 for African Americans, and 378 for Afro-Caribbeans.

Weighted response rates from the NLAAS (with interviews conducted in English, Spanish, Mandarin, Tagalog and Vietnamese) were 75.5% for Latinos and 65.6% for Asians.19 Response rate in the NCS-R for all groups was 70.9%. In the NSAL the response rate was 70.9% for African Americans and 77.7% for Afro-Caribbeans.17

Written informed consent was obtained from all participants and study methods were approved by the Institutional Review Boards at the principal investigators’ institutions.

Measures

PTSD and Other Psychiatric Disorders

Using DSM-IV criteria, PTSD and other psychiatric disorders were assessed using the World Mental Health Composite International Diagnostic Interview (WMH-CIDI), administered by trained lay interviewers. DSM-IV criteria define PTSD as a psychiatric syndrome resulting from trauma exposure (Criterion A1) that resulted in intense fear, helplessness or horror at the time of exposure (Criterion A2) in addition to three groups of symptoms: 1) re-experiencing of the trauma (Criterion B); 2) avoidance of activities reminiscent of exposure and/or emotional numbing (Criterion C); and 3) hyperarousal (Criterion D). Further, symptoms must last at least one month (Criterion E) and result in distress and/or impairment (Criterion F). The CIDI asks about specific potentially traumatic events (PTEs), followed by questions on duration and severity of symptoms in each of the PTSD symptom clusters. The CIDI-PTSD module is dichotomously scored as meeting DSM-IV criteria or not.

We use the term “probable lifetime PTSD” for two reasons. First, to standardize PTSD across the three surveys, reported reactions were based only on the worst trauma event. This approach may slightly overestimate lifetime prevalence, but it provides a very similar prevalence estimate20 based on reactions to both worst event and random event exposure, in cases of more than one traumatic event. Second, for Latinos, the CIDI-PTSD performs well identifying PTSD negative cases (negative predictive value of 98.8% 21). However, when blinding clinician and respondent to previous answers on the CIDI and when asking about the same traumatic events in the Structured Clinical Interview (SCID), the CIDI for Latinos does not always identify the same PTSD positive cases (within the same individual) as the SCID. This pattern of denying previously reported traumatic events in a diagnostic re-interview has been observed in less acculturated immigrant and refugee populations, as a result of greater dissociative reactions to trauma.22 The CIDI-PTSD module has demonstrated fair to moderate concordance with the SCID (AUC = 0.6–0.7)23 and the Clinical Calibration study (AUC = 0.7–0.8).24 We contend that the CIDI provides a reasonable method for comparing populations25 in their probable risk of PTSD.

Factors Associated with the Traumatic Event

For each reported PTE, respondents were asked about the number of occurrences. The CIDI-PTSD assessment of lifetime occurrence of PTEs contains 27 items, including: 1) interpersonal violence (e.g., combat, rape, child abuse, residence in war zone); 2) other threats to the physical well-being of respondent (e.g., exposure to disaster, life-threatening illness/accident); 3) threats to the physical well-being of others (e.g., witness to violence, torture) and ; 4) open-ended questions (e.g., private events which respondent does not wish to discuss). The frequency of exposure for each of 11 types of PTEs in Table 2 were tallied and further coded into 0 (if the particular type of PTE was not reported), 1 or 2 or more. We also analyzed the number of PTEs as a continuous measure.

Table 2. Proportions of Persons Who Reported Potentially Traumatic Events in 11 Discrete Categories, and a Global Category of any Trauma by Race/Ethnicity in a US Sample.

(Age, gender, and education adjusted weight; with Benjamini-Hochberg multiple comparisons adjustment)1

Non-Latino White
Latino
Asian
African American
Afro-Caribbean
Total
n =5071
n =3264
n =2178
n =4249
n =1476
N =16238
% SE % SE vs. W6 % SE vs. W6 vs. L7 % SE vs. W6 vs. L7 vs. A8 % SE vs. W6 vs. L7 vs. A8 vs. AA9 % SE
Any Trauma 84.1 1.06 79.1 1.68 ** 70.6 1.60 *** *** 84.0 0.98 ** *** 83.5 1.88 *** 82.8 0.86
 Combat 5.6 0.56 4.0 0.58 6.2 0.74 8.9 0.56 *** *** 6.0 2.22 5.8 0.42
 Other Political Violence 11.3 0.54 15.8 0.98 *** 24.8 1.51 *** *** 10.8 0.70 *** *** 13.7 1.73 *** 12.5 0.41
 Victimization2 27.5 1.34 29.3 1.76 16.1 1.15 *** *** 29.1 1.22 *** 27.1 3.08 *** 27.4 1.01
 Personal Violence3 22.4 0.91 26.2 1.46 14.0 1.04 *** *** 29.3 1.30 *** *** 30.3 1.78 *** *** 23.3 0.68
 Other Personal Assault4 7.9 0.62 6.1 0.65 6.9 0.95 8.0 0.58 7.4 1.14 7.6 0.46
 Loss 47.7 1.39 38.7 1.31 *** 26.4 1.33 *** *** 51.9 1.23 *** *** 47.0 3.38 *** 46.0 1.04
 Witness Violence 36.9 1.02 37.9 1.68 27.8 1.64 *** *** 44.0 1.20 *** ** *** 40.2 2.36 *** 37.5 0.80
 Accident 27.1 1.09 24.4 1.20 16.4 1.26 *** *** 23.5 0.75 * *** 21.4 2.72 25.8 0.85
 Disaster 22.1 1.18 23.9 1.35 20.9 1.54 19.6 1.21 * 28.8 1.44 *** *** *** 22.0 0.88
 Illness 26.1 0.90 18.3 1.35 *** 11.9 0.79 *** *** 20.6 0.81 *** *** 17.6 2.60 * * 23.8 0.67
 Other Traumas5 13.6 0.82 11.8 0.89 8.5 1.18 ** 11.9 0.58 13.3 1.62 * 12.9 0.60
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*

p<.05,

**

p<.01,

***

p<.001 Indicate minority race/ethnic group different from non-Latino white reference group

1

Adjusted for age, gender, and education by weighting each group to represent the age, gender, education distribution of the 2000 census

2

Victimization: Includes child physical and/or sexual abuse; rape, domestic partner abuse; sexual molestation/assault (other than rape)

3

Personal Violence: Includes purposely, or accidentally, causing injury or death to another; torturing or killing another; physical assault by another (not including domestic violence)

4

Other Personal Assault: Includes mugging, held-up or threatened; kidnapped, held captive; or exposure to man-made disaster

5

Other Traumas: Include other traumatic exposure not otherwise assessed (e.g., private events which respondent does not wish to discuss)

6

Non-Latino White,

7

Latino,

8

Asian,

9

African American

Sociodemographic Factors

Race and ethnicity were obtained through self-report using U.S. Census categories: non-Latino white (reference in multivariate analyses because it is the largest), African American, Latino, Asian and Afro-Caribbean. Mixed race was 6%, so we assigned those cases to their self-selected primary category unless one of the designations was Latino, in which case we followed Census rules for assigning to the Latino category independent of race. A dummy variable was used to code for nativity (immigrant as reference). Age was coded using four categories. Gender was coded using a dummy variable (with male as reference). Marital status was classified as never married, or widowed/divorced/separated (married as reference). Education was based on number of years, and employment status was coded using three categories (employed as reference; unemployed and out of the labor force). Poverty level was based on the U.S. Census designation with above poverty level as reference. Region was determined based on state of residence and coded into four categories using U.S. Bureau of Labor criteria. Urbanicity was coded using county density (metro counties as reference).

Clinical Factors

PTSD risk increases if the respondent has other psychiatric disorders, so lifetime assessment of affective and/or substance use disorders were obtained from the CIDI. Retrospective dates of onset distinguished childhood (≤ 18 years) from adult onset of disorders.

Social Support Factors

We measured family and friend support using items selected from the Family and Friend Support Scales (α=0.58 and 0.69, respectively). Sample26 questions measure the frequency of talking on the phone or getting together with family or relatives, degree of reliance on relatives or friends for help, and discussion of worries. Both scales were transformed to range from 0–1 with higher scores indicating greater support.

Statistical Analyses

To tackle aim 1, we first tested whether there were differences in sociodemographic, clinical and social support factors as well as in adjusted rates of probable PTSD across the ethnic/racial groups. Significance tests for group differences in all described analyses were conducted using Rao–Scott statistics for the Pearson chi-squared test for survey studies,27,28 We used an α-level of .05 for all statistical analyses, but adjusted for multiple comparisons using Benjamini-Hochberg methods.29 We then evaluated whether there were differences in the exposure to PTEs (aim 2), after adjusting for age, gender and education differences by weighting the sample to make the ethnic/racial groups the same in age, gender, and education distributions. We proceeded to assess whether there was differential symptom endorsement of the worst event across ethnic/racial groups, using the same adjustments. The last statistical model addressing our third aim was a logistic regression fitting the log odds of a lifetime CIDI diagnosis of PTSD as a function of ethnic/racial group (Model 1) and then estimating if the differences remained after adjusting for sociodemographic, clinical and social support factors (Model 2). We adjusted for the type and frequency of traumatic events (Model 3), and for differential symptom endorsement by eliminating one criterion at a time from the diagnostic algorithm to appraise whether this would eliminate PTSD conditional risk differences. All descriptive and model-based analyses were conducted with STATA 10.1 statistical software28 using survey analysis methods to incorporate sampling weights19 and account for the complex survey design.

RESULTS

Differences in Sociodemographic, Clinical and Social Support Factors and in PTSD Prevalence

Table 1 shows that the racial/ethnic groups differ in many ways that might be associated with PTSD risk, including sociodemographic, clinical and social support factors. For example, Latinos, Asians and Afro-Caribbeans are more likely to be immigrants, while non-Latino whites are more likely to be above the poverty line. At the bottom of Table 1, we report the adjusted lifetime prevalence of probable PTSD. Most strikingly only 1.9% of Asians report lifetime PTSD, in contrast to 7.8% of African Americans, 6.9% of non-Latino whites, 6.3% of Afro-Caribbeans, and 4.6% of Latinos. The overall adjusted population estimate (6.4%) is similar to the overall lifetime PTSD prevalence reported for the NCS-R.22 After we adjusted for age, gender, and education, the 12-month prevalence of probable PTSD is lower for Asians (1.1%) than for all other groups and higher for African American, Afro-Caribbeans and non-Latino whites.

Table 1.

Distribution of Sociodemographic, Clinical, and Social Support Variables, and Adjusted Prevalence Rates Across Racial/Ethnic Groups in a US Sample

Variables Non-Latino White
Latino
Asian
African American
Afro-Caribbean
Total
n =5071
n =3264
n =2178
n =4249
n =1476
N =16238
% SE % SE vs. W3 % SE vs. W3 vs. L4 % SE vs. W3 vs. L4 vs. A5 % SE vs. W3 vs. L4 vs. A5 vs. AA6 % SE
Born in US *** *** *** *** *** *** *** * ***
 US-born 96.6 0.5 48.6 2.13 22.8 3.0 97.7 0.3 32.6 2.9 87.2 0.9
 Immigrant 3.4 0.5 51.4 2.13 77.2 3.0 2.3 0.3 67.4 2.9 12.8 0.9
Age Category *** *** ** *** *** ***
 18–34 years 27.8 1.3 48.5 1.51 39.6 1.6 36.3 1.3 40.7 1.7 31.8 1.0
 35–49 years 30.7 1.1 30.4 1.04 32.6 1.7 33.6 0.8 31.5 1.4 31.1 0.8
 50–65 years 22.8 1.2 13.4 0.81 17.9 1.2 18.6 0.9 17.0 1.3 21.0 0.9
 65+ years 18.7 1.1 7.7 0.84 9.9 1.6 11.6 0.7 10.8 2.4 16.2 0.8
Gender * * ** *** *
 Male 47.4 1.0 51.8 1.52 47.4 1.1 43.9 0.8 49.7 2.9 47.6 0.8
 Female 52.6 1.0 48.2 1.52 52.6 1.1 56.1 0.8 50.3 2.9 52.4 0.8
Marital *** *** *** *** *** *** *** *** *** *
 Married 54.3 1.4 51.1 1.6 65.3 1.9 32.1 1.1 37.4 2.6 51.9 1.1
 Never Married 22.4 1.4 30.6 1.3 25.2 1.4 38.4 1.3 39.1 2.1 25.3 1.1
 Widowed/Divorced/Separated 23.4 0.8 18.3 1.1 9.5 1.0 29.6 0.8 23.5 1.6 22.8 0.6
Education *** *** *** *** *** *** * *** *** ***
 11 years or less 13.2 1.0 42.6 1.7 14.7 1.4 24.0 1.1 20.1 1.8 18.0 0.8
 12 years 31.4 1.4 27.4 1.1 17.3 1.2 37.9 1.0 30.4 1.9 31.0 1.0
 13 – 15 years 28.6 1.0 19.8 1.1 25.3 1.4 24.3 0.9 27.3 3.3 27.0 0.7
 16 years or more 26.8 1.4 10.2 0.9 42.7 2.0 13.9 1.0 22.2 1.4 24.1 1.0
Employment ** *** *** *** *** *** ***
 Employed 66.0 1.0 64.2 1.7 65.0 1.4 65.9 1.0 76.0 1.5 65.8 0.7
 Unemployed 5.0 0.5 7.9 0.9 6.0 0.6 9.1 0.6 8.0 1.0 5.8 0.4
 Out of labor force 29.0 1.0 27.9 1.6 29.1 1.5 25.0 1.0 16.0 1.7 28.4 0.7
Region *** *** *** *** *** *** *** *** *** ***
 Northeast 21.4 3.7 15.5 1.3 15.3 3.4 15.8 0.9 56.9 5.3 20.1 2.7
 Midwest 26.5 2.3 9.1 1.7 8.8 1.9 18.6 1.7 4.2 1.1 22.6 1.6
 South 32.8 2.9 31.9 3.8 8.6 1.8 56.4 2.1 31.2 5.1 34.1 2.1
 West 19.3 2.6 43.5 3.6 67.3 4.1 9.1 0.8 7.8 1.9 23.2 1.9
Poverty *** *** *** *** *** *** *** ***
 Above poverty 90.8 0.6 1.8 82.8 1.2 75.8 1.2 85.6 1.5 86.8 0.6
 Below poverty 9.2 0.6 25.9 1.8 17.2 1.2 24.2 1.2 14.4 1.5 13.2 0.6
Urbanicity ** *** * ** *** *** *** ***
 Non-metro counties 25.8 6.5 8.1 3.6 3.4 1.6 12.5 2.4 0.0 . 21.1 5.0
 Metro counties 74.2 6.5 91.9 3.6 96.6 1.6 87.5 2.4 100.0 . 78.9 5.0
Other Lifetime dx
 Affective dx 21.1 0.8 15.5 0.6 *** 9.9 1.0 *** *** 12.3 0.6 *** *** * 13.9 2.2 ** 18.9 0.6
 Substance dx 14.8 0.7 12.4 1.2 4.2 0.6 *** *** 11.4 0.6 *** *** 8.9 2.5 * 13.6 0.5
Childhood onset dx‡
 Affective dx 7.9 0.4 6.3 0.6 * 3.9 0.6 *** ** 4.0 0.3 *** *** 7.3 1.6 * * 7.1 0.3
 Substance dx 7.7 0.5 5.8 0.7 * 2.3 0.5 *** *** 4.2 0.4 *** * ** 6.3 2.4 * 6.8 0.4
Family Support
 Mean(SE) 0.69 0.0 0.65 0.0 *** 0.59 0.0 *** *** 0.66 0.0 *** *** 0.65 0.0 *** *** 0.68 0.0
Friend Support
 Mean(SE) 0.69 0.0 0.54 0.0 *** 0.57 0.0 *** * 0.65 0.0 *** *** *** 0.67 0.0 *** *** 0.66 0.0
Adjusted PTSD1,2
 Lifetime prevalence- worst event 6.9 0.5 4.6 0.6 * 1.9 0.5 *** ** 7.8 0.5 *** *** 6.3 1.1 *** 6.4 0.4
 12-month prevalence-worst event 2.8 0.3 2.5 0.4 1.1 0.4 * * 3.1 0.3 ** *** 3.1 0.9 ** 2.7 0.2
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*

p < .05,

**

p < .01,

***

p < .001 indicate race/ethnic group difference

‡

onset at age 18 or prior

1

Applied Benjamini-Hochberg adjustment to control for inflated type 1 error

2

Adjusted for age, gender, and education by weighting each group to represent the age,

3

Non-Latino White,

4

Latino,

5

Asian,

6

African American

Types of Traumatic Exposures after Adjustments

We next examined the proportions of persons in each ethnic/racial group who reported PTEs in 11 discrete categories, as well as a global category of any trauma (Table 2). Fewer Asian reported any PTEs (70.6%) than non-Latino whites (84.1%), African Americans (84.0%), Afro-Caribbeans (83.5%) or Latinos (79.1%), after age, gender, and education adjustment. Latinos also reported significantly lower exposure (79.1%) than non-Latino whites. In contrast, African Americans and Afro-Caribbeans were similar to the non-Latino whites (84.0% and 83.5% respectively).

The pattern was complicated when the specific traumas were considered. Larger proportions of Asians reported exposure to political violence than any of the other ethnic/racial groups. Although African Americans and Afro-Caribbeans had similar rates of exposure to any trauma as non-Latino whites, they reported significantly higher rates of exposure to personal violence. Similarly, African Americans were more likely to have witnessed violence than non-Latino whites, Latinos and Asians.

PTSD Diagnostic Criteria in Reaction to Worst Event

To determine if the differences in prevalence were due to differences in types of traumatic exposure, we examined the proportion of persons with reported trauma exposure who met criteria for PTSD criteria other than A, Part 1 (exposure). These adjusted proportions are displayed in Table 3. Compared to all other groups, Asians were less likely to meet all criteria for PTSD except for an intense response to the worst trauma endorsed (Criterion A, Part 2). Latino participants were less likely than non-Latino whites to report PTSD symptoms that extended beyond one month (Criterion E). African Americans and Afro-Caribbeans were more likely than all other groups to meet all criteria, with the exception that Afro-Caribbeans were similar to non-Latino whites and Latinos in rates of dysfunction reported following traumatic exposure (Table 3, Criterion F).

Table 3. PTSD Diagnostic Criteria Associated with Worst Event by Race/Ethnicity Among Those Exposed to Any Trauma in a US Sample.

(Adjusted for age, gender, and education; with Bejamini-Hochberg multiple comparisons adjustment)

Criteria Non-Latino White
Latino
Asian
African American
Afro-Caribbean
Total
n = 3654
n = 2611
n = 1588
n =3447
n =1173
N =12473
n % SE n % SE vs W1 n % SE vs W1 vs L2 n % SE vs W1 vs L2 vs A3 n % SE vs W1 vs L2 vs A3 vs AA4 n % SE
Criteria A Part 1: Trauma Exposed 3654 100.0 0.00 2611 100.0 0.00 1588 100.0 0.00 3447 100.0 0.00 1173 100.0 0.00 12473 100.0 0.00
Criteria A Part 2: Intense fear, helplessness, or horror 1105 28.1 1.20 714 27.2 1.53 376 24.7 1.39 1344 37.3 0.84 *** *** *** 451 36.9 2.08 *** *** *** 3990 29.0 0.87
Criteria B: Re- experiencing of event, recurrent recollections and distress 619 12.7 0.62 373 12.5 1.13 92 6.5 0.84 *** *** 955 24.6 0.85 *** *** *** 336 27.4 1.56 *** *** *** 2375 13.9 0.47
Criteria C: Persistent avoidance of stimuli associated with trauma and numbing of general responsiveness 603 12.2 0.67 342 11.5 1.19 94 6.4 0.76 *** *** 851 21.7 0.73 *** *** *** 269 21.4 1.87 *** *** *** 2159 13.0 0.50
Criteria D: Persistent Hyperarousal 602 12.2 0.59 329 10.9 1.13 87 6.1 0.94 *** *** 845 21.6 0.76 *** *** *** 270 22.6 1.64 *** *** *** 2133 13.0 0.46
Criteria E: Symptoms > 1 Month 552 11.2 0.61 284 9.0 0.77 * 65 4.1 0.71 *** *** 704 18.2 0.75 *** *** *** 219 18.7 1.50 *** *** *** 1824 11.5 0.45
Criteria F: Cause clinically significant distress or impairment in areas of functioning 530 11.0 0.61 266 8.7 1.00 65 4.7 0.77 *** *** 554 13.6 0.71 * *** *** 151 12.0 1.89 *** 1566 10.8 0.48
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*

p < .05,

**

p < .01,

***

p < .001 indicate minority race/ethnic group different from non-Latino White reference group

1

Non-Latino White,

2

Latino,

3

Asian,

4

African American

Because reactivity to traumatic exposure may depend upon type of event experienced, we examined rates of criteria endorsement stratified on trauma types (data available from authors). Criterion A, Part 2 was the only criterion consistently observed to be higher in African Americans compared to non-Latino whites in almost all prevalent trauma types examined.

Group Comparisons after Adjustments for Differences

The baseline model of Table 4 (Model 1) shows that Latinos (OR=0.67, 95% CI=0.52–0.86) and Asians (OR=0.28, 95% CI=0.17–0.47) have lower odds of a lifetime probable PTSD while African Americans have higher odds (OR=1.33, 95% CI=1.07–1.64) than non-Latino whites. The reduced odds observed for Asians persist after adjusting for sociodemographic, clinical and social support factors identified as risk or protective factors30 (Model 2) and also factors associated with the number and frequency of traumatic events (Model 3; OR= 0.54, 95% CI=0.30–0.96). Rather than reducing the risk differential for African Americans, adjustment for sociodemographic, clinical and social support factors increase the difference between African Americans and non-Latino whites relative to the baseline model (Model 2; OR=1.71, 95% CI=1.32, 2.21). Once we adjust for event type and frequency, it slightly reduces the differences but African Americans still remain significantly higher (Model 3; OR=1.50, 95% CI=1.13–1.99). In sensitivity analyses, we used a continuous variable for frequency of PTEs and found the same results (data available from authors). In addition, we used logistic regression models where we took out one criteria at a time (A2, B, C, D, E and F) from the diagnostic algorithms to evaluate whether differential symptoms endorsement could account for ethnic/racial differences in PTSD risk (data not shown), and found that it did not explain the higher conditional PTSD risk for African Americans or the lower risk for Asians as compared to non-Latino whites. An identical pattern of results was obtained using an alternate analysis in which time to the first documented episode of PTSD (using retrospective reports of age of PTSD onset) was the outcome and covariates were entered into a Cox proportional hazards model (OR=0.50, 95% CI=0.32, 0.80 for Asian and OR=1.29, 95% CI=1.04, 1.60 for African American; data not shown).

Table 4.

Relation of Probable PTSD to Race/Ethnicity (Model 1), with Adjustments for Demographic, Clinical, and Social Support Variables (Model 2), and for Additional Adjustments for Type and Frequency of Traumatic Events (Model 3) in Logistic Regression Models in a US Sample

Lifetime PTSD vs. no lifetime PTSD
N =16238
Model 1
Model 2
Model 3
OR 95% CI OR 95% CI OR 95% CI
Race/Ethnicity
 Non-Latino White 1 1 1
 Latino 0.67 (0.52 – 0.86)** 0.79 (0.59 – 1.07) 0.76 (0.54 – 1.07)
 Asian 0.28 (0.17 – 0.47)*** 0.45 (0.27 – 0.77)** 0.54 (0.30 – 0.96)*
 African American 1.33 (1.07 – 1.64)** 1.71 (1.32 – 2.21)*** 1.5 (1.13 – 1.99)**
 Afro-Caribbean 1 (0.64 – 1.57) 1.45 (0.81 – 2.59) 1.26 (0.65 – 2.44)
Nativity
 US-born 1 1
 Immigrant 0.7 (0.52 – 0.94)* 0.87 (0.61 – 1.24)
Age Category
 18–34 years 1 1
 35–49 years 0.95 (0.71 – 1.28) 0.93 (0.69 – 1.27)
 50–65 years 0.92 (0.71 – 1.20) 0.88 (0.66 – 1.17)
 65+ years 0.22 (0.14 – 0.35)*** 0.28 (0.17 – 0.47)***
Gender
 Male 1 1
 Female 2.88 (2.43 – 3.43)*** 2.46 (1.94 – 3.12)***
Marital
 Married 1 1
 Never Married 0.86 (0.61 – 1.20) 1 (0.71 – 1.39)
 Widowed/Divorced/Separated 1.6 (1.26 – 2.05)*** 1.38 (1.09 – 1.75)**
Education
 11 years or less 1 1
 12 years 0.69 (0.55 – 0.88)** 0.68 (0.54 – 0.86)**
 13 – 15 years 0.84 (0.67 – 1.06) 0.79 (0.62 – 1.02)
 16 years or more 0.97 (0.71 – 1.32) 1 (0.76 – 1.32)
Employment
 Employed 1 1
 Unemployed 0.75 (0.53 – 1.05) 0.72 (0.50 – 1.02)
 Out of labor force 1.49 (1.22 – 1.81)*** 1.44 (1.17 – 1.76)***
Region
 Northeast 1 1
 Midwest 0.86 (0.56 – 1.34) 1.02 (0.69 – 1.52)
 South 0.81 (0.59 – 1.12) 1.01 (0.79 – 1.29)
 West 0.85 (0.61 – 1.17) 0.94 (0.70 – 1.25)
Poverty
 Above poverty 1 1
 Below poverty 1.07 (0.84 – 1.37) 1.04 (0.83 – 1.30)
Urbanicity
 Non-metro counties 1 1
 Metro counties 0.89 (0.71 –1.11) 0.85 (0.70 – 1.04)
Lifetime affective dx
 Negative 1 1
 Positive 3.51 (2.51 – 4.92)*** 2.71 (1.87 – 3.91)***
Lifetime substance dx
 Negative 1 1
 Positive 2.41 (1.80 – 3.24)*** 1.78 (1.33 – 2.37)***
Childhood onset affective dx
 Negative 1 1
 Positive 1.64 (1.20 – 2.26)** 1.41 (1.01 – 1.96)*
Childhood onset substance dx
 Negative 1 1
 Positive 1.01 (0.67 – 1.52) 1.05 (0.73 – 1.53)
Family support scale
 Continuous measure 0.53 (0.39 – 0.72)*** 0.77 (0.55 – 1.10)
Friend support scale
 Continuous measure 0.79 (0.55 – 1.12) 0.78 (0.55 – 1.09)
Combat
 0 1
 1 2.25 (1.16 – 4.37)*
 2 or more than 2 2.43 (1.24 – 4.79)*
Other Political Violence
 0 1
 1 0.79 (0.49 – 1.26)
 2 or more than 2 0.97 (0.70 – 1.34)
Victimization
 0 1
 1 1.82 (1.22 – 2.72)**
 2 or more than 2 3.52 (2.79 – 4.44)***
Personal Violence
 0 1
 1 1.74 (1.27 – 2.37)***
 2 or more than 2 1.27 (0.99 – 1.63)
Other Personal Assault
 0 1
 1 1.06 (0.64 – 1.77)
 2 or more than 2 1.46 (0.70 – 3.03)
Loss
 0 1
 1 1.52 (1.11 – 2.07)**
 2 or more than 2 1.45 (1.13 – 1.85)**
Witness Violence
 0 1
 1 1.38 (1.02 – 1.86)*
 2 or more than 2 1.18 (0.91 – 1.52)
Accident
 0 1
 1 1 (0.74 – 1.35)
 2 or more than 2 1.23 (0.96 – 1.57)
Disaster
 0 1
 1 0.99 (0.59 – 1.64)
 2 or more than 2 0.73 (0.53 – 0.99)*
Illness
 0 1
 1 1.14 (0.92 – 1.42)
 2 or more than 2 1.68 (1.23 – 2.30)**
Other
 0 1
 1 2.19 (1.76 – 2.73)***
 2 or more than 2 2.2 (1.37 – 3.53)**
Open in a new tab

Note: PTSD = Posttraumatic Stress Disorder

*

p < .05,

**

p < .01,

***

p < .001

DISCUSSION

In a nationally representative survey, we found that African Americans have higher, while Asians and Latinos have lower prevalence rates of probable lifetime PTSD, as compared to non-Latino whites. These differences remain for Asians and African Americans after adjustment for sociodemographic, clinical and social support factors. Results are consistent with Roberts and colleagues5 using a different data set, different diagnostic measures and an expanded set of covariates. Agreement across these studies with different instruments might be due to both studies using DSM-IV criteria for establishing probable PTSD in large national studies that considered similar adjustment factors.

Higher conditional risk of probable lifetime PTSD among African Americans and lower risk for Asians does not appear associated with differential reaction to traumatic events. Although certain PTE classes (e.g., combat) were more common among African Americans, adjusting for these differences did not eliminate their higher rates of probable PTSD. This finding is inconsistent with some findings of studies of combatants31 that finds higher PTSD rates for Latinos. This inconsistency might be explained by changes in the social and economic composition of volunteer forces, where determinants of enlistment are associated with accumulated social and economic disadvantage – particularly for Latinos.32 Greater cumulative exposure to trauma and disadvantage for minority enlistees rather than in the general Latino population might disproportionably put them at risk for PTSD in subsequent combat-linked events.

Political violence was more frequently reported by Latinos and Asians as compared to non-Latino whites. Yet, these same groups report lower rates of probable PTSD compared with non-Latino whites. This is surprising given the documented association of political violence with PTSD among immigrants.33 This could be linked to political violence being overrepresented among political dissidents, who are typically altruistic,34 may anticipate violence, and prepare for it psychologically. In addition, we did not find a higher overall rate of probable PTSD for Latinos, as previously reported.35 Because the NLAAS is weighted to represent the U.S. Latino non-institutionalized population, which is overwhelmingly Mexican, our findings may differ from previous studies that included predominantly Caribbean Latinos for which high rates of PTSD have been repeatedly documented.35–37

While statistical adjustments for type of traumatic event and frequency help us identify what might be associated with higher conditional risk of PTSD, the interpretation of traumatic experiences may be quite diverse in different ethnic/racial groups.38,39 Our analysis suggests that there are important questions about potential mechanisms for PTSD risk among racial/ethnic minorities that cannot be answered by our data. These mechanisms may involve environmental risk exposure (e.g., living in unsafe environments) or repeated discriminatory experiences40 and racial stigmatization5 that may predispose certain groups to neuroendocrine alterations and increase their PTSD risk.40 Both greater exposure to discrimination41 and unsafe environments are more likely observed for African Americans than non-Latino whites, but the absence of these data in our three studies preclude us from testing this hypothesis.

In contrast to findings for African Americans, Asians reported lower probable PTSD prevalence and less likelihood of endorsing all criteria except Criterion A2 (intense fear, helplessness or horror) for traumatic exposure. This is significant since occurrence of A2 symptoms is considered an indication of PTE severity and a predictor of future PTSD. Notably, our Asian sample consisted of more individuals with higher education,42 which may contribute to different results from regional studies.43 Although we adjusted for education, greater coping skills offered by education may facilitate better adjustments after traumatic events.44 Differences in disclosure of trauma in Asians may also explain these findings. Kinzie and colleagues22 reported difficulties diagnosing PTSD among Southeast Asian refugees, with only 46% of cases previously diagnosed being concordant with a diagnostic re-interview. The diagnostic criteria for PTSD may not fully capture how less acculturated Asian groups express reactions to traumatic exposures,36,45 or whether they experience greater dissociative reactions to trauma leading them to prospectively deny such events. Depressive symptoms that are highly comorbid with PTSD or somatization may also mask the presence of PTSD in Asians. Other reports46 call attention to the potential under detection of PTSD in Latinos given their likelihood to somatize and withhold information. In survey studies, the possibility of response bias in psychopathology assessments must be considered. Yet, one recent study47 of the PTSD Checklist-Civilian Version finds no differential item functioning for Spanish compared to English speakers; however, there has not been similar testing for Asian populations. The capacity of structured instruments like the CIDI to reliably reach accurate psychiatric diagnoses in some cultural groups requires further examination.48–50

Study Limitations

We were unable to examine variations in probable PTSD across sub-ethnic/racial categories (e.g., Vietnamese), because of limited sample size. Also, probable PTSD rates for African Americans could be even higher if the studies included incarcerated populations, which are disproportionately African American and Latino and known to have high rates of PTSD.50 Another important caveat is that results for both Afro-Caribbeans and Asians are limited by relatively small sample sizes. Subsequent studies of PTSD risk across racial/ethnic groups need to illuminate whether response bias can explain differential risk for PTSD.37

Clinical Implications

Although lifetime prevalence estimates are subject to methodological shortcomings, these data provide a useful measure of risk for probable PTSD with respect to the worst traumatic event, as they are more likely to be recalled than other life stressors.1 Patterns of results may be specific to the structured interview used; yet our results are similar to Roberts’,5 the only other available national study.

Clinicians should thoroughly screen for trauma exposure across ethnic/racial minorities and factors that might exacerbate risk for PTSD. This includes individual characteristics (i.e., out of the workforce), types of trauma (i.e., combat, victimization, personal assault, loss, illness) and likelihood of a lifetime affective or substance use disorder. Clinicians should also consider the different resources for addressing trauma consequences (i.e., available support). Without exploration of the patient’s interpretation of how traumatic experiences have affected him/her and the expectations about help after traumatic exposure, it might be difficult to understand differential risk for PTSD across ethnic/racial groups.

Acknowledgments

This work was supported by the National Institutes of Health (NIH) research grant National Latino and Asian American Study (NLAAS), #U01 MH62209, which was funded by the National Institute of Mental Health, as well as the Substance Abuse and Mental Health Services Administration/Center for Mental Health Services (SAMHSA/CMHS) and the Office of Behavioral and Social Sciences Research (OBSSR), and by the National Institute of Mental Health (NIMH) research grant Advanced Center for Mental Health Disparities, #1P50 MH073469.

Contributor Information

Margarita Alegría, Email: malegria@charesearch.org, Center for Multicultural Mental Health Research, Cambridge Health Alliance, Somerville, MA, and Harvard Medical School, Boston, MA, 120 Beacon St., 4th Floor, Somerville, MA 02143, Phone: (617) 503-8447, Fax: (617) 503-8430.

Lisa R. Fortuna, Email: Lisa.Fortuna@umassmed.edu, Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA, University of Massachusetts Medical School, Department of Psychiatry, Biotech1, Rm. 115, Worcester, MA 01655, Phone: (508)856-7842; Fax: (508)856 6426.

Julia Y. Lin, Email: Julia.Lin@va.gov, Cooperative Studies Program Coordinating Center, VA Palo Alto Healthcare System, Palo Alto, CA, Cooperative Studies Program Coordinating Center (151K), VA Palo Alto Healthcare System, 701 B. N. Shoreline Blvd., Mountain View, CA 94043-3208, Phone: (650)493-5000, option 1, then option 2 (for Menlo Park), ext. 27974; Fax: (650)852-3228.

L. Frances Norris, Email: fran.norris@dartmouth.edu, National Center for PTSD and Department of Psychiatry, Dartmouth Medical School, Hanover, NH, NCPTSD, VA Medical Center, 215 North Main Street, White River Junction VT 05009, Phone: (802)-296-5132; (Fax): 802-296-5135.

Shan Gao, Email: Shan_Gao@URMC.Rochester.edu, Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY, University of Rochester Medical Center, School of Medicine and Dentistry, 601 Elmwood Ave, Box 630, Rochester, NY 14642, Phone: (585)275-1651; Fax: (585) 295-9622.

David T. Takeuchi, Email: dt5@u.washington.edu, School of Social Work, University of Washington, Seattle, WA, University of Washington, 4101 15th Avenue, NE, Seattle, Washington 98105-6299, Phone: (206) 543-5133; Fax: (206) 221-3910.

James S. Jackson, Email: jamessj@umich.edu, Department of Psychology, University of Michigan, Ann Arbor, MI, Office of the Director, 426 Thompson Street, Ann Arbor, MI 48106, Phone: (734)763-2491; Fax: 734 764 3520.

Patrick E. Shrout, Email: pat.shrout@nyu.edu, Department of Psychology, New York University, NY, NY, Department of Psychology, New York University, 6 Washington Place, Room 455, New York, NY 10003, Phone: (212)-998-7895; Fax: (212)-995-4866.

Anne Valentine, Email: avalentine@charesearch.org, Center for Multicultural Mental Health Research, Cambridge Health Alliance and Harvard Medical School, 120 Beacon St., 4th Floor, Somerville, MA 02143, Phone: (617) 503-8451; Fax: (617) 503-8430.

References

  • 1.Kessler R, Andrews G, Colpe L, et al. Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychol Med. 2002;32(6):959–976. doi: 10.1017/s0033291702006074. [DOI] [PubMed] [Google Scholar]
  • 2.Breslau N, Kessler R, Chilcoat H, et al. Trauma and posttraumatic stress disorder in the community: The 1996 Detroit area survey of trauma. Arch Gen Psychiatry. 1998;55(7):626–632. doi: 10.1001/archpsyc.55.7.626. [DOI] [PubMed] [Google Scholar]
  • 3.Adams RE, Boscarino JA. Differences in mental health outcomes among whites, African Americans, and Hispanics following a community disaster. Psychiat. 2005;68(3):250–265. doi: 10.1521/psyc.2005.68.3.250. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Stephens KA, Sue S, Roy-Byrne P, et al. Ethnoracial variations in acute PTSD symptoms among hospitalized survivors of traumatic injury. J Trauma Stress. 2010;23(3):384–392. doi: 10.1002/jts.20534. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Roberts AL, Gilman SE, Breslau J, et al. Race/ethnic differences in exposure to traumatic events, development of post-traumatic stress disorder, and treatment-seeking for post-traumatic stress disorder in the United States. Psychol Med. 2011;41(1):71–83. doi: 10.1017/S0033291710000401. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Alcántara C, Casement MD, Lewis-Fernández R. Conditional risk for PTSD among Latinos: A systematic review of racial/ethnic differences and sociocultural explanations. Clin Psychol Rev. 2012;33(1):107–119. doi: 10.1016/j.cpr.2012.10.005. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Helzer JE, Robins LN, McEvoy L. Post-traumatic stress disorder in the general population. N Engl J Med. 1987;317(26):1630–1634. doi: 10.1056/NEJM198712243172604. [DOI] [PubMed] [Google Scholar]
  • 8.Brewin CR, Andrews B, Valentine JD. Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. J Consult Clin Psychol. 2000;68(5):748. doi: 10.1037//0022-006x.68.5.748. [DOI] [PubMed] [Google Scholar]
  • 9.Pole N, Gone JP, Kulkarni M. Posttraumatic stress disorder among ethnoracial minorities in the United States. Clin Psychol. 2008;15(1):35–61. [Google Scholar]
  • 10.Galea S, Vlahov D, Resnick H, et al. Trends of probable post-traumatic stress disorder in New York City after the September 11 terrorist attacks. Am J Epidemiol. 2003;158(6):514–524. doi: 10.1093/aje/kwg187. Epub 2003/09/11. [DOI] [PubMed] [Google Scholar]
  • 11.Galea S, Tracy M, Norris F, et al. Financial and social circumstances and the incidence and course of PTSD in Mississippi during the first two years after Hurricane Katrina. J Trauma Stress. 2008;21(4):357–368. doi: 10.1002/jts.20355. Epub 2008/08/23. [DOI] [PubMed] [Google Scholar]
  • 12.Fortuna L, Porche M, Alegría M. Political violence, psychosocial trauma, and the context of mental health services use among immigrant Latinos in the United States. Ethn Health. 2008;13(5):435–463. doi: 10.1080/13557850701837286. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Marshall GN, Orlando M. Acculturation and peritraumatic dissociation in young adult Latino survivors of community violence. J Abnorm Psychol. 2002;111(1):166–174. doi: 10.1037//0021-843x.111.1.166. [DOI] [PubMed] [Google Scholar]
  • 14.Lee C-S, Chang J-C, Liu C-Y, et al. Acculturation, psychiatric comorbidity and posttraumatic stress disorder in a Taiwanese aboriginal population. Soc Psychiatry Psychiatr Epidemiol. 2009;44(1):55–62. doi: 10.1007/s00127-008-0405-2. [DOI] [PubMed] [Google Scholar]
  • 15.Alegría M, Takeuchi D, Canino G, et al. Considering context, place and culture: The National Latino and Asian American Study. Int J Methods Psychiatr Res. 2004;13(4):208–220. doi: 10.1002/mpr.178. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Kessler R, Merikangas K. The National Comorbidity Survey Replication (NCS-R): Background and aims. Int J Methods Psychiatr Res. 2004;13:60–68. doi: 10.1002/mpr.166. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Neighbors H, Caldwell C, Williams D, et al. Race, ethnicity, and the use of services for mental disorders: Results from the National Survey of American Life (NSAL) Arch Gen Psychiatry. 2007;64:1–10. doi: 10.1001/archpsyc.64.4.485. [DOI] [PubMed] [Google Scholar]
  • 18.Heeringa S, Wagner J, Torres M, et al. Sample designs and sampling methods for the Collaborative Psychiatric Epidemiology Studies (CPES) Int J Methods Psychiatr Res. 2004;13(4):221–240. doi: 10.1002/mpr.179. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Heeringa S. National Institutes of Mental Health (NIMH) data set. Collaborative Psychiatric Epidemiology Survey Program (CPES): Integrated weights and sampling error codes for design-based analysis. 2007 Available from: http://www.icpsr.umich.edu/cocoon/cpes/using.xml?section=Weighting.
  • 20.Breslau N, Peterson E, Poisson L, et al. Estimating post-traumatic stress disorder in the community: lifetime perspective and the impact of typical traumatic events. Psychol Med. 2004;34(4):889–898. doi: 10.1017/s0033291703001612. [DOI] [PubMed] [Google Scholar]
  • 21.Alegría M, Shrout P, Torres M, et al. Lessons learned from the clinical reappraisal study of the Composite International Diagnostic Interview with Latinos. Int J Methods Psychiatr Res. 2009;18(2):84–95. doi: 10.1002/mpr.280. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Kinzie JD, Boehnlein JK, Leung PK, et al. The prevalence of posttraumatic stress disorder and its clinical significance among Southeast Asian refugees. Am J Psychiatry. 1990;147:913–917. doi: 10.1176/ajp.147.7.913. [DOI] [PubMed] [Google Scholar]
  • 23.Haro J, Arbabzadeh-Bouchez S, Brugha T, et al. Concordance of the Composite International Diagnostic Interview version 3.0 (CIDI 3.0) with standardized clinical assessments in the WHO World Mental Health Surveys. Int J Methods Psychiatr Res. 2006;15(4):167–180. doi: 10.1002/mpr.196. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24.Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593–602. doi: 10.1001/archpsyc.62.6.593. [DOI] [PubMed] [Google Scholar]
  • 25.de Vries GJ, Olff M. The lifetime prevalence of traumatic events and posttraumatic stress disorder in the Netherlands. J Trauma Stress. 2009;22(4):259–267. doi: 10.1002/jts.20429. [DOI] [PubMed] [Google Scholar]
  • 26.Mulvaney-Day N, Alegría M, Sribney W. Social cohesion, social support and health among Latinos in the United States. Soc Sci Med. 2007;64(2):477–495. doi: 10.1016/j.socscimed.2006.08.030. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Rao J, Scott A. On chi-squared tests for multiway contingency tables with cell proportions estimated from survey data. Ann Stat. 1984;12:46–60. [Google Scholar]
  • 28.StataCorp. Stata Corp Release 10. College Station, TX: StataCorp LP; 2007. [Google Scholar]
  • 29.Benjamini Y, Hochberg Y. Controlling the false discovery rate: a practical and powerful approach to multiple testing. J R Stat Soc Series B Stat Methodol. 1995;57(1):289–300. [Google Scholar]
  • 30.Keane TM, Marshall AD, Taft CT. Posttraumatic stress disorder: Etiology, epidemiology, and treatment outcome. Annu Rev Clin Psychol. 2006;2:161–197. doi: 10.1146/annurev.clinpsy.2.022305.095305. [DOI] [PubMed] [Google Scholar]
  • 31.Kulka RA, Schlenger WE, Fairbank JA, et al. Trauma and the Vietnam War Generation: Report of Findings from the National Vietnam Veterans Readjustment Study. Brunner Mazel; 1990. [Google Scholar]
  • 32.Nayback AM. Health disparities in military veterans with PTSD: Influential sociocultural factors. J Psychosoc Nurs Ment Health Serv. 2008;46(6):42–51. [PubMed] [Google Scholar]
  • 33.Eisenman D, Gelberg L, Liu H, et al. Mental health and health-related quality of life among adult Latino primary care patients living in the United States wtih previous exposure to political violence. JAMA. 2003;290(5):627–634. doi: 10.1001/jama.290.5.627. [DOI] [PubMed] [Google Scholar]
  • 34.Ailinger D, Dear MR, Holley-Wilcox P. Predictors of function among older Hispanic immigrants: A five-year follow-up. Nurs Res. 1993;42(4):240–244. [PubMed] [Google Scholar]
  • 35.Galea S, Vlahov D, Tracy M, et al. Hispanic ethnicity and post-traumatic stress disorder after a disaster: Evidence from a general population survey after September 11, 2001. Ann Epidemiol. 2004;14(8):520–531. doi: 10.1016/j.annepidem.2004.01.006. [DOI] [PubMed] [Google Scholar]
  • 36.Liu A, Tan H, Zhou J, et al. A short DSM-IV screening scale to detect posttraumatic stress disorder after a natural disaster in a Chinese population. Psychiatry Res. 2008;159(3):376–381. doi: 10.1016/j.psychres.2007.08.015. Epub 2008/05/09. [DOI] [PubMed] [Google Scholar]
  • 37.Pole N, Best S, Metzler T, et al. Why are Hispanics at greater risk for PTSD? Cultur Divers Ethnic Minor Psychol. 2005;11(2):144–161. doi: 10.1037/1099-9809.11.2.144. [DOI] [PubMed] [Google Scholar]
  • 38.Alim TN, Feder A, Graves RE, et al. Trauma, resilience, and recovery in a high-risk African-American population. Am J Psychiatry. 2008;165(12):1566–1575. doi: 10.1176/appi.ajp.2008.07121939. Epub 2008/11/19. [DOI] [PubMed] [Google Scholar]
  • 39.Cusack KJ, Grubaugh AL, Yim E, et al. Are there racial differences in the experience of harmful or traumatic events within psychiatric settings? Psychiatr Q. 2007;78(2):101–115. doi: 10.1007/s11126-006-9031-x. Epub 2007/03/09. [DOI] [PubMed] [Google Scholar]
  • 40.Cannon MS, Locke BZ. Being black is detrimental to one’s mental health: Myth or reality? Phylon (1960-) 1977;38(4):408–428. [Google Scholar]
  • 41.Williams DR, Neighbors HW, Jackson JS. Racial/ethnic discrimination and health: Findings from community studies. Am J Public Health. 2003;93:200–208. doi: 10.2105/ajph.93.2.200. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 42.Friedman MJ, Schnurr PP, Sengupta A, et al. The Hawaii Vietnam veterans project: Is minority status a risk factor for posttraumatic stress disorder? J Nerv Ment Dis. 2004;192(1):42. doi: 10.1097/01.nmd.0000105999.57129.ee. [DOI] [PubMed] [Google Scholar]
  • 43.deRoon-Cassini TA, Mancini AD, Rusch MD, et al. Psychopathology and resilience following traumatic injury: A latent growth mixture model analysis. Rehabil Psychol. 2010;55(1):1–11. doi: 10.1037/a0018601. [DOI] [PubMed] [Google Scholar]
  • 44.Okazaki S. Sources of ethnic differences between Asian American and white American college students on measures of depression and social anxiety. J Abnorm Psychol. 1997;106(1):52–60. doi: 10.1037//0021-843x.106.1.52. Epub 1997/02/01. [DOI] [PubMed] [Google Scholar]
  • 45.Lopez A, Boccellari A, Hall K. Posttraumatic stress disorder in a Central American refugee. Hosp Community Psychiatry. 1988;39(12):1309–1311. doi: 10.1176/ps.39.12.1309. [DOI] [PubMed] [Google Scholar]
  • 46.Miles JNV, Marshall GN, Schell TL. Spanish and English versions of the PTSD Checklist-Civilian version (PCL-C): Testing for differential item functioning. J Trauma Stress. 2008;21(4):369–376. doi: 10.1002/jts.20349. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 47.Villasenor Y, Waitzkin H. Limitations of a structured psychiatric diagnostic instrument in assessing somatization among Latino patients in primary care. Med Care. 1999;37(7):637–646. doi: 10.1097/00005650-199907000-00003. Epub 1999/07/29. [DOI] [PubMed] [Google Scholar]
  • 48.Alegría M, Canino G, Shrout P, et al. Prevalence of mental illness in immigrant and non-immigrant U.S. Latino groups. Am J Psychiatry. 2008;165:359–369. doi: 10.1176/appi.ajp.2007.07040704. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 49.Bourque LB, Shen H. Psychometric characteristics of Spanish and English versions of the civilian Mississippi scale. J Trauma Stress. 2005;18(6):719–728. doi: 10.1002/jts.20080. [DOI] [PubMed] [Google Scholar]
  • 50.Steadman HJ, Osher FC, Robbins PC, et al. Prevalence of serious mental illness among jail inmates. Psychiatr Serv. 2009;60(6):761–765. doi: 10.1176/ps.2009.60.6.761. [DOI] [PubMed] [Google Scholar]

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