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. Author manuscript; available in PMC: 2023 Jan 1.
Published in final edited form as: Aging Ment Health. 2020 Dec 9;26(1):196–204. doi: 10.1080/13607863.2020.1855627

Is the Black-White Mental Health Paradox Consistent across Age, Gender, and Psychiatric Disorders?

Courtney S Thomas Tobin 1,2, Christy L Erving 3,4, Taylor W Hargrove 5, Lacee A Satcher 6
PMCID: PMC8187467  NIHMSID: NIHMS1703731  PMID: 33291956

Abstract

Objectives:

The Black-White mental health epidemiological paradox (i.e., Black Americans’ lower or similar rates of mental disorder relative to Whites) characterizes the literature on race and mental health. Yet, research has generally paid less attention to how such findings may vary across other social statuses that shape mental health. This study assessed whether the Black-White paradox is consistent across gender, age groups, and psychiatric disorders, including lifetime mood, anxiety, and substance use disorders.

Method:

We used data from the National Comorbidity Survey-Replication (NCS-R) and National Survey of American Life (NSAL), 2001–2003 (N=4,591 African Americans; 6,668 non-Hispanic Whites). Psychiatric disorders were measured with the World Mental Health Survey Initiative version of the WHO Composite International Diagnostic Interview (WMH-CIDI). Binary logistic regression models were conducted to assess racial patterns of lifetime mental disorders across age and gender. Wald tests were performed to assess age and gender group differences in Black-White patterns of mental disorder.

Results:

The Black-White mental health paradox generally extends across lifetime mood, anxiety, and substance use disorders and is consistent across age and gender groups. One exception is middle-aged (45–64 years) Black men, who had higher odds of lifetime substance use disorder relative to their White male middle-aged peers. This difference is no longer statistically significant after accounting for education and employment. We also found more similarity in mental disorders between older Blacks and Whites relative to their younger counterparts, suggesting that Black-White mental health differences are most pronounced among younger age groups.

Conclusion:

Our findings contribute to the broader literature on the Black-White mental health paradox by demonstrating that this epidemiological pattern persists across various mental disorder types and, at times, depends on age group and gender. Given that the paradox is less pronounced among older adults, future research should consider the ways life course theory might inform our understanding of the paradox. Findings also suggest that substance use services are critical to address the needs of middle-aged Black men of lower socioeconomic status who are disproportionately affected by substance use disorder, yet have relatively lower mental health care utilization rates.

Keywords: race/ethnicity, mental disorders, National Survey of American Life, National Comorbidity Survey-Replication

INTRODUCTION

Existing research indicates that mental health is socially distributed in the U.S. and, at times, in unexpected directions. That is, stress theory predicts that greater exposure to stressors and limited access to coping resources increase the risk of poor mental health (Pearlin, 1999; Turner, 2013). Therefore, socially disadvantaged groups such as Black Americans would be expected to be at greater risk of mental health problems relative to Whites, as they are more likely to be incarcerated, experience socioeconomic disadvantage across the life course, have lower incomes for a given level of education, accrue markedly lower levels of wealth, and face higher exposure to social stressors (Ayalon & Gum, 2011; Brown, 2016; Proctor, Semega, & Kollar, 2016; Ryan & Bauman, 2016; Western & Petit, 2010; Williams et al., 2019). However, a growing body of epidemiological research provides evidence indicating that Black Americans report similar or lower rates of psychiatric disorders than Whites despite these adversities (Barnes, Keyes, & Bates, 2013; Breslau et al., 2006; Jackson et al., 2010; Kiecolt, Hughes, & Keith 2008; Mouzon, 2013, 2014, 2017). Often referred to as the “Black-White mental health paradox”, this pattern challenges theoretical expectations and our understanding of status-based health inequalities. Although comparative analyses have demonstrated the paradox within numerous epidemiological studies (Barnes, Keyes, & Bates, 2013; Breslau et al., 2006; Gibbs et al., 2013), less work has focused on how these patterns may change across two critical dimensions of stratification: age and gender. Inattention to these factors risks overlooking population groups most at-risk for poor mental health, particularly among more recent cohorts.

Recent findings suggest that the paradox varies across independent subgroups such as gender or age (e.g., Barnes et al., 2013; Erving, Thomas & Frazier, 2019)—yet, unclear is the extent to which the paradox may depend upon multiple social statuses across several mental health outcomes. Indeed, accumulating evidence supports the notion that social statuses such as race, gender, and age intersect to uniquely shape pathways to health (Bowleg, 2012; Brown et al., 2016; Hargrove et al., 2020; Rao et al. 2018). Better understanding subgroup differences can shed light on unexpected mental health patterns while also having implications for prevention strategies, intervention programs, and improving mental health care outcomes.

While the age-patterning of psychiatric disorders has been well-documented (Kessler et al., 2005; Mirowsky & Ross, 2017; Sutin et al., 2013), the extent to which Black-White differences in mental health are consistent across different age groups remains unclear. Age is a key dimension of inequality for understanding social disparities in health (Ferraro, 2016). Insights from life course theory—namely that social factors cumulatively combine over time to differentially influence health (Elder, Johnson, & Crosnoe, 2003)—suggest that the nature of Black-White differences in mental health outcomes may be distinct for different age groups.

Studies examining the racial patterning of mental illness either only adjust for age in their analysis (e.g., Erving et al., 2019; Gibbs et al., 2013), or tend to focus a particular age group (Louie & Wheaton, 2018; Woodward et al., 2012). Louie & Wheaton (2018), for example, examined three cohorts of Blacks and Whites, yet they limited their samples to respondents aged 4 to 18 years. In general, their findings showed that the oldest cohort of Blacks (born between 1957–1969) reported lower rates of anxiety and mood disorders relative to their White counterparts, while the youngest cohort (born between 1983–1991) reported higher rates of anxiety disorder compared to Whites. Thus, there is a possibility that among young adults, Blacks may experience higher prevalence of mental health problems compared to their White counterparts. A consideration of early adulthood is particularly important, as mental disorder prevalence is highest among young adults compared to middle and older age (Kessler et al., 2005). Research among mid-to-late life adults (i.e., 60 years and older), however, indicates that non-Hispanic Whites have relatively higher rates of lifetime psychiatric disorders in general, and mood disorders in particular compared to their African American counterparts (Jimenez et al., 2010; Taylor & Chatters, 2020; Woodward et al., 2012). Nevertheless, it remains unclear whether these patterns are similar across early adulthood and middle age. This paper will address the limitation of prior research by investigating whether the Black-White paradox is applicable to four different age groups.

In addition to age, much of the paradox literature has given less attention to the role of gender. Gender is a significant axis of inequality, as it structures lived experienced and life chances. For example, women—particularly Black women—hold fewer positions of power, are more likely to work part-time, and receive less pay than men for similar jobs (Read & Gorman, 2010). Further, Black women experience unique disadvantages as they age relative to Black men and Whites, including steeper declines in income post-retirement (Hogan & Perrucci, 2007), greater likelihood to transition into widowhood (Angel et al., 2007), and substantially less wealth (Addo & Lichter, 2013). In late life, these disadvantages could elicit mental disorder to a greater magnitude among Black women compared to men and White women. Recently, Erving, Thomas, & Frazier (2019) examined how gender might affect the paradox, finding that, with little exception, the paradox extends across genders and multiple psychiatric disorders; nevertheless, Black women experienced higher rates of lifetime PTSD compared to White women. The analysis, however, did not ascertain the extent to which these patterns might also vary by age, so it is unclear whether the paradox is reflected across multiple disorders for women and men of different age groups.

In one of the only studies, to our knowledge, that assesses age and gender distinctions in the paradox, Barnes, Keyes, & Bates (2013) found very little variation in the paradox by these demographic factors. However, the study only focused on depression. Thus, it remains unknown if this race patterning by age and gender persists across a variety of mental disorders. As one of the most comprehensive studies to date, Neighbors & Williams (2001) examined the race patterning of mental disorder by gender, age, and specific psychiatric disorders; however, data were extracted from the Epidemiological Catchment Area Study collected in the mid-1980s, a data source that is representative of six metropolitan areas. Though quite extensive in its coverage of age and gender in the racial patterning of mental disorders, what do more recent estimates tell us? How might these findings differ in the context of a nationally representative sample of Whites and Blacks?

In sum, the current study extends prior research on the race paradox in mental health by examining Black-White differences in mental illness among various age groups, across gender, and by different psychiatric disorder types. This subgroup analysis is designed to accomplish the overall goal of clarifying the roles of age and gender in the Black-White mental health paradox. Such analyses are necessary to inform public health interventions and to more effectively identify at-risk groups. This goal is addressed with three main aims: 1) Examine racial differences in psychiatric disorder types; 2) Evaluate the extent to which Black-White mental health patterns vary across age groups; and 3) Assess whether race patterns of mental disorder vary by age and gender, two key dimensions of social stratification.

METHOD

Sample

Data were from the National Comorbidity Survey-Replication (NCS-R) and the National Survey of American Life (NSAL), collected between 2001 and 2003. A stratified random sampling approach was used in order to provide a sample that was both nationally representative and racially diverse (see Pennell et al. 2004 for a detailed description of data collectionprocedures). For both data sources, respondents were randomly selected from a sequential listing of eligible household members. Once a respondent was selected, no substitution could be made. The NCS-R survey population included adults age 18 and older residing in households in the coterminous U.S. (N=9282). Interviews were conducted in English and lasted an average of 2 hours with a 71% response rate (Pennell et al., 2004). The NSAL sampled African Americans (n=3570), Blacks of Caribbean descent (n=1621) and non-Hispanic Whites (n=891; Jackson et al., 2004). These samples were representative and reflect national distributions on sociodemographic variables such as gender, region, urbanicity, educational attainment, income, and marital status (Jackson et al., 2004). The overall response rate was 72.3%. Using a computer-assisted instrument, most interviews (86%) were conducted face-to-face with race/ethnicity matching of interviewers and respondents. Consistent with prior paradox research (Barnes, Keyes, & Bates, 2013; Erving, Thomas, & Frazier, 2019), NCS-R and NSAL were merged to create a large, nationally representative sample of U.S.-born non-Hispanic African Americans (in NSAL, NCS-R) and Whites (in NCS-R). The restricted sample examined in the present study includes 4,591 African Americans and 6,668 non-Hispanic Whites.

Measures

Psychiatric Disorders

The World Mental Health Survey Initiative version of the WHO Composite International Diagnostic Interview (WMH-CIDI) was used to assess psychiatric disorders in the NSAL and NCS-R. This instrument assesses the most common and severe mental disorders using diagnostic criteria established by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association, 1994). To assess the robustness of the Black-White paradox across multiple measures of mental health, we include three measures of the most commonly diagnosed categories of psychiatric disorder: any mood disorder (major depressive disorder, bipolar 1 and 2, dysthymia), any anxiety disorder (panic disorder, agoraphobia, social phobia, generalized anxiety disorder, post-traumatic stress disorder), and any substance use disorder (alcohol abuse, alcohol dependence, drug abuse, drug dependence). We also assess risk of any mental disorder (a compilation of any mood disorder, any anxiety disorder, and substance disorder).

Sociodemographic Characteristics

Race is self-reported and distinguishes between non-Hispanic African Americans and non-Hispanic Whites. Based on previous research (Barnes, Keyes, & Bates, 2013), we divided the sample into four distinct age groups: 18–29 years, 30–44 years, 45 to 64 years, and 65 years and older. We also conduct gender-stratified analyses, with separate models for women and men. In the adjusted models, we control for indicators of socioeconomic status available across both data sources in order to determine whether any observed racial differences are attributable to socioeconomic inequalities (Erving et al., 2019; Gibbs et al., 2013). Socioeconomic status measures include educational attainment (less than high school [reference], high school education/some college, and college degree) and employment status (unemployed [reference], employed, and not in the labor force).

Analysis

All analyses were conducted with STATA 16 (StataCorp, 2019). Due to the data’s complex sampling strategy, survey procedures are used to correct for unequal probabilities of selection, non-response, and design effects in the sample. We first report descriptive statistics for Black-White patterns of mental disorder, education, and employment for women and men within each age group. For the regression analysis, we use binary logistic regression and report odds ratios (OR). In Table 2, we include ORs to demonstrate the Black-White pattern of mental disorder in the entire sample, then by gender, and then by age group. In Table 3, to assess the extent to which Black-White patterns of mental disorder differ across gender and age, we ran separate analyses for women and men. With each gender, we also ran stratify analyses by each age group (18–29, 30–44, 45 to 64, and 65 years and older). The first model is unadjusted and only includes the race covariate. The second model adjusts for education and employment status to ensure that observed racial patterns in mental health were not due to group differences in these factors. For the adjusted models reported in Tables 2 and 3, we used the suest post-estimation command in STATA to conduct Wald tests in order to assess whether the Black-White coefficients significantly differ across gender and age groups. In Table 4, we report non-significance and statistically significant p-values for each pairwise coefficient comparison. Results for this post-hoc analysis will reveal whether, after adjustment for socioeconomic factors, there are critical ages for women and men in which race differences in mental health are more or less prominent.

Table 2:

Black-White Odds Ratios for Lifetime Mental Disorders

Unadjusted OR (95% CI) Adjusted OR (95% CI)
Panel A: Full Sample
Any Mood Disorder 0.57*** (0.50, 0.64) 0.51*** (0.45, 0.57)
Any Anxiety Disorder 0.79*** (0.71, 0.89) 0.71*** (0.63, 0.80)
Any Substance Use Disorder 0.84* (0.72, 0.98) 0.72*** (0.61, 0.84)
Any Mental Disorder 0.75*** (0.67, 0.84) 0.66*** (0.59, 0.75)
Panel B: Gender-Stratified
WOMEN
Any Mood Disorder 0.53*** (0.47, 0.60) 0.50*** (0.44, 0.57)
Any Anxiety Disorder 0.83** (0.73, 0.94) 0.74*** (0.65, 0.85)
Any Substance Use Disorder 0.72** (0.57, 0.90) 0.57*** (0.46, 0.71)
Any Mental Disorder 0.71*** (0.64, 0.79) 0.63*** (0.56, 0.72)
MEN
Any Mood Disorder 0.59*** (0.46, 0.75) 0.53*** (0.41, 0.68)
Any Anxiety Disorder 0.69** (0.56, 0.85) 0.65*** (0.52, 0.80)
Any Substance Use Disorder 0.97 (0.80, 1.17) 0.81* (0.66, 0.99)
Any Mental Disorder 0.79* (0.66, 0.95) 0.71** (0.58, 0.86)
Panel C: Age-Stratified 18–29 years
Any Mood Disorder 0.70** (0.54, 0.89) 0.68** (0.53, 0.88)
Any Anxiety Disorder 0.87 (0.69, 1.09) 0.85 (0.66, 1.08)
Any Substance Use Disorder 0.40*** (0.28, 0.56) 0.39*** (0.27, 0.55)
Any Mental Disorder 0.64*** (0.50, 0.80) 0.62*** (0.50, 0.79)
30–44 years
Any Mood Disorder 0.48*** (0.38, 0.60) 0.43*** (0.34, 0.54)
Any Anxiety Disorder 0.63*** (0.53, 0.75) 0.56*** (0.46, 0.67)
Any Substance Use Disorder 0.72* (0.56, 0.92) 0.62** (0.47, 0.81)
Any Mental Disorder 0.66*** (0.56, 0.77) 0.58*** (0.49, 0.70)
45–64 years
Any Mood Disorder 0.53*** (0.43, 0.66) 0.52*** (0.42, 0.64)
Any Anxiety Disorder 0.80* (0.66, 0.96) 0.76** (0.63, 0.92)
Any Substance Use Disorder 1.18 (0.94, 1.50) 1.08 (0.86, 1.37)
Any Mental Disorder 0.77** (0.65, 0.91) 0.75** (0.63, 0.89)
65+ years
Any Mood Disorder 0.40*** (0.25, 0.64) 0.36*** (0.21, 0.59)
Any Anxiety Disorder 0.89 (0.60, 1.33) 0.79 (0.52, 1.21)
Any Substance Use Disorder 1.89 (1.00, 3.58) 1.70 (0.86, 3.37)
Any Mental Disorder 0.88 (0.64, 1.21) 0.79 (0.56, 1.12)
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Odds ratios less than 1 indicate that Whites are more likely to experience the disorder compared to Blacks.

CI = Confidence Interval

For Panel A, adjusted models control for education, employment, gender, and age.

For Panel B, adjusted models control for education, employment, and age.

For Panel C, adjusted models control for education, employment, and gender.

*

p < .05,

**

p < .01,

***

p < .001

Table 3:

Black-White Odds Ratios for Lifetime Disorders by Age Group among Women and Men

Women Men
Unadjusted OR (95% CI) Adjusted OR (95% CI) Unadjusted OR (95% CI) Adjusted OR (95% CI)
18–29 years
Any Mood Disorder 0.70* (0.51, 0.97) 0.76 (0.54, 1.05) 0.60* (0.40, 0.92) 0.63* (0.41, 0.98)
Any Anxiety Disorder 0.86 (0.68, 1.09) 0.87 (0.67, 1.15) 0.77 (0.50, 1.17) 0.84 (0.54, 1.30)
Any Substance Use Disorder 0.25*** (0.16, 0.40) 0.24*** (0.15, 0.38) 0.55** (0.36, 0.85) 0.53** (0.35, 0.81)
Any Mental Disorder 0.65** (0.50, 0.84) 0.67** (0.50, 0.90) 0.58** (0.40, 0.84) 0.60** (0.41, 0.88)
30–44 years
Any Mood Disorder 0.41*** (0.32, 0.52) 0.38*** (0.29, 0.49) 0.55** (0.37, 0.83) 0.46*** (0.31, 0.70)
Any Anxiety Disorder 0.66*** (0.53, 0.82) 0.59*** (0.47, 0.74) 0.51*** (0.37, 0.70) 0.46*** (0.33, 0.63)
Any Substance Use Disorder 0.79 (0.55, 1.12) 0.64* (0.44, 0.94) 0.72 (0.52, 1.01) 0.59** (0.41, 0.84)
Any Mental Disorder 0.62*** (0.52, 0.74) 0.56*** (0.46, 0.68) 0.68** (0.53, 0.88) 0.59*** (0.45, 0.78)
45–64 years
Any Mood Disorder 0.50*** (0.39, 0.64) 0.52*** (0.40, 0.65) 0.55** (0.37, 0.81) 0.54** (0.36, 0.81)
Any Anxiety Disorder 0.79* (0.63, 0.98) 0.77* (0.62, 0.95) 0.77 (0.56, 1.06) 0.74 (0.53, 1.02)
Any Substance Use Disorder 0.84 (0.58, 1.21) 0.81 (0.59, 1.11) 1.50** (1.14, 1.97) 1.27 (0.95, 1.70)
Any Mental Disorder 0.65*** (0.55, .076) 0.66*** (0.55, 0.79) 0.95 (0.72, 1.25) 0.87 (0.66, 1.16)
65+ years
Any Mood Disorder 0.38*** (0.22, 0.64) 0.34*** (0.20, 0.59) 0.45 (0.16, 1.24) 0.36 (0.11, 1.11)
Any Anxiety Disorder 0.95 (0.63, 1.44) 0.83 (0.55, 1.25) 0.77 (0.38, 1.57) 0.62 (0.26, 1.47)
Any Substance Use Disorder 2.52 (0.87, 7.29) 1.99 (0.60, 6.56) 1.79 (0.79, 4.02) 1.55 (0.65, 3.66)
Any Mental Disorder 0.74 (0.51, 1.07) 0.66* (0.45, 0.97) 1.13 (0.69, 1.84) 0.92 (0.52, 1.64)
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Odds ratios less than 1 indicate that Whites are more likely to experience the disorder compared to Blacks.

CI = Confidence Interval

Adjusted models control for education and employment status.

*

p < .05,

**

p < .01,

***

p < .001

Table 4:

Post-hoc test of the equality of coefficients for Black-White Comparison

Any
Mood
Disorder		 Any
Anxiety
Disorder		 Any
Substance
Disorder		 Any
Mental
Disorder
Table 2 , Panel B: Gender-Stratified
Women vs. Men NS NS p = .004 NS
Table 2 , Panel C: Age-Stratified
18–29 years vs. 30–44 years p = .012 p = .007 p = .019 NS
18–29 years vs. 45–64 years NS NS p < .001 NS
18–29 years vs. 65+ years p = .012 NS p = .002 NS
30–44 years vs. 45–64 years NS p = .022 p = .004 p = .036
30–44 years vs. 65+ years NS NS p = .007 NS
45–64 years vs. 65+ years NS NS NS NS
Table 3 , Women
18–29 years vs. 30–44 years p = .003 p = .021 p <.001 NS
18–29 years vs. 45–64 years NS NS p <.001 NS
18–29 years vs. 65+ years p = .014 NS p <.001 NS
30–44 years vs. 45–64 years NS NS NS NS
30–44 years vs. 65+ years NS NS p = .037 NS
45–64 years vs. 65+ years NS NS p = .048 NS
Table 3 , Men
18–29 years vs. 30–44 years NS p = .042 NS NS
18–29 years vs. 45–64 years NS NS p = .001 NS
18–29 years vs. 65+ years NS NS p = .034 NS
30–44 years vs. 45–64 years NS p = .032 p = .003 NS
30–44 years vs. 65+ years NS NS p = .039 NS
45–64 years vs. 65+ years NS NS NS NS
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Significance tests were performed for the adjusted models in Tables 2 and 3 using the suest postestimation command in STATA 16.0.

NS = Not significant

p = p-values reported when statistically significant

RESULTS

Prevalence Rates

Table 1 presents weighted prevalence rates of mental disorder for Blacks and Whites by gender and age group. White women have higher prevalence rates of mental health disorders than Black women at all age ranges except for ages 65 and over, in which White and Black women have comparable prevalence rates. The results for men are also consistent with the Black-White mental health paradox, with one exception: middle-aged (45–64) Black men have higher rates of any substance use disorder (24%) relative to White men in the same age group (17.4%). In addition, there are no significant racial differences in mental disorder among older men (65 years and older). In fact, it appears that Black men’s mental health advantage over Whites dissipates in older age.

Table 1:

Descriptive Statistics

N Lifetime Psychiatric Disorders Education Employment
Mood Anxiety Substance Any LTH HS CG EM NILF UEM
WOMEN
Black
18–29 years 696 17.5 26.2 4.0 34.0 .22 .69 .08 .65 .18 .17
30–44 years 1054 14.8 24.3 8.7 34.8 .18 .67 .15 .76 .13 .10
45–64 years 832 15.7 25.1 6.6 32.5 .23 .59 .18 .63 .29 .08
65+ years 348 5.8 13.8 2.9 18.2 .49 .40 .11 .18 .76 .06
White
18–29 years 691 23.2* 29.2 14.1* 44.0* .11* .67 .22* .72* .18 .10*
30–44 years 1015 29.7* 32.7* 10.8 46.2* .08* .58* .34* .77 .16 .07*
45–64 years 1138 27.1* 29.8* 7.8 42.5* .10* .61 .29* .69 .23 .08
65+ years 760 14.2* 14.5 1.2 23.1 .25* .62* .14 .12 .72 .16*
MEN
Black
18–29 years 395 9.7 14.4 11.6 25.6 .18 .73 .09 .76 .10 .14
30–44 years 573 11.1 12.6 17.4 30.3 .17 .66 .17 .84 .08 .08
45–64 years 500 10.2 16.3 24.0 35.4 .27 .56 .17 .69 .25 .06
65+ years 193 2.9 6.9 12.1 19.3 .50 .37 .13 .14 .81 .05
White
18–29 years 637 15.2* 18.0 19.3* 37.2* .13* .67 .20* .75 .18* .07*
30–44 years 966 18.4* 22.1* 22.7* 38.9* .09* .60* .32* .91* .08 .01*
45–64 years 976 17.1* 20.2 17.4* 36.7 .12* .54 .33* .79* .16* .05
65+ years 485 6.2 8.7 7.2 17.5 .25* .51* .23* .18 .62* .20*
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Proportions are presented.

LTH = Less than high school; HS = High School/Some College; CG = college graduate; EM=Employed; NILF = Not in labor force; UEM=Unemployed

*

Significantly different from Blacks in the same gender and age group.

Regression Analysis

Before assessing whether the Black-White mental health paradox persists at the intersection of gender and age, in Table 2 we first show results from logistic regressions assessing whether the Black-White mental health paradox is reflected in the full sample (Panel A). These models are then stratified by gender (Panel B) and age group (Panel C) separately. In Panel A, the results indicate Blacks experience significantly lower odds of all psychiatric disorder to Whites in both the unadjusted and adjusted (controlling for education, employment, gender, and age) models. These results replicate the Black-White mental health paradox. In Panel B, we find continued evidence of the Black mental health advantage among women across all four measures of mental disorder, in both the unadjusted and adjusted models. Among men, Blacks experience relatively lower odds of the four mental disorder measures compared to Whites, with one exception: in the unadjusted model, Black men and White men do not significantly differ in odds of having a substance use disorder.

In Panel C, we test whether the paradox exists across the following age groups: 18–29, 30–44, 45–64, and 65 years and older. Across almost all age groups and psychiatric disorders, Blacks have higher odds of mental disorders than their White counterparts. Three exceptions should be noted. First, among 18–29 year olds, Blacks and Whites do not significantly differ in their odds of having a lifetime anxiety disorder. Second, among middle-aged adults (45–64 years old), Blacks do not significantly differ from Whites in odds of having a substance use disorder. Third, the Black mental health advantage is less pronounced among older adults (ages 65+). While older Blacks have significantly lower odds of mood disorder compared to older Whites (unadjusted model: OR = .40, p<.001; adjusted model: OR = .36, p<.001), there is no significant racial difference in anxiety, substance use, or any mental disorders. Posthoc testing for the adjusted models reveal that Blacks’ lower risk for any substance use disorder is most pronounced in young adulthood (i.e., age 18–34). Similar advantages in any substance use disorder, however, are not documented in mid- and late-life (i.e., 45 years and over) (see Table 4).

Testing the Black-White Mental Health Paradox at the Intersection of Gender and Age

In Table 3, we assess whether the Black-White mental health paradox persists at the intersection of gender and age by conducting separate analyses for women and men within each age group (18–29, 30–44, 45 to 64, and 65 years and older).

Women.

In Table 3, we find compelling evidence of the Black-White mental health paradox for women across different age groups, and different measures of mental disorder. In all the age and mental disorder comparisons, Black women never experience significantly higher odds of mental disorder than White women. In most instances, Black women experience significantly lower odds of a given mental health disorder than their same-aged, White counterparts. For some outcomes and age groups, results suggest comparable rates of mental disorders among Black and White women. For example, the Black-White difference in substance abuse disorders is significant only among young adults (age 18–29)—Black and White women aged 30 and older experience similar rates of substance abuse disorders. Further, young Black White women report comparable odds of anxiety disorder, as the odds ratio among 18–29 year olds is not statistically significant.

Results from Table 4, which test for significant differences in the race coefficient across age groups, indicate that Black women’s lower risk for anxiety disorders is the largest or most pronounced for those ages 30–44 years (compared to the youngest group) (see Table 4). In addition, contrary to expectations consistent with the life course disadvantage of older Black women, Black women’s advantage in mood disorders is larger in late life (65 and older) and between the ages of 30 and 44 years compared to young adulthood (18–29 years).

Men.

Logistic regression analyses for men are also presented in Table 3. Again, we find evidence for the Black-White mental health paradox across different age groups, and different measures of mental disorder, with one exception: middle-aged (45–64 years) Black men have a higher odds of substance use disorder relative to middle-aged White men (OR=1.50, p<.01). However, after adjusting for education and employment, this difference is reduced and falls outside the statistical significance threshold.

With regards to anxiety disorders, Black men’s lower risk compared to White men is the most pronounced when they are between the ages of 30 and 44 years old (compared to young adulthood and late life, see Table 4); in fact, the odds ratio is only significant for the 30–44 year old group. In terms of substance use disorders, Black men’s mental health advantage is greatest in the relatively younger cohorts: post-hoc analyses confirm that the “race” coefficient for younger age groups (18–29 years and 30–44 years) significantly differs from mid-life to older adults (45–64 and 65+ years). Among middle-aged (45–64) and older (65 years and older) adults, Blacks and Whites do not significantly differ in odds of having any mental disorders in general or any specific mental disorder type after adjustments for socioeconomic factors.

DISCUSSION

The primary objective of this study was to test the robustness of the epidemiological finding that Blacks experience lower or similar rates of mental disorder relative to Whites (i.e., the Black-White mental health paradox) by incorporating gender and age statuses. In particular, we evaluated the extent to which the Black-White mental health paradox varies for women and men at different ages, and whether the paradox persists across three mental disorder types. In general, our findings indicate that the paradox is consistent across age, gender, and mental disorders. However, there is more similarity in mental disorder prevalence among older Black and White adults relative to their younger counterparts. Thus, nuances in the age patterning of the paradox provide insights for understanding the racial patterning of mental disorder prevalence across the life course. Below, we describe major findings from the study, as well as their implications for future research.

First, the Black-White mental health paradox exists for both women and men across mental disorder type (i.e., mood, anxiety, substance use). This finding is generally consistent with past research (Erving, Thomas, & Frazier, 2019; Neighbors & Williams, 2001; Rosenfield, 2012). However, prior work shows some gendered patterns in mental health problems when specific disorders are examined (e.g., PTSD) (Erving, Thomas, & Frazier, 2019). Due to small sample size challenges, we were unable to include specific mental disorders, and instead included broader mental disorder types. Nevertheless, this study revealed that the racial patterning of mental health varies by age group among women and men, with fewer Black-White differences in older adulthood.

Second, we found evidence of the Black mental health advantage for young to middle- aged adults (18–64 years of age) across mental disorders. Among older adults (65 years and older), however, the Black mental health advantage was less pronounced, particularly for substance use disorders. In other words, we observed greater similarity in mental disorder between Blacks and Whites in older adulthood relative to earlier life course stages. This set of findings is inconsistent with life course perspectives that emphasize persistent or growing racial disparities in physical health in mid-to-late life (Brown, O’Rand, & Adkins, 2012; Brown, Richardson, Hargrove, & Thomas, 2016). Racial disparities in physical health are most pronounced in early and middle adulthood, but are generally smaller (though still apparent) in old age (Brown et al., 2012; Lariscy, 2017). Consistent with the aging-as-leveler hypothesis, due to the adversities Blacks experience across the life course, those who are most robust (either physically or mentally) are able to survive to older ages (Brown et al., 2016; Kim & Miech 2009). Findings here support this perspective, as aging into older adulthood appears to level out racial differences in mental disorder observed in early adulthood.

Furthermore, mental disorder prevalence was lower for older adults relative to their younger counterparts which suggests that, despite challenges that accompany aging (e.g., physical health problems, the death of social network members), a substantial proportion of older Black and White adults experience relatively good psychological health. Alternatively, due to waning physical ability, perhaps older adults are less likely to prioritize mental health problems or seek professional help for psychological issues due to the necessity of addressing more pressing issues associated with declining physical health.

Third, when examining differences by gender and age, more variation in the race patterning of mental disorders emerged. Though, generally speaking, Black men and women had similar or lower rates of mental disorder across different ages and different psychiatric disorders than their White counterparts, one exception is noteworthy. Middle-aged Black men (ages 45–64) had higher risk of substance use disorder compared to their White male middle-aged peers. Yet, this advantage was explained by education and employment. Indeed, there are substantial socioeconomic differences between the two groups; in addition, lower SES is associated with higher prevalence of alcohol and drug abuse (Collins, 2016; Nicholson & Ford, 2019). Middle- aged Black men face a severe disadvantage in education (27% have less than high school education compared to 12% of White middle-aged men), and 69% of Black men in this age group are employed compared to 79% of White middle-aged men. Thus, if socioeconomic resources were similar across the groups, there would be no racial disparity in substance use disorder among middle-aged men. Another consideration is that middle-aged Black men in this sample were born between 1937 and 1958, living through critical periods characterized by national socio-historical changes in the economy, and differential access to highly valued resources such as education and basic civil rights (Allen & Farley, 1986; Louie & Wheaton, 2018; Welch, 2003). Therefore, an understanding of middle-aged Black men’s higher risk for substance use disorder compared to White men must take these contextual factors into account.

While this study adds to our understanding of the paradox, no study is without limitations. First, the data used for this study include noninstitutionalized adults. Excluding institutionalized populations could potentially obscure racial differences in mental disorder, especially given high incarceration rates of Black men in particular (Western & Pettit, 2010), and the relatively higher rates of institutionalization in nursing home facilities among older adults. Second, due to lack of available data, this study did not assess racial differences in personality disorders or serious mental disorders such as schizophrenia. However, Gibbs and colleagues (2013) showed that Blacks experience higher rates of paranoid personality disorder compared to Whites. Thus, there is a possibility that the racial patterning of personality disorders differs by race for women and men, as well as over the life course.

Relatedly, some research suggests that Blacks experience worse subjective mental health (e.g., life satisfaction, happiness, depressive symptoms) compared to Whites (Hughes & Thomas, 1998). For example, recent research by Hargrove et al. (2020) examining depressive symptoms across a thirty-year period of the life course, ages 12–42 years, demonstrates a decline in depressive symptoms across adolescence and young adulthood and a subsequent increase in the early 30s. In terms of racial differences, Black Americans reported more depressive symptoms than Whites, and these differences persisted over time. Using the 2016 National Health Interview Survey, Watkins & Johnson (2018) assessed age and gender differences in the racial patterning of reported psychological distress (i.e., Kessler distress scale). Their findings showed higher psychological distress among young White women and middle-aged White men compared to all other race, age, and gender groups.

Moreover, the impact of this psychological distress on participants’ lives was lowest for older African American men and young African American women. These and similar studies exploring age, gender, and race differences in depressive symptoms and psychological distress highlight the complexity of these patterns for symptom scale measures of mental health. Future work should parse through these age, gender, and race trends in subjective measures of mental health relative to psychiatric disorders.

Last, data from this study were collected seventeen years ago. Thus, there is a possibility that mental health patterns have changed, thereby influencing the race, gender, and age distribution of psychiatric disorders. This point is especially critical given recent racial unrest in the U.S. due to the public violence inflicted upon unarmed Black men and women, and the resulting political struggle against racism and demands for criminal justice system reform. We submit that the mental health challenges of Black Americans in the aggregate have likely increased due to the high levels of explicit racial bias and consistent exposure to violence against Black bodies. Nevertheless, these data remain one of the primary sources for capturing psychiatric disorder at the national level. It will be important to track the mental health consequences of recent events and how such events influence racial inequality in mental health.

This study contributes to the ongoing discussion of the Black-White paradox by using nationally representative data to demonstrate that the paradox generally extends across lifetime mood, anxiety, and substance use disorders, age groups, and gender, with only one exception. Nevertheless, future research is necessary to explore additional socio-historical forces that have contributed to the finding that middle-aged Black men suffer from higher rates of substance use disorder relative to their similarly aged White male counterparts. Indeed, men in the sample were young adults or adolescents during the 1950s–1980s, a dynamic era riddled with neighborhood, interpersonal, and state-sanctioned violence against Black men and women, yet increased economic opportunity for Whites, particularly men. For older men in the sample, born during the height of Jim Crow in the 1940s, this era made the violence they witnessed as small children even more conspicuous (Allen & Farley, 1986). In addition, the crack cocaine epidemic of the 1980s ravaged Black communities. That the 1980s in America was simultaneously a “golden-age” for white men and a decade of devastation for Black men speaks to the racial differences in outcomes among men in these eras and onward. These contextual factors likely impacted Black men’s substance use disorder rates, as some could have used substances to cope with societal racism and dehumanization. In sum, the finding that middle-aged Black men experience higher rates of substance abuse than similarly aged White men is an important exception to the Black-White mental health paradox that merits future empirical investigation.

Though results from our study generally reflect a Black mental health advantage, this population is also less likely to utilize mental health services for a host of reasons, including health care access, stigma, and (justified) mistrust of the health care system (Hines, Cooper, & Shi 2017). In terms of mental health practice, mental health screenings at the point of contact with a primary care physician may more effectively identify mental health needs among Black Americans in particular. Furthermore, the disproportionately higher rates of substance use disorder among Black men in mid-life suggests that cost-effective substance use services should be made available to those who are uninsured.

Contributor Information

Courtney S. Thomas Tobin, UCLA Fielding School of Public Health, University of California, Los Angeles; Department of Community Health Sciences.

Christy L. Erving, Vanderbilt University; Department of Sociology.

Taylor W. Hargrove, Faculty Fellow, Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599.

Lacee A. Satcher, Department of Sociology, Vanderbilt University.

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