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. Author manuscript; available in PMC: 2020 Oct 1.
Published in final edited form as: Psychol Med. 2018 Oct 31;49(13):2215–2226. doi: 10.1017/S0033291718003082

Racial/ethnic Variation in Trauma-Related Psychopathology in the United States: A Population-Based Study

Katie A McLaughlin 1, Kiara Alvarez 2, Mirko Fillbrunn 2, Jennifer Greif Green 3, James S Jackson 4, Ronald C Kessler 5, Ekaterina Sadikova 5, Nancy A Sampson 5, Corrie Vilsaint 2, David R Williams 6, Margarita Alegría 2
PMCID: PMC6494744  NIHMSID: NIHMS990917  PMID: 30378513

Abstract

Background:

The prevalence of lifetime mental disorders among Black, Latino, and Asian adults is consistently lower than among Whites in the U.S. Factors that explain these racial/ethnic differences are largely unknown. We examined whether differences in exposure to traumatic events (TEs) or vulnerability to trauma-related psychopathology across racial/ethnic groups explained the lower rates of psychopathology among racial/ethnic minorities.

Methods:

We estimated the prevalence of TE exposure and associations with onset of DSM-IV depression, anxiety and substance disorders and with lifetime PTSD in the Collaborative Psychiatric Epidemiology Surveys, a national sample with substantial proportions of Black, Latino, and Asian Americans (N=13,775).

Results:

TE exposure varied consistently across racial/ethnic groups. Asians were most likely to experience organized violence—particularly being a refugee—but had the lowest exposure to all other TEs. Blacks had the greatest exposure to participation in organized violence, sexual violence, and other TEs, Latinos had the highest exposure to physical violence, and Whites were most likely to experience accidents/injuries. Racial/ethnic minorities had lower odds of depression, anxiety, and substance disorder onset and lifetime PTSD relative to Whites. Neither variation in TE exposure nor vulnerability to psychopathology following TEs across racial/ethnic groups explained these differences, with one exception. Asians were less likely to develop PTSD following TEs than Whites.

Conclusions:

Lower prevalence of mental disorders among racial/ethnic minorities does not appear to reflect reduced vulnerability to TEs, with the exception of PTSD among Asians. This highlights the importance of investigating other potential mechanisms underlying racial/ethnic differences in psychopathology.

The prevalence of mental disorders varies widely as a function of race/ethnicity in the U.S. Numerous population-based studies have found lower lifetime prevalence of depression, anxiety, and substance disorders among Black, Latino, and Asian people than Whites (Breslau et al. 2005, 2006; Gilman et al. 2008). The factors that explain these racial/ethnic differences are largely unknown.

One possibility is that racial/ethnic minorities are less likely than Whites to develop psychopathology following experiences of adversity, such as traumatic events (TEs). Over two-thirds of U.S. adults have experienced a TE (Kessler et al. 1995; Roberts et al. 2011). TE exposure is strongly associated with virtually all commonly occurring forms of psychopathology (Kessler et al. 1995; Roberts et al. 2011; Walsh et al. 2017). Racial/ethnic differences in trauma-related psychopathology could arise due to variation in either exposure to TEs or vulnerability to developing psychopathology after a TE. With regard to the first possibility, trauma-related psychopathology is more common following certain TE types (e.g., interpersonal violence) than others (Kessler et al. 1995; Breslau et al. 1998), and differences in the prevalence of exposure to different types of TEs could contribute to variation in rates of psychopathology across racial/ethnic groups. Prior studies examining such variability have produced inconsistent findings (Kilpatrick & Acierno 2003; Hatch & Dohrenwend 2008). For example, some studies report higher rates of violence exposure among Whites than other groups, whereas others report higher rates of violence exposure among Blacks as compared to Whites; such discrepancies have been found even in studies conducted in the same city (Breslau et al. 1991, 1998; Norris 1992; Turner & Lloyd 2004). In a national sample, Whites were more likely than racial/ethnic minorities to experience any TE and TEs within their social networks. In contrast, Blacks and Hispanics had higher rates of exposure to violence, particularly child maltreatment and witnessing domestic violence; Blacks, Hispanics, and Asians had higher exposure to war-related TEs than Whites (Roberts et al. 2011). Although existing evidence consistently finds racial/ethnic differences in exposure to specific TE types, the pattern varies considerably across studies and few population-based studies assessing a wide range of TEs have been conducted.

Alternatively, racial/ethnic minorities might exhibit lower disorder prevalence rates because they are less vulnerable to developing psychopathology following TEs than Whites. Resilience to trauma may arise due to greater psychological preparedness to experience TEs among minority groups who routinely encounter discrimination, stigma, and structural oppression in the U.S. (Kessler et al. 1999; Williams et al. 2003; Hatzenbuehler et al. 2013; Lewis et al. 2015). Greater psychological preparedness has been shown to protect against psychopathology following TE exposure (Basoglu et al. 1997). Racial/ethnic differences in psychopathology following TEs have been studied primarily with regard to PTSD and findings are mixed. Some studies report no racial/ethnic differences in conditional risk of PTSD (i.e., risk of developing PTSD following exposure to a TE) among Blacks and Whites (Breslau et al. 1991; Norris 1992), and others observe higher conditional risk of PTSD among Blacks relative to Whites (Breslau et al. 1998; Roberts et al. 2011; Alegría et al. 2013). Multiple studies document lower conditional risk of PTSD among Asians than Whites after accounting for variability in exposure to different types of TEs across groups (Roberts et al. 2011; Alegría et al. 2013). Few studies have examined racial/ethnic differences in trauma-related psychopathology other than PTSD.

Here, we examine racial/ethnic differences in exposure to a wide range of TEs, associations of TEs with the subsequent onset of depression, anxiety, and substance disorders, and conditional risk of PTSD following TE exposure. We examine these associations using pooled data from three nationally representative samples of psychiatric disorders in the U.S. that include substantial proportions of Black, Latino, and Asian Americans. We predicted that Black, Latino, and Asians would be less likely than Whites to develop mental disorders, including PTSD, following exposure to TEs.

Methods

Sample

Participants were drawn from the Collaborative Psychiatric Epidemiology Studies (CPES) Dataset (N=13,775) (Heeringa et al. 2004). The CPES includes pooled data from three population-based surveys of mental disorders among U.S. household residents ages 18 and older: the National Comorbidity Survey-Replication (NCS-R) (Kessler & Merikangas 2004), the National Latino and Asian American Study (NLAAS) (Alegria et al. 2004), and the National Survey of American Life (NSAL) (Jackson et al. 2004). The NCS-R, NLAAS, and NSAL surveys were conducted in coordination between 2001 and 2003 to assess mental health among U.S. household residents from varying racial/ethnic groups. The NCS-R was based on a probability sample of English-speaking household residents without regard to race/ethnicity, and the NSAAL and NSAL were based on probability samples of households that over-sampled areas known to have high concentrations of African Americans, Caribbean Blacks, Asian Americans and Latinos. All surveys were based on multi-stage clustered area probability household samples that represent the household population of the contiguous U.S. These samples were merged to create a single, nationally-representative study using design-based analysis weights. The final merged sample was further adjusted for the residual differences between the sample and the U.S. household population on a range of socio-demographic and geographic characteristics. Details about the design of each survey and procedures for merging the samples can be found elsewhere (Alegria et al. 2004; Heeringa et al. 2004; Jackson et al. 2004; Kessler & Merikangas 2004; Pennell et al. 2004).

The NCS-R included 9,282 respondents (70.9% response rate). The survey was administered in two parts. Part I included a core diagnostic assessment, and Part II assessed correlates and additional disorders and was administered to all Part I respondents with a lifetime disorder and a probability subsample of other respondents (n=5,692). TEs were assessed in Part II, which is the focus of the current report. The Part II sample was weighted to adjust for differential selection probabilities of Part I respondents. The current analysis includes the 4,180 NCS-R participants who identified as White. The NLAAS included 2,554 Latino (75.5% response rate) and 2,095 Asian American (65.6% response rate) respondents and administered interviews in Spanish, Mandarin, Cantonese, Tagalog and Vietnamese in addition to English. The ethnic backgrounds of NLAAS participants included a wide range of countries in South Asia (e.g., India), East Asia (e.g., China, Japan, Korea), Southeast Asia (e.g., Vietnam), and the Pacific Islands (e.g., the Philippines). Non-Latino White respondents (n=183) were dropped from the NLAAS sample. The NSAL included 3,570 African Americans (70.7% response rate) and 1,621 Black respondents of Caribbean descent (77.7% response rate) and was conducted between February 2001 and March 2003. We excluded the Non-Hispanic Whites (n=1006; 72.3% response rate) from the NSAL sample. All interviews were conducted in English (Jackson et al., 2004). Respondents from each survey who reported their race/ethnicity as “Other” were dropped as this group was too small to allow statistical comparisons with other racial/ethnic groups. This resulted in a final sample of 13,775 respondents, consistent with prior work that pooled these three surveys (Molina et al. 2012). Recruitment, consent and field procedures were approved by the Human Subjects Committees of the University of Michigan, Harvard Medical School, Cambridge Health Alliance and the University of Washington. Informed consent was obtained before conducting surveys for all participants.

Race/ethnicity

Race/ethnicity was coded as Asian, Latino, Black and White using a hierarchical system. Respondents who reported being Asian were coded Asian regardless of any additional response provided. The same approach was used for remaining respondents who reported being Latino, then those who reported being Black. Remaining respondents were coded as White if they reported no other race or ethnicity.

Exposure to traumatic experiences

Respondents were asked about lifetime exposure to 27 different types of TEs and two open-ended questions about exposure to “any other” TE and to any “private” TE the respondent did not want to discuss. Positive responses were followed by probes to assess number of lifetime exposures and age at first exposure to each TE type. Exploratory factor analysis of these TEs in a large, cross-national sample (Liu et al. 2017) found 6 TE groups: 5 reflecting exposure to organized violence (e.g., civilian in a war zone, relief worker in a war zone, refugee); 5 related to participation in organized violence (e.g., combat experience, witnessed atrocities); 3 reflecting physical violence victimization (witnessed violence at home as a child; beaten by a caregiver as a child; victim of assault); 7 related to sexual violence (e.g., raped, sexually assaulted, beaten by a romantic partner); 6 involving accidents/injuries (e.g., natural disaster, toxic chemical exposure, motor vehicle accident); and 3 that were not strongly correlated with any other TEs (mugged or threatened with a weapon, manmade disaster other than chemical exposure, unexpected death of a loved one). TEs were classified into these 6 groups for all analyses.

Diagnostic assessment

DSM-IV mental disorders were assessed with the Composite International Diagnostic Interview (CIDI) (Kessler & Üstun 2004), a fully-structured interview administered by trained lay interviewers. We focus on disorders assessed in all CPES samples, including major depression, generalized anxiety disorder (GAD), social phobia, agoraphobia with or without panic disorder (hereafter referred to as agoraphobia), post-traumatic stress disorder (PTSD), and both alcohol and substance abuse with/without dependence. PTSD was assessed in relation to the lifetime TE the respondent identified as “worst” (i.e., as causing the most severe and persistent PTSD symptoms). As described elsewhere (Kessler et al. 2005), generally good concordance was found between diagnoses based on the CIDI and those based on blinded clinical reappraisal interviews with the Structured Clinical Interview for DSM-IV (SCID) (First et al. 2002).

Analysis Methods

Prevalence of TEs and disorders by race/ethnicity were examined using cross-tabulations. Associations of TE with disorder onset were estimated using discrete-time survival analysis with person-year as the unit of analysis (Singer & Willett 1993) for all outcomes except PTSD. We created a person-level file for each disorder. Data were censored at the year of first onset of the disorder or age of interview for those with no history of the focal disorder. TEs were examined as time-varying predictors (based on the 6 TE categories described above) coded 0 until the age of first exposure to a TE within the category and 1 for each year after that exposure. To evaluate whether racial/ethnic differences in disorder onset were explained by differences in TE exposure or variation in TE associations with disorder outcomes, we estimated three survival models for each disorder. The first model examined associations of race/ethnicity with disorder onset controlling for respondent age (18–29, 30–44, 45–59 and 60+), sex, and person-year. Model 2 added controls for TE types that were associated with the focal disorder to determine whether racial/ethnic variation in disorder onset was the result of differences in TE exposure. To identify relevant TE covariates, we first examined associations of the 6 TE categories with each focal disorder. TE categories unrelated to that disorder were not included in the final models. For TE categories associated with a particular disorder, we examined whether this association varied across TE types in that category. If the magnitude of association varied across TE types, only those TEs that were associated with the focal disorder were retained to avoid over-fitting the model. If all TEs in a category were associated with the disorder, a count of TEs in this category was used (see Supplemental Table 1 for details on specific TE covariates for each disorder). We estimated interactions between race/ethnicity and all TE variables that were retained in the model. If these interactions were significant as a set, we identified the specific interaction terms that were significant and ran stratified analyses examining TE-disorder onset associations separately within each racial/ethnic group. Model 3 examined Model 1 in the subset of respondents with no exposure to the TEs included in Model 2, with the assumption that racial/ethnic differences would be reduced among those with no TE exposure if lower vulnerability to trauma-related psychopathology occurred among racial/ethnic minorities relative to Whites. Because PTSD was assessed only in relation to the worst lifetime TE for the NSAL, associations of TEs with PTSD were examined using logistic regression rather than survival analysis. For PTSD, Model 1 examined race/ethnicity as a predictor adjusting for age and sex. Model 2 was estimated in the subset of participants who experienced a TE and controlled for age at first TE exposure. Model 3 additionally controlled for each respondent’s worst TE and examined racial/ethnic differences in the association of each TE type with PTSD.

Regression coefficients and standard errors were exponentiated and reported as ORs with 95% confidence intervals (CIs). Statistical significance was evaluated using .05-level two-sided tests based on the design-based Taylor series method (Wolter 1985) implemented in the SAS software system (SAS Institute Inc. 2008) to adjust for the weighting and clustering of observations.

Results

Lifetime Disorder Prevalence by Race/Ethnicity

Lifetime prevalence of all DSM-IV/CIDI disorders varied significantly as a function of race/ethnicity (Table 1). Lifetime prevalence was lowest among Asian respondents and highest among Whites for all disorders except PTSD, where prevalence was highest among Black respondents. As compared to Whites, Asian respondents had lower odds of all lifetime disorders (ORs=0.3–0.6), Latino respondents had lower odds of depression, GAD, social phobia, drug abuse/dependence, and PTSD (ORs=0.6–0.7), and Black respondents had lower odds of all disorders except PTSD (ORs=0.4–0.7).

Table 1.

Lifetime prevalence of DSM-IV/CIDI disorders by race/ethnicity (n = 13,775)

Diagnosis Asiana % (SE) Latinoa % (SE) Blacka % (SE) Whitea % (SE) Asian vs Whiteb
OR (95% CI)		 Latino vs Whiteb
OR (95% CI)		 Black vs Whiteb
OR (95% CI)		 F, p-value
Major Depressive Episode 8.98 (0.82) 15.20 (0.74) 10.15 (0.48) 20.73 (0.83) 0.45* (0.34,0.60) 0.73* (0.64,0.83) 0.43* (0.38,0.49) 58.16, p<.001
Generalized Anxiety Disorder 2.63 (0.32) 4.62 (0.50) 4.21 (0.42) 8.69 (0.52) 0.34* (0.24,0.47) 0.60* (0.44,0.80) 0.47* (0.36,0.60) 20.49, p<.001
Social Phobia 5.18 (0.57) 7.58 (0.71) 7.29 (0.48) 12.68 (0.49) 0.57* (0.37,0.86) 0.67* (0.54,0.83) 0.53* (0.43,0.64) 15.87, p<.001
Agoraphobia with/without Panic 2.44 (0.46) 5.53 (0.68) 4.89 (0.42) 6.21 (0.33) 0.43* (0.27,0.70) 0.79 (0.59,1.04) 0.74* (0.59,0.93) 5.64, p=.007
Alcohol abuse/dependence 3.60 (0.65) 10.80 (1.09) 9.29 (0.64) 13.38 (0.68) 0.33* (0.21,0.51) 0.82 (0.64,1.06) 0.66* (0.54,0.80) 12.33, p<.001
Drug abuse/dependence 2.21 (0.48) 6.07 (0.67) 6.04 (0.50) 7.94 (0.41) 0.39* (0.24,0.62) 0.72* (0.54,0.97) 0.68* (0.54,0.86) 7.56, p<.001
PTSD based on worst eventc 1.64 (0.44) 3.77 (0.51) 6.73 (0.40) 5.59 (0.53) 0.26* (0.14,0.46) 0.63*(0.45,0.88) 1.12 (0.90,1.39) 11.23, p<.001
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*

p ≤ .05

a

Prevalence estimates are reported at the person-level.

b

Models were estimated using discrete-time survival analysis (other than for PTSD) and controlled for person-year, age, and sex.

c

The PTSD model was estimated using logistic regression and controlled for age and sex.

Exposure to Traumatic Experiences by Race/Ethnicity

Lifetime prevalence of TE exposure varied by race/ethnicity for all 6 TE categories, although specific patterns varied across category (Figure 1, Table 2). Asian respondents had the lowest rate of TE exposure for all categories except exposure to organized violence where they had the highest lifetime prevalence (22.7%), followed by Latino (10.6%), White (7.0%) and Black (6.9%) respondents. Racial/ethnic variation in exposure to organized violence was driven largely by differences in the odds of being a refugee, which were higher for Asian, Latino, and Black respondents compared to Whites (ORs=2.9–75.0). Black respondents had the highest exposure to participation in organized violence (35.4% relative to 24.4–31.0% for other groups), sexual violence (37.4% relative to 23.0–36.8% for other groups), and the other TE category (58.4% relative to 31.9–52.4% for other groups). Higher odds of exposure to 4 of 10 TE types involving organized violence (ORs=1.2–2.9), 3 of 7 TEs involving sexual violence (ORs=1.2–1.4), and 1 of 3 Other TEs was observed among Black relative to White respondents. In contrast, Latino respondents had the highest rates of physical violence victimization (29.4% relative to 15.0–23.7% for other groups), with higher exposure to all 3 physical violence TE types relative to Whites (ORs=1.3–1.8). Whites were more likely to report accidents and injuries (53.4%) than other racial/ethnic groups (36.0–43.6%; ORs=1.12–1.38).

Figure 1.

Figure 1.

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Lifetime prevalence of traumatic experiences in the United States as a function of race/ethnicity (N=13,775).

Table 2.

Lifetime prevalence of traumatic experiences (TEs) by race/ethnicity (n = 13,775)

Traumatic Experience Types Asiana
% (SE)		 Latinoa
% (SE)		 Blacka
% (SE)		 Whitea
% (SE)		 Asian vs Whiteb
OR (95% CI)		 Latino vs Whiteb
OR (95% CI)		 Black vs Whiteb
OR (95% CI)		 F, p-value
Exposure to organized violence
 Relief worker in war zone 1.39 (0.20) 1.10 (0.27) 1.89 (0.23) 1.45 (0.28) 1.37 (0.46, 4.04) 0.92 (0.39, 2.14) 1.48 (0.86, 2.54) 0.94, p=.42
 Civilian in war zone 9.35 (0.88) 3.85 (0.46) 1.71 (0.25) 2.17 (0.33) 1.93 (1.00, 3.71) 0.98 (0.56, 1.70) 0.67 (0.40, 1.13) 2.38, p=.067
 Civilian in region of terror 8.02 (0.68) 5.12 (0.65) 3.11 (0.38) 2.63 (0.38) 0.96 (0.44, 2.10) 1.22 (0.71, 2.10) 0.98 (0.66, 1.45) 0.21, p=.89
 Refugee 12.37 (1.15) 3.84 (0.48) 0.93 (0.26) 0.53 (0.15) 74.95* (34.74, 161.71) 32.1* (15.02, 68.63) 2.89* (1.11, 7.56) 49.96, p<.001
 Kidnapped 2.38 (0.46) 1.36 (0.24) 1.51 (0.23) 1.41 (0.21) 0.78 (0.38, 1.61) 0.89 (0.50, 1.56) 1.01 (0.66, 1.54) 0.20, p=.90
 Any 22.71 (1.25) 10.60 (1.00) 6.91 (0.56) 6.95 (0.61) 2.59* (1.91, 3.52) 1.58* (1.21, 2.08) 1.07 (0.86, 1.33) 13.74, p<.001
Participation in organized violence
 Witnessed death/serious injury 21.93 (1.12) 27.14 (1.86) 32.21 (1.14) 27.75 (0.96) 0.59* (0.47, 0.74) 1.06 (0.89, 1.26) 1.24* (1.08, 1.42) 13.89, p<.001
 Accidentally caused injury/death 0.48 (0.16) 2.32 (0.37) 1.69 (0.27) 1.26 (0.15) 0.38 (0.12, 1.24) 2.33* (1.37, 3.95) 1.40 (0.87, 2.24) 5.04, p=.002
 Combat experience 3.55 (0.42) 2.84 (0.52) 6.25 (0.42) 5.11 (0.56) 0.83 (0.44, 1.54) 0.92 (0.53, 1.60) 1.62* (1.11, 2.36) 3.33, p=.019
 Purposely injured/tortured/killed 0.91 (0.25) 2.04 (0.32) 3.63 (0.41) 1.70 (0.22) 1.02 (0.47, 2.20) 1.42 (0.87, 2.33) 2.24* (1.47, 3.42) 4.95, p=.002
 Witnessing atrocities 3.78 (0.42) 2.86 (0.58) 5.27 (0.52) 6.10 (0.60) 0.52* (0.27, 1.00) 0.60 (0.35, 1.02) 0.96 (0.67, 1.38) 2.38, p=.068
 Any 24.42 (1.11) 28.95 (2.00) 35.41 (1.11) 30.98 (0.96) 0.60* (0.50, 0.71) 1.04 (0.89, 1.20) 1.27* (1.15, 1.41) 26.20, p<.001
Physical violence victimization
 Beaten up by someone else 4.94 (0.52) 8.84 (0.89) 5.80 (0.57) 6.82 (0.52) 0.70 (0.48, 1.03) 1.45* (1.06, 1.97) 0.83 (0.62, 1.11) 5.80, p<.001
 Witnessed physical fight at home 8.01 (0.76) 18.66 (0.98) 17.69 (0.85) 12.32 (0.83) 0.99 (0.7, 1.41) 1.81* (1.46, 2.25) 1.42* (1.19, 1.69) 11.47, p<.001
 Beaten up by caregiver 5.72 (0.60) 11.28 (0.64) 5.19 (0.51) 6.02 (0.29) 0.85 (0.56, 1.27) 1.34* (1.01, 1.78) 0.74* (0.57, 0.95) 4.44, p=.004
 Any 14.96 (0.93) 29.39 (1.27) 23.71 (0.86) 19.05 (1.02) 0.90 (0.75, 1.09) 1.58* (1.34, 1.87) 1.15 (0.99, 1.33) 17.84, p<.001
Sexual violence victimization
 Raped 2.96 (0.39) 6.68 (0.54) 10.06 (0.62) 8.38 (0.70) 0.41* (0.28, 0.59) 0.92 (0.71, 1.20) 1.05 (0.83, 1.34) 10.22, p<.001
 Sexually assaulted 7.98 (0.67) 8.85 (0.73) 12.63 (0.72) 12.36 (0.59) 0.73* (0.56, 0.97) 0.96 (0.77, 1.20) 0.93 (0.79, 1.09) 1.70, p=.17
 Stalked 5.37 (0.55) 7.82 (0.74) 12.75 (0.77) 9.49 (0.64) 0.53* (0.39, 0.73) 0.70* (0.54, 0.92) 1.24* (1.03, 1.51) 12.94, p<.001
 Beaten up by romantic partner 2.57 (0.52) 6.72 (0.72) 9.84 (0.63) 6.87 (0.82) 0.49* (0.29, 0.84) 1.17 (0.82, 1.66) 1.39* (1.06, 1.82) 7.17, p<.001
 Traumatic event to loved one 3.93 (0.64) 7.73 (0.54) 9.62 (0.60) 9.57 (0.73) 0.47* (0.31, 0.71) 0.74* (0.58, 0.95) 0.91 (0.73, 1.14) 5.07, p=.002
 Some other event 3.57 (0.60) 3.83 (0.41) 4.02 (0.32) 7.92 (0.54) 0.47* (0.26, 0.85) 0.52 (0.25, 1.09) 0.51* (0.32, 0.81) 4.02, p=.009
 Private event 6.43 (0.85) 7.71 (0.83) 8.15 (0.44) 6.49 (0.42) 1.48* (1.06, 2.07) 1.34* (1.01, 1.79) 1.26* (1.06, 1.49) 3.40, p=.017
 Any 22.97 (1.54) 29.74 (1.33) 37.36 (1.09) 36.79 (1.70) 0.56* (0.47, 0.68) 0.86 (0.74, 1.01) 1.09 (0.95, 1.24) 19.35, p<.001
Accidents/injuries
 Natural disaster 18.33 (1.15) 18.70 (1.10) 14.22 (1.08) 18.22 (1.05) 1.26 (0.98, 1.62) 0.96 (0.76, 1.22) 0.76* (0.61, 0.95) 4.67, p=.003
 Toxic chemical exposure 1.79 (0.38) 4.53 (0.46) 5.89 (0.48) 7.79 (0.50) 0.29* (0.16, 0.51) 0.64* (0.47, 0.88) 0.83 (0.65, 1.06) 6.55, p<.001
 Automobile accident 12.90 (0.73) 18.69 (0.76) 17.79 (0.50) 19.76 (1.11) 0.79* (0.62, 1.00) 1.08 (0.92, 1.26) 0.90 (0.78, 1.03) 4.21, p=.006
 Life-threatening illness 7.97 (0.68) 8.94 (0.72) 12.07 (0.54) 17.75 (0.76) 0.61* (0.47, 0.79) 0.68* (0.55, 0.84) 0.77* (0.67, 0.87) 8.91, p<.001
 Child with serious illness 4.09 (0.44) 7.17 (0.63) 9.92 (0.49) 12.33 (0.89) 0.40* (0.30, 0.54) 0.80 (0.60, 1.05) 0.91 (0.75, 1.10) 13.15, p<.001
 Other life threatening accident 4.20 (0.41) 7.13 (0.83) 6.23 (0.50) 10.27 (0.59) 0.48* (0.35, 0.66) 0.77 (0.56, 1.06) 0.62* (0.50, 0.78) 9.81, p<.001
 Any 36.01 (1.44) 43.57 (.98) 43.12 (1.13) 53.44 (1.51) 0.72* (0.65, 0.80) 0.88* (0.80, 0.97) 0.83* (0.75, 0.91) 15.29, p<.001
Other
 Mugged/threatened with a weapon 9.98 (0.80) 22.25 (1.38) 24.73 (1.19) 16.82 (0.61) 0.68* (0.54, 0.86) 1.39* (1.17, 1.65) 1.55* (1.33, 1.80) 20.94, p<.001
 Man-made disaster 3.86 (0.51) 3.92 (0.57) 6.40 (0.44) 6.59 (0.59) 0.57 (0.30, 1.07) 0.72 (0.48, 1.08) 1.05 (0.83, 1.32) 2.38, p=.068
 Unexpected death of loved one 23.61 (1.12) 34.41 (1.24) 47.45 (1.36) 43.32 (1.42) 0.54* (0.45, 0.64) 0.82* (0.71, 0.95) 1.10 (0.97, 1.24) 23.71, p<.001
 Any 31.89 (1.20) 46.71 (1.67) 58.38 (1.31) 52.36 (1.37) 0.64* (0.55, 0.73) 0.99 (0.90, 1.10) 1.19* (1.09, 1.30) 26.03, p<.001
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*

p ≤ .05

a

Prevalence estimates are reported at the person-level.

b

Models were estimated using discrete-time survival analysis predicting first onset of each TE type as a function of race/ethnicity and controlled for person-year, age, and sex.

Racial/Ethnic Differences in Disorder Onset

Lifetime disorder onset varied as a function of race/ethnicity for all disorders in models that did not adjust for TE exposure (Table 3). Asian and Black respondents had significantly lower odds of lifetime disorder onset as compared to Whites for all disorders examined (ORs=0.33–0.57 for Asians relative to Whites; ORs=0.43–0.74 for Blacks relative to Whites). Latino respondents had reduced odds of depression, GAD, and social phobia onset relative to Whites (ORs=0.60–0.73). These patterns were largely unchanged in Model 2, which included controls for exposure to TEs associated with onset of the focal disorder (see Supplemental Table 1 for details on TE variables for each disorder). With the addition of TE exposure to the model, both Asian (ORs=0.35–0.59) and Black (ORs=0.42–0.75) respondents continued to have reduced odds of onset for every disorder as compared to Whites, and Latinos had reduced odds of onset of all disorders other than agoraphobia (ORs=0.58–0.71). No interactions were observed between race/ethnicity and TEs in predicting disorder onset, with one exception. Race/ethnicity interacted with rape in predicting onset of alcohol abuse/dependence (F3,998.88=5.15, p=.002, see Table 4). To interpret this interaction, we examined the association of rape with onset of alcohol abuse/dependence relative to all other TEs included in Model 2 for alcohol use disorders. Inspection of the coefficients indicated that the reduced odds of alcohol abuse/dependence onset was even more pronounced following rape for Asian (OR=0.27), Latino (OR=0.47), and Black (OR=0.27) respondents as compared to Whites than following other TE types (ORs=0.36–0.79). In Model 3, which examined associations of race/ethnicity with disorder onset among respondents without lifetime exposure to the TE types included in Model 2, racial/ethnic differences were similar to the prior two models (Table 3). Asian respondents had significantly reduced odds of all disorders except agoraphobia (ORs=0.20–0.53), Black respondents had reduced odds of every disorder (ORs=0.32–0.68), and Latino respondents had lower odds of all but GAD and alcohol abuse/dependence (ORs=0.54–0.69) relative to Whites.

Table 3.

Racial/ethnic differences (ORs) in disorder onset and lifetime PTSD (n = 13,775)a

Model lb
OR (95% CI)e 		Model 2c
OR (95% CI)e 		Model 3d
OR (95% CI)e
Major Depressive Episode
 Asian 0.45* (0.34,0.60) 0.54* (0.41, 0.70) 0.34* (0.20, 0.59)
 Latino 0.73* (0.64, 0.83) 0.71* (0.62, 0.82) 0.65* (0.48, 0.89)
 Black 0.43* (0.38, 0.49) 0.42* (0.36, 0.47) 0.32* (0.25, 0.42)
 F, p-value 58.16, p<.001 59.55, p<.001 27.05, p<.001
GAD
 Asian 0.34* (0.24, 0.47) 0.42* (0.30, 0.58) 0.20* (0.09, 0.43)
 Latino 0.60* (0.44, 0.80) 0.58* (0.43, 0.79) 0.69 (0.43, 1.11)
 Black 0.47* (0.36,0.60) 0.46* (0.35, 0.59) 0.36* (0.21, 0.61)
 F, p-value 20.49, p<.001 17.54, p<.001 9.33, p<.001
Social Phobia
 Asian 0.57* (0.37, 0.86) 0.59* (0.39, 0.90) 0.53* (0.32, 0.86)
 Latino 0.67* (0.54, 0.83) 0.61* (0.49, 0.77) 0.64* (0.48, 0.84)
 Black 0.53* (0.43, 0.64) 0.51* (0.42, 0.63) 0.55* (0.44, 0.68)
 F, p-value 15.87, p<.001 16.61, p<.001 11.15, p<.001
Agoraphobia with/without Panic
 Asian 0.43* (0.27, 0.70) 0.50* (0.31, 0.80) 0.47 (0.22, 1.00)
 Latino 0.79 (0.59, 1.04) 0.76 (0.57, 1.02) 0.78 (0.51, 1.19)
 Black 0.74* (0.59, 0.93) 0.75* (0.60, 0.95) 0.68* (0.51, 0.92)
 F, p-value 5.64, p<.001 4.56, p=.003 3.03, p=.028
Alcohol abuse/dependence
 Asian 0.33* (0.21, 0.51) 0.35* (0.22, 0.55) 0.27* (0.15, 0.48)
 Latino 0.82 (0.64, 1.06) 0.71* (0.54, 0.93) 0.78 (0.55, 1.11)
 Black 0.66* (0.54, 0.80) 0.63* (0.52, 0.77) 0.66* (0.52, 0.84)
 F, p-value 12.33, p<.001 12.04, p<.001 8.57, p<.001
Drug abuse/dependence
 Asian 0.39* (0.24, 0.62) 0.43* (0.25, 0.72) 0.36* (0.18, 0.71)
 Latino 0.72* (0.54, 0.97) 0.61* (0.43, 0.87) 0.54* (0.29, 0.98)
 Black 0.68* (0.54, 0.86) 0.60* (0.46, 0.79) 0.58* (0.37, 0.90)
 F, p-value 7.56, p<.001 7.82, p<.001 4.68, p=.003
PTSD based on worst eventf,g,h
 Asian 0.26* (0.14, 0.46) 0.31* (0.17, 0.56) 0.40* (0.22, 0.74)
 Latino 0.63* (0.45, 0.88) 0.69* (0.49, 0.97) 0.75 (0.53, 1.07)
 Black 1.12 (0.90, 1.39) 1.16 (0.95, 1.43) 1.04 (0.84, 1.30)
 F, p-value 11.23, p<.001 9.15, p<.001 3.70, p=.013
Open in a new tab
*

p ≤ .05

a

Models for all disorders except PTSD were estimated in a discrete-time survival framework. Models for PTSD were estimated using logistic regression.

b

Model 1 adjusted for person-year, age, and sex for all disorders except PTSD (see footnote f for details on PTSD model).

c

Model 2 adjusted for person-year, age, sex, and TE variables that were significantly associated with the focal disorder (see Supplemental Table 1 for details on TE variables included for each disorder) for all disorders other than PTSD (see footnote g for details on PTSD model).

d

Model 3 was estimated in the subset of respondents who did not experience the TE variables associated with the focal disorder, and adjusted for person-year, age, sex for all disorders other than PTSD (see footnote h for details on PTSD model).

e

White respondents served as the reference group in all models.

f

For PTSD, Model 1 adjusted for age and sex and included all respondents, regardless of TE exposure.

g

For PTSD, Model 2 adjusted for age, sex, and age at exposure to worst TE and was estimated only among respondents with a lifetime TE.

h

For PTSD, Model 3 adjusted for age, sex, age at exposure to worst TE, and type of worst TE and was estimated only among respondents with a lifetime TE.

Table 4.

Interactions between race/ethnicity and TE types in predicting psychopathology (n = 13,775)

Asian % (SE) OR (95% CI)a Black % (SE) OR (95% CI)a Latino % (SE) OR (95% CI)a White % (SE) OR (95% CI) F
p-value
Alcohol
 Rapeb 2.01 (0.33)
0.27 (0.06, 1.33)		 7.76 (0.58)
0.47* (0.27, 0.83)		 5.37 (0.50)
0.27* (0.12, 0.60)		 5.32 (0.47)
--		 5.15
p=.002
 All other TEsb 97.99 (0.33)
0.36* (0.23, 0.56)		 92.24 (0.58)
0.66* (0.54, 0.81)		 94.63 (0.50)
0.79 (0.60, 1.03)		 94.68 (0.47)
--		 10.76
p<.001
PTSD
 Rape/sexual assaultc 3.61 (0.48)
0.52 (0.18, 1.49)		 6.23 (0.46)
0.94 (0.65, 1.36)		 3.81 (0.34)
0.63 (0.28, 1.40)		 6.65 (0.49)
--		 0.83
p=.48
 Private/undisclosed TEc 1.30 (0.32)
1.42 (0.41, 4.89)		 1.63 (0.26)
2.88* (1.25, 6.62)		 1.33 (0.32)
2.77 (0.76, 10.13)		 2.19 (0.27)
--		 2.31
p=.08
 All other TEsc 95.09 (0.64)
0.30* (0.16, 0.56)		 92.15 (0.50)
1.02 (0.80, 1.30)		 94.86 (0.44)
0.70 (0.46, 1.05)		 91.17 (0.56)
--		 11.42
p<.001
Open in a new tab
*

p ≤ .05

a

Models for alcohol use disorder were estimated in a discrete-time survival framework. Models for PTSD were estimated using logistic regression.

b

The proportion of person-years in which respondents had a lifetime history of being raped.

c

The proportion of respondents exposed to at least one lifetime TE that endorsed the focal TE as their worst lifetime TE.

Racial/Ethnic Differences in Lifetime PTSD

Both Asian (OR=0.26) and Latino (OR=0.63) respondents had lower odds of lifetime PTSD than Whites in a model that did not adjust for TEs (Table 3). These differences were similar in magnitude among those with a lifetime TE (ORs=0.31–0.69) and in a final model adjusting for each respondent’s worst lifetime TE and age of TE exposure (ORs=0.40–0.75). No differences in the odds of lifetime PTSD were observed among Blacks relative to Whites in any of the models (ORs=1.04–1.12). In the final model, race/ethnicity interacted with TE type in predicting PTSD (F9,131=35.42, p<0.001) driven by two TEs whose association with PTSD exhibited a different pattern of racial/ethnic variation than other TEs: rape/sexual assault and unidentified events (i.e., events the respondent did not want to discuss with the interviewer). The association of rape/sexual assault (F3,137=0.83, p=.48) and unidentified events (F3,137=2.31, p=.08) with PTSD did not differ across racial/ethnic groups. In contrast, the association of all other TE types with PTSD varied by race/ethnicity (F3,137=11.42, p<.001), with Asians exhibiting lower risk of PTSD following TE exposure (OR=0.30) and Blacks and Latinos exhibiting similar risk (OR=0.70–1.02) as Whites.

Discussion

We investigated the possibility that racial/ethnic differences in exposure to TEs or in vulnerability to psychopathology following TE exposure might contribute, in part, to lower rates of psychopathology among racial/ethnic minorities than Whites. Although lifetime prevalence of TE exposure varied across racial/ethnic groups, no racial/ethnic group experienced consistently elevated or reduced rates of TE exposure across all TE types. In terms of vulnerability to trauma-related psychopathology, racial/ethnic differences in the onset of depression, anxiety, and substance disorders following TEs were minimal. In contrast, racial/ethnic variation in conditional risk of PTSD emerged for most TE types such that Asians had lower odds of developing PTSD following a TE than Whites. These findings suggest that increased resilience following TEs is not a major factor explaining the lower prevalence of mental disorders among racial/ethnic minorities as compared to Whites, with the exception of PTSD among Asians.

Prior research examining racial/ethnic differences in exposure to TEs has largely relied on geographically limited community samples or studies of specific TE types (e.g., natural disaster, assaultive violence); these studies have produced inconsistent findings with regard to racial/ethnic variation in the prevalence of exposure to particular types of TEs (Kilpatrick & Acierno 2003; Hatch & Dohrenwend 2008). Here, racial/ethnic differences in TE exposure were observed across all TE types, and the patterns align closely with a prior U.S. population-based study (Roberts et al. 2011). Asians were most likely to experience TEs involving exposure to organized violence, particularly being a refugee, but had the lowest rates of exposure to all other TE types. Being displaced from one’s native country often occurs in the context of political violence and involves cumulative experiences of stress and adversity following resettlement (Silove 1999; Fazel et al. 2012). Refugees have consistently been found to have elevated rates of psychopathology as compared to non-displaced people (Porter & Haslam 2005). Yet, Asian Americans had the lowest prevalence of psychopathology of any group; this could reflect that the likelihood of being a refugee was not high in an absolute sense among Asians (12.4%) despite being relatively more common than in other groups (0.5–3.8%) or could be related to the substantially lower rates of exposure to other TE types among Asians relative to other racial/ethnic groups. Black and Latino respondents had the highest prevalence of exposure to most forms of interpersonal violence, with the rates of participation in organized violence and sexual violence highest among Blacks and exposure to physical violence greatest among Latinos. Higher levels of exposure to violence among Black and Latino adults as compared to Whites have been reported in several prior studies, although physical and sexual violence were not differentiated (Breslau et al. 1998; Roberts et al. 2011). In contrast, Whites had the greatest exposure to accidents and injuries, also consistent with prior work (Roberts et al. 2011). Given that Black and Latino adults were most likely to experience the types of TEs that are most strongly associated with psychopathology (i.e., physical and sexual violence) (Kessler et al. 1995; Breslau et al. 1998; Liu et al. 2017), differences in TE exposure in these groups is unlikely to contribute to their lower rates of psychopathology relative to Whites.

We found little evidence for racial/ethnic variation in vulnerability to trauma-related psychopathology other than PTSD. Consistent with prior research, Black, Latino, and Asian adults were less likely to develop depression, anxiety, and substance disorders than Whites (Breslau et al. 2005, 2006; Gilman et al. 2008). Racial/ethnic variation in vulnerability to psychopathology following TEs did not explain these differences. First, the magnitude of racial/ethnic differences in disorder onset was virtually unchanged after accounting for TE exposure. Second, interactions of race/ethnicity with TE exposure in predicting disorder onset were largely absent. In the one significant interaction observed, the association of rape with alcohol abuse/dependence was lower for Black, Latino, and Asian respondents than Whites; however, given the large number of interactions tested across multiple TE types and disorder outcomes, this finding should be interpreted with caution. The lack of racial/ethnic differences in vulnerability to trauma-related psychopathology is consistent with a prior study suggesting an absence of racial/ethnic differences in the association of stressful life events with anxiety and depression onset (Turner & Lloyd 2004). Finally, racial/ethnic differences remained unchanged in the sample who had never experienced lifetime TEs associated with the disorder outcome of interest, where group differences would have been smaller had variation in trauma-related vulnerability been a meaningful factor underlying racial/ethnic differences in disorder onset. Altogether, greater resilience to TEs does not appear to play a role in explaining the lower rates of depression, anxiety, and substance disorders among Black, Latino, and Asian Americans as compared to Whites.

The pattern of racial/ethnic differences in PTSD differed somewhat from other forms of psychopathology. PTSD was less common among Asian and Latino adults than Whites. Lower odds of PTSD for Asians and Latinos relative to Whites persisted when examined only among those with a lifetime TE and remained significant only for Asians after adjusting for the type and age-of-onset of each respondent’s worst TE. This pattern suggests that the lower odds of PTSD among Asians is not explained by differences in the types of TEs experienced. However, it is possible that racial/ethnic differences in the number of lifetime TEs or in exposure to other forms of adversity and discrimination could contribute to differential vulnerability to PTSD across groups (Brewin et al. 2000; Loo et al. 2005; McLaughlin et al. 2010, 2017), which could be examined in future studies. Greater lifetime prevalence of PTSD among Blacks and lower prevalence among Asians relative to Whites have been reported in several prior studies (Norris 1992; Roberts et al. 2011; Alegría et al. 2013), although here lifetime prevalence did not differ significantly for Blacks and Whites.

Several limitations are worth noting. First, exposure to TEs, disorder age-of-onset, and symptoms were assessed retrospectively. Recall bias produces lower disorder prevalence estimates in retrospective than prospective studies (Moffit et al. 2010; Takayanagi et al. 2014). If recall biases varied by race/ethnicity, they could have contributed to group differences in psychopathology, although there is little evidence to suggest that such biases play a meaningful role in the lower rates of psychopathology among racial/ethnic minorities. Second, conditional risk of PTSD was examined only in relation to the TE endorsed as the worst. Assessing PTSD in relation to a worst event rather than a randomly selected event has been shown to inflate lifetime prevalence estimates in several studies (Kessler et al. 1995; Breslau et al. 1998). Examining racial/ethnic differences in PTSD in relation to a randomly selected event is an important goal for future studies. Finally, we did not have sufficient power to examine racial/ethnic differences in TE-disorder associations across subgroups of Blacks, Latinos, and Asians based on ethnicity and nativity, which have been associated with psychopathology in prior studies (Alegria et al. 2007; Williams et al. 2007).

Lower prevalence of lifetime mental disorders among racial/ethnic minorities does not appear to reflect reduced vulnerability to TEs, with the exception of lower vulnerability to PTSD among Asians. A similar pattern of racial/ethnic differences was found for depression, anxiety, and substance disorders in those with and without a lifetime TE and after adjusting for group differences in TE exposure, and interactions between race/ethnicity and TEs in predicting disorder onset were largely absent. These results highlight the importance of investigating other potential mechanisms underlying racial/ethnic differences in psychopathology.

Supplementary Material

supplemental file

Acknowledgments

Financial Support

Research reported in this publication was supported by the National Institute on Minority Health and Health Disparities (NIMHD) of the National Institutes of Health under Award Number R01MD009719. Dr. Kiara Alvarez is supported by the National Institute of Mental Health (NIMH) under Award Number K23MH112841. Dr. Jackson is supported by the NIMHD Center for Integrative Approaches to Health Disparities (P60-MD002249). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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