Depression and Mood Disorder Among African American and White Women

To the Editor

We have critical concerns with the article by Weaver et al.¹ There were very few cases of major depressive disorder and mood disorder among focal subgroups (often <10). Misclassification of depression can thus have a disproportionate impact on estimates. Furthermore, age, education, household income, and marital status adjustment assumes there are, within the joint distributions of factors, at least some white and African American women with depression in all urbanicity subgroups. Mathematically, this is impossible, and basic positivity assumptions are not satisfied.

Regarding the urbanicity comparisons, rural white women had higher prevalence than their urban counterparts for just 2 of 4 outcomes; in the other 2, results were in a similar direction as those of African American women (although of less magnitude), with rural women having slightly lower prevalence. To infer distinct etiologies of mood disorders for white and African American women based on analyses in which half of the results are consistent across demographic groups is puzzling.

Finally, the national sample weights cannot be assumed to be appropriate for approximating regional-specific estimates, especially if weighting factors interact with exposures in association with depression.²

The authors speculated that increased risk for depression among rural white women may be owing to labor force pressure, multiple role strain, and traditional sex roles.¹ They implicitly assume that these same causal factors are less operative in African American women. Instead, they suggest that African American women disproportionately benefit from “resources and coping strategies” including religiosity, social ties, and reliance on grandmothers for care-giving. While these coping differences may be operative in some pathways (eg, religiosity is associated with lower depression risk, and the African American population has higher reported religiosity), these conclusions risk minimizing the role of structural, economic, and sex discrimination experienced by African American women, while potentially reifying stereotypes. Attempts to separate depression etiologies based on lived experiences of white and African American individuals are often fraught with problematic assumptions lacking empirical support. For example, the Weaver et al¹ conclusion is consistent with literature suggesting stressors affect African American mental health to a lesser extent than that of white individuals.³ We have^4,5 and will continue to refute such hypotheses based on poor conceptualization and contradictory empirical evidence. Existing theories do point to fruitful paths forward; for example, established experimental research on cognitive reappraisal and external attribution in the context of systematic marginalization and discrimination should, perhaps, be given more attention in epidemiology. Off-support analyses and ill-conceived conclusions move us back rather than forward.