Physical Disability and Depression: Clarifying Racial/Ethnic Contrasts

Physical Disability and Depression: Clarifying Racial/Ethnic Contrasts

Journal of Aging and Health 22(7) 977­–1000 © The Author(s) 2010 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0898264309360573 http://jah.sagepub.com

Robyn Lewis Brown, MS1 and R. Jay Turner, PhD2

Abstract Objective: This study assesses racial/ethnic disparities in depressive symptoms among persons who are physically disabled and evaluates the extent to which variation in stress exposure, coping resources, and feelings of shame associated with disability account for observed differences. Method: Data are drawn from a Miami-Dade County study that oversampled persons with physical disabilities. The sample used in this study includes individuals of Cuban and other Hispanic heritage, African Americans, and non-Hispanic Whites who identify as physically disabled (N = 550). Results: Cubans and other Hispanics report higher levels of depressive symptoms. This elevation in risk is largely explained by variations in stress exposure, available coping resources, and shame. Findings also suggest that feelings of shame may condition the relationships between both stress exposure and coping resources and depressive symptomatology. Discussion: Findings demonstrate racial/ethnic differences in depressive symptoms among persons with physical disabilities and highlight the importance of stress exposure, coping resources, and shame for understanding these differences. Keywords disability, depression, race/ethnicity, stress process theory 1

Florida State University, Tallahassee Vanderbilt University, Nashville,TN

2

Corresponding Author: Robyn Lewis Brown, MS, Department of Sociology and Center for Demography and Population Health, Florida State University, 615 Bellamy Building, Tallahassee, FL 32306-2270 Email: [email protected]

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Evidence accumulated over several decades leaves little doubt that physical disability is associated with elevated risk for psychological distress, generally, and depression, in particular (e.g., Breslin, Gnam, Franche, Mustard, & Lin, 2006; Mirowsky & Ross, 1999; Rosenbaum & Raz, 1977; Schieman, van Gundy, & Taylor, 2002; Turner & McLean, 1989; Turner & Noh, 1988). Physical disability—broadly defined as an “impairment that substantially limits one or more major life activities” (Americans With Disabilities Act, 1990)—is associated with as much as a threefold increase in depressive symptoms (Mirowsky & Ross, 1999; Turner & Beiser, 1990; Turner & Turner, 2004). One interpretation of this body of evidence is that living with physical disability has mental health significance because of associated limits on social involvement and because the performance of key and valued social roles such as spouse, parent, and economic provider can become more difficult and undermine one’s self-image. This perspective is consistent with the view that physical disability represents a source of enduring social stress (Avison & Turner, 1988; Koenig, Pappas, Holsinger, & Bachar, 1995; Turner & Beiser, 1990; Turner & McLean, 1989). Chronic stress, of course, is among the best documented risk factors for high levels of distress and depression (Aneshensel, 1992; Kessler, Price, & Wortman, 1985; Thoits, 1984; Turner, Wheaton, & Lloyd, 1995). Although the association between physical disability and depressive symptoms is well established, it is not clear whether the mental health implications of physical limitation apply across race/ethnicity. This may be particularly problematic with respect to Hispanics living in the United States for two reasons. First, relatively little is known about mental health contingencies within Hispanic populations. Available evidence suggests that, overall, Hispanics report greater psychological distress than non-Hispanic Whites (Kessler et al., 1994; Vega & Rumbaut, 1991), though some evidence indicates that Cuban immigrants report lower levels of depressive symptoms than non-Hispanic Whites and other nonimmigrant Hispanic groups (Moscicki, Rae, Regier, & Locke, 1987; Narrow, Rae, Moscicki, Locke, & Regier, 1990). (In contrast, African Americans tend to report the same, or lower, levels of psychological distress compared to non-Hispanic Whites; Vega & Rumbaut, 1991; Williams & Harris-Reid, 1999; Wilson & Williams, 2004). Second, at least among those 65 years and older, the prevalence of physical disability appears to be higher for Hispanics than for the majority population (McNeil, 2001), and Hispanics are found to experience greater functional limitations than Whites (Markides, Rudkin, Angel, & Espino, 1997; Stump, Clark, Johnson, & Wolinsky, 1997; Zsembik, Peek, & Peek, 2000). The significance of the latter observation is amplified in the context of the fact that Hispanics now represent the largest minority group in the United

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States and that this growth is especially evident among older adults. As an illustration, recent data projects the number of non-Hispanic Whites above age 65 to grow by 74% by the year 2030; in this same period, the number of Hispanics in this age category is expected to grow by 254% (U.S. Department of Health and Human Services, 2006). Given the obvious relationship between age and onset of disability, substantial increases in the number of Hispanic adults with a physical disability can be anticipated. This article examines whether there are racial/ethnic differences in the relationship between physical disability and depression using data from a large community study, including a representative sample of persons of Cuban and other Hispanic (predominantly Central and South American) heritage, African Americans, and non-Hispanic Whites, all of whom reported a physical disability. Particular attention is paid to the potential impact of immigration and racial/ethnic variation in the severity of limitation and to the question of whether functional limitations have a differential impact on persons of different racial/ethnic backgrounds. Because we conceptualize physical disability as a source of chronic stress, we evaluate racial/ethnic variation in its significance in the context of the stress process model (Billings & Moos, 1982; Pearlin, Lieberman, Menaghan, & Mullan, 1981). This perspective focuses on the health significance of stress exposure and evaluates the influence of variations in social resources, life circumstances, and personal attributes. Accordingly, we consider the extent to which stress exposure, personal resources, and social resources account for potential racial/ethnic variation in depressive symptoms within the context of physical disability. In addition, because physical disability challenges one’s ability to meet normative interpersonal expectations, the stress process model examined includes consideration of the role of shame associated with physical limitation.

Background The demonstration of important social status variations in exposure to social stressors, other than physical limitation (Turner & Avison, 2003; Turner et al., 1995), supports an expectation of racial/ethnic variation in the mental health significance of physical disability. Social status differences in general stress exposure have become increasingly apparent from studies that have considered a broad array of sources or types of stress exposure, including major and potentially traumatic life events, recent life events, discrimination, and chronic stress (Turner & Avison, 2003; Wheaton, 1994). It is for this reason that we rely on a version of the stress process model (Pearlin, 1989; Pearlin et al., 1981) to examine racial/ethnic differences in depressive symptoms in the context of physical disability.

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There are several assumptions that guide applications of this model. The first is that individual experience is socially patterned by ascribed and achieved social statuses (Link & Phelan, 1995; Pearlin et al., 1981). Second, social statuses are understood to influence health outcomes partly because they affect one’s exposure to social stress (Pearlin et al., 1981; Turner & Avison, 2003). Social statuses additionally influence one’s availability of coping resources, which include the perceived strength of social bonds and personal attributes such as self-esteem and mastery (Thoits, 1995; Turner & Turner, 2004). Although there is a paucity of information on racial/ethnic variation in the mental health significance of physical disability, variation across other social statuses has been reported. For example, physical disability is less predictive of symptoms among those of higher socioeconomic status (SES; Aneshensel, Frerichs, & Huba, 1984; Miech & Shanahan, 2000; Turner & Turner, 2004), and the strength of the disability–depression relationship declines with increasing age (Henderson et al., 1998; Turner & McLean, 1989; Turner & Noh, 1988). Also, although considerable evidence indicates that women tend to experience more depressive symptoms than men (Henderson et al., 1998; Kessler et al., 1994; Nolen-Hoeksema, Grayson, & Larson, 1999), among the physically disabled, significant gender contrasts are generally not observed (Breslin et al., 2006; Turner, Lloyd, & Taylor, 2006; Turner & Noh, 1988). In contrast, we are aware of no prior research that has effectively considered variations in depressive symptoms among Hispanics, African Americans, and non-Hispanic Whites with physical limitations. We are also not aware of any study that has considered the significance of racial/ethnic variation in the severity of functional limitation, immigrant status, or vulnerability to limitation for associated differences in depressive symptoms. We hypothesize that racial/ethnic differences in level of depressive symptoms among persons who are physically disabled arise, in part, from associated differences in exposure to other forms of stress. This view is consistent with Vega and Rumbaut’s (1991) suggestion that ethnic minorities may experience lower psychological well-being because they tend to encounter greater physical strain and are exposed to a higher level of stress than the majority population. The availability of coping resources, such as mastery, self-esteem, and social support, has also been linked with fewer depressive symptoms among persons with a physical disability (Turner & Noh, 1988; Yang, 2006). Mastery refers to a sense of personal control (Pearlin & Schooler, 1978), whereas self-esteem refers to a positive sense of self-worth (Rosenberg, 1981). The proposition that physical disability often challenges one’s sense of personal

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control and self-worth (Pearlin et al., 1981) is supported by the observation that both mastery and self-esteem partly mediate the relationship between physical disability and psychological distress (Bruce, 2001; Turner & Noh, 1988; Yang, 2006). In addition, difficulties managing a disability may challenge one’s ability to engage in meaningful social interactions, leading to deficits in perceived social support. Perceived social support refers to one’s level of certainty that he or she is loved, valued, and cared for by significant others (Cobb, 1976). The lower levels of perceived family and friend support found among physically limited individuals are known to contribute to their lower psychological well-being compared to nonlimited counterparts (Allen, Ciambrone, & Welch, 2000; Taylor & Lynch, 2004; Thompson & Heller, 1990). Going beyond the personal resources or attributes typically considered within the stress process perspective, we hypothesize that feelings of shame associated with a physical disability may have additional mental health significance. Shame represents feelings of rejection or inadequacy (Scheff, 2000). As Kemper (1987) has noted, when we are made to feel embarrassed, blamed, criticized, rejected, or humiliated, we experience shame. Shame is said to be the most social of all emotions (Scheff, 2000), deriving from perceived ineptitude in social relationships (Gordon, 1981). The hypothesis that feelings of shame associated with physical disability may represent a unique source of strain is consistent with the distinction drawn between primary and secondary stressors in stress research. Stress researchers have long acknowledged that primary stressors, such as disability, often spur additional forms of stress that have the capacity to produce as much or more distress than stressors considered to be primary (Pearlin, 1989). This hypothesis is informed by an understanding of disability as a challenge to core ideologies regarding American individualism, which encompasses a variety of beliefs about personal responsibility and the autonomy of individuals in achieving their personal goals (Crocker, Major, & Steele, 1998; Kluegel & Smith, 1981, 1986). Given the proposition that physical limitations have mental health significance partly because they interfere with one’s performance of valued social roles, it seems likely that shame arising from perceived interpersonal and instrumental shortcomings may constitute an independent risk factor for depression and/or mediate or moderate the mental health relevance of physical limitations. Shame may also indirectly influence well-being by interacting with the experience of other stressors or affecting mastery, self-esteem, and the perception of being supported by others. After all, it seems likely that feelings of shame may hamper efforts to effectively cope with stress, threaten

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an individual’s self-esteem and sense of mastery, and interfere with one’s capacity to gain and maintain supportive relationships. Consistent with this view, the findings of several qualitative studies indicate that feelings of shame accompanying perceived interpersonal failures are commonly linked with low psychological well-being among persons with physical limitations (Rousso, 1982; Taleporos & McCabe, 2002; Wendell, 1996). Within analyses assessing the capacity of the stress process model to account for racial/ethnic differences in depressive symptoms in the context of physical disability, we examine the direct and interactive significance of variations in the experience of shame.

Method Sample Data were drawn from a study of Miami-Dade County residents that included an oversampling of individuals with a physical disability. A representative sample of 10,000 households was screened with respect to sex, age, ethnicity, disability status, and language preference. Using this sampling frame, the full study sample included even numbers of women and men, even numbers of people screened as having a physical disability and those not, and equivalent numbers of the four major ethnic groups comprising 95% of Miami-Dade County residents (non-Hispanic Whites, Cubans, other Hispanics, and African Americans). From 2000 to 2001, 1,986 interviews were completed, with a success rate of 82%. Interviews were administered by well-trained and predominantly bilingual interviewers using computerized questionnaires in either English or Spanish, as preferred by each participant. The Spanish version of the questionnaire was developed in a five-step process: translation by a professional translator, review and revision of the translation by bilingual psychologists and sociologists knowledgeable about the constructs being assessed, back translation of modified text, revision based on the results of a back translation, and focus group work with bilingual individuals of diverse background to ensure comparable meaning of the Spanish version across persons of differing national origins. The majority of interviews took place in the homes of participants. However, a small number of interviews were conducted at alternative sites or by telephone when requested by participants. Study participants included 1,086 adults screened as having no physical disability and 900 adults who self-reported or were reported by a family member as having a health problem that limited the kinds of activities they could engage in. Of the 900 respondents who were screened as having activity

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limitations, 550 confirmed this status within the actual interview and provided complete responses to study questions. The analyses to be presented were based on information gathered from these 550 participants. It should be noted that the oversampling of persons screened as physically limited resulted in a greater proportion of older respondents than in the general population. Although ages in the sample ranged from 18 to 93, the median age was 62. It should also be noted that the majority of Hispanic respondents were foreign born. Ninety-five percent of the Cuban respondents and 94% of the nonCuban Hispanic respondents were born outside the United States, compared to 18% of non-Hispanic White respondents and 4% of African American respondents.

Measures Summary statistics for all study variables are presented in Table 1. Depressive symptoms. The dependent variable, depressive symptoms, is estimated using a modified version of the 20-item Center for Epidemiological Studies Depression Scale (CES-D), for which there is ample evidence of reliability and validity (Comstock & Helsing, 1976; Devins & Orme, 1985; Radloff, 1977). The CES-D is the most commonly used checklist instrument for assessing psychological distress (Vega & Rumbaut, 1991). We employ a 15-item measure that excludes somatic complaints to avoid potential confounding of mental and physical health status. This shortened measure remains internally reliable (a = .84). Included as independent variables are race/ethnicity, level of functional limitation, two measures of immigrant status, four measures of stress exposure, two measures of personal resources, and two measures of social support. Race/ethnicity is a dummy variable, including relatively equivalent numbers of non-Hispanic Whites (n = 133), African Americans (n = 215), Cubans (n = 121), and other Hispanics, who are referred to as “non-Cuban Hispanic” in the analyses (n = 81). The non-Cuban Hispanic designation primarily represents individuals who identify as Colombian or Colombian American (27%), Nicaraguan or Nicaraguan American (15%), and Dominican or Dominican American (7%) as well as non-Cuban Hispanics who identify simply as Hispanic or Latino/Latina (31%). In all regression analyses, non-Hispanic Whites are the reference category. Level of limitation. Our measure of level of functional limitation is an adaptation of the models of disability proposed by the U.S. Academy of Science’s Institute of Medicine (1991) and the World Health Organization (2001). Degree of limitation is assessed by considering activities or abilities that are compromised and the extent to which they are compromised. Pooling from

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Table 1. Summary Statistics of Study Variables (N = 550) Characteristic

Range

M

3-48 13.954 Depressive symptoms Race/ethnicity (%) Non-Hispanic White 0,1 23.50 African American 0,1 39.33 Cuban 0,1 21.10 Non-Cuban Hispanic 0,1 16.07 Level of limitation -0.688-4.955 0.925 Foreign born (%) 0,1 40.72 Major life events -1.868-4.491 0.189 Discrimination events -1.741-5.351 0.105 Recent life events -0.575-5.183 0.134 Chronic strains -0.780-4.648 0.194 Mastery -3.008-1.457 -0.249 Self-esteem -3.451-0.657 -0.066 Family support -4.633-0.846 -0.021 Friend support -2.652-0.839 -0.035 Shame -0.524-5.741 1.337 Control variables Sex (% female) 0,1 56.50 Age 20-93 59.787 Socioeconomic status -2.359-2.702 -0.287

SD 7.761 — — — — 1.218 — 1.095 1.098 1.061 1.104 1.032 0.925 1.041 1.084 1.030 — 15.191 0.946

several previously employed measures (Fries, Spitz, Kraines, & Holman, 1980; Jette, 1980; Jette & Deniston, 1978; Katz, Downs, Cash, & Grotz, 1970; Lawton & Brody, 1969; Nagi, 1976; Rosow & Breslau, 1966), our 19-item index captures difficulties related to the performance of activities of daily living (ADLs), instrumental activities of daily living (IADLs), and physical mobility (survey items available on request). This measure yields an alpha coefficient of .91. Immigrant status. We assess immigrant status with a dummy variable based on the question “Where were you born?” Respondents who were not born in the United States are coded 1 (foreign born) and respondents born in the United States are coded 0. We also report on analyses considering the length of time foreign-born respondents have lived in the United States. Length of time in the United States is assessed in years. Stress exposure. We assess a wide range of potentially stressful occurrences conceptualized in terms of four dimensions of stress exposure: lifetime exposure to major events (41 items), discrimination events (9 items), recent life events (32 items regarding the past 12 months), and chronic stress (39 items).

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The chronic stress measure is an adaptation of Wheaton’s (1994) scale, modified to better capture the kinds of enduring stressors older individuals are likely to experience. Discriminatory events, major life events, and recent life events are also indexed by previously employed measures (Turner & Avison, 2003; Williams, Yu, Jackson, & Anderson, 1997). Consistent with common practice, each score is a straight count of the number of stressors reported. Personal resources. Mastery is measured using the seven-item scale developed by Pearlin and Schooler (1978). The scale is internally reliable, with an alpha of .78. Self-esteem is indexed by a shortened version of Rosenberg’s (1981) widely used measure (a = .91). Social resources. Two dimensions of social support are considered: social support from family and support from friends. Assessment is by a revised version of the Provisions of Social Relations Scale that has been employed in prior community studies and for which evidence of both reliability and construct validity is available (Barrett & Turner, 2005; Turner & Marino, 1994). Participants were asked to indicate whether each of eight statements about support from friends and each of eight statements about support from family were very true, moderately true, somewhat true, or not at all true. The indices are a standardized sum of these items (a = .95 and .88 for friend support and family support, respectively). Shame. It is assessed by a three-item index derived from a larger measure of stigma that was developed out of focus group work conducted among physically disabled volunteers. Respondents were asked how often they feel embarrassed, judged, and ashamed of their activity limitations. These items form an internally reliable index (a = .78), and factor analysis provided assurance that this measure is not confounded with depressive symptomatology. Control variables include gender, age, and SES. Gender is coded 1 for females and 0 for males. Age is employed as a continuous measure in years. SES is estimated in terms of three components—income, education, and occupational prestige level (Hollingshead, 1957). This measure provides a general assessment of SES while reducing sample loss associated with missing data. We selected this approach because information on household income could not be obtained for 15% of the overall sample and about a quarter of the Hispanic subsample, including Cubans and non-Cuban Hispanics. Scores on these three dimensions are standardized, summed, and divided by the number of measures on which each respondent provided data.

Results Are there racial/ethnic differences in levels of depressive symptoms among persons with physical disability? If so, to what extent are observed differences

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explained by the proposed stress process model? Our examination of these questions begins with Table 2, which presents the intercorrelations of major study variables. It is noteworthy that, among this sample of physically disabled individuals, significant racial/ethnic variations in average levels of depressive symptoms are observed. Compared to the aggregate, African American and non-Hispanic White respondents report lower levels of depressive symptoms, whereas persons of Cuban and other Hispanic ancestry report higher levels. We also find that foreign-born respondents report higher levels of depressive symptoms than respondents born in the United States. The potential relevance of the stress process model for understanding racial/ethnic differences in level of depressive symptoms is also suggested by these findings. Each of the variables comprising this model is significantly correlated with depressive symptoms. In addition, variations in these variables by race/ethnicity are generally consistent with the hypothesis that the stress process variables may mediate the relationship between race/ethnicity and depressive symptoms. Higher levels of recent life events and chronic stress and lower levels of self-esteem were reported by non-Cuban Hispanics, and both Cubans and non-Cuban Hispanics reported lower levels of mastery. Also noteworthy is that, relative to the full sample, higher levels of shame were reported by non-Cuban Hispanics. In the analysis presented as Table 3, we assess whether racial/ethnic differences in levels of depressive symptoms among individuals with physical limitations are observed when sociodemographic characteristics, differences in level of limitation, and immigrant status are controlled. We also consider the potentially moderating influence of level of limitation for race/ethnic and immigrant status differences in this association. Model 1 reveals that race/ ethnicity, age, and SES all contribute significantly and independently to the prediction of depressive symptoms. Relative to non-Hispanic Whites, African Americans are at lower risk, whereas both Cubans and other Hispanics are at elevated risk. Consistent with expectations based on prior research, increases in both age and SES are inversely related to depressive symptoms, and women do not report significantly more symptoms than men. Our consideration of the significance of one’s level of limitation and immigrant status supports three conclusions: First, as illustrated in Model 2, level of limitation is predictive of depression, but it does not appear to substantially influence the observed racial/ethnic differences in levels of depressive symptoms. Second, the multiplicative interaction terms for race/ ethnicity by level of limitation considered in Model 4 make clear that increases in limitation are associated with a significantly greater increase in

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*Significant at .05.

Depressive symptoms Non-Hispanic White African American Cuban Non-Cuban Hispanic Level of limitation Foreign born Major life events Discrimination events Recent life events Chronic stress Mastery Self-esteem Family support Friend support Shame

0.008 -0.146* -0.066 -0.019 -0.104* 0.035

0.040

-0.595*

0.056

0.155*

-0.005

— —

-0.026

-0.261

-0.005

-0.031

-0.069

-0.040 -0.094* 0.128* 0.079 0.032 0.111* -0.106* 0.145* 0.051 0.127* -0.089* -0.076

0.211* 0.174*

0.217*

0.258*

0.175*

0.198*

0.233*

0.383* -0.508* -0.485* -0.370* -0.268* 0.486*

-0.050

— —

—

-0.209*

-0.157*

-0.067

0.587*

0.010

-0.071

-0.049

0.168* -0.092* -0.115* -0.048 -0.115* 0.173*

-0.021 -0.265* -0.211* -0.050 0.007 0.261*

0.149* -0.028

0.008

0.007

0.379*

0.063 0.458* -0.221* -0.008 -0.162* -0.029 -0.049 -0.202* -0.207* 0.057 0.076 0.242*

0.002

-0.203* 0.441*

0.350* -0.071 -0.096* -0.223 0.009 0.362*

0.232*

0.481* 1.000 -0.062 -0.192* 1.000 -0.032 -0.104* 0.412* 1.000 -0.116* -0.240* 0.179* 0.363* 1.000 -0.005 -0.050 0.182* 0.250* 0.254 1.000 0.145* 0.323* -0.297* -0.336* -0.251* -0.108* 1.000

1.000

1.000

-0.118* 1.000

1.000

1.000

0.449* -0.137*

-0.036

1.000 — 1.000

1.000

1.000

-0.109*

1.000

Non- Major Recent Depressive Hispanic African Other Level of Foreign life Discrimination life Chronic Self- Family Friend symptoms White American Cuban Hispanic limitation born events events events stress Mastery esteem support support Shame

Table 2. Correlation Matrix of Depressive Symptoms, Race/Ethnicity, Level of Limitation, and Hypothesized Mediators (N = 550)

988

 

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Model 1

Model 2

Model 3

Model 4

Note: OLS = ordinary least squares. Standard errors are given in parentheses. *Significant at .05. **significant at .01. ***significant at .001.

African American -2.207** (0.863) -2.357** (0.831) -2.303** (0.849) -2.189* (1.059) Cuban 3.209** (0.139) 3.199** (0.927) 2.929* (1.259) 2.015 (1.401) Non-Cuban Hispanic 3.163* (1.060) 3.164** (1.024) 2.892* (1.339) 1.285 (1.255) Female 0.734 (0.652) 0.256 (0.609) 0.264 (0.610) 0.310 (0.607) Age -0.079*** (0.025) -0.104*** (0.020) -0.105*** (0.021) -0.104*** (0.021) Socioeconomic -1.572*** (0.423) -1.463*** (0.341) -1.453*** (0.342) -1.432*** (0.344) status Level of limitation 1.541*** (0.246) 1.545*** (0.247) 1.052* (0.521) Foreign born 0.361 (1.142) 0.383 (1.138) African American × -0.031 (0.642) Level of limitation Cuban × Level 0.941 (0.705) of limitation Non-Cuban Hispanic × 1.802** (0.806) Level of limitation Level of limitation × Foreign born Constant 17.568*** (1.545) 17.981*** (1.495) 17.957*** (1.498) 18.293*** (1.548) R-squared .143 .201 .201 .213



18.288*** (1.505) .206

0.937* (0.481)

—

—

1.113*** (0.521) -0.502 (1.223) —

-2.250* (0.847) 2.882* (1.256) 2.943* (1.336) 0.288 (0.609) -0.104*** (0.021) -1.408*** (0.342)

Model 5

Table 3. OLS Regression of Depressive Symptoms on Social Characteristics, Level of Limitation, and Immigrant Status (N = 550)

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depressive symptoms among non-Cuban Hispanics compared with nonHispanic Whites. Third, though significant differences in depressive symptoms are not observed among foreign-born and U.S.-born respondents (Model 3), greater limitation is associated with higher levels of symptoms among foreignborn respondents compared to U.S.-born respondents (Model 5). Because virtually all of the Cuban and non-Cuban Hispanic respondents are foreign born, we are unable to effectively consider racial/ethnic differences in variation by immigrant status in the association between level of limitation and depressive symptoms. Additional analyses (not presented) considered whether the amount of time lived in the United States influences the association between level of limitation and depressive symptoms among foreign-born respondents. Years lived in the United States are not found to significantly predict depressive symptoms, and we find no evidence that the association between level of limitation and depressive symptoms varies by the amount of time lived in the United States. The explanatory utility of the stress process model, elaborated to include the construct of shame, was evaluated in analyses presented as Table 4. These analyses control for sociodemographic characteristics, level of limitation, and immigrant status. Each of the model’s components makes a significant independent contribution to the prediction of level of depressive symptoms. The R-squared coefficients demonstrate that the personal resources of mastery and self-esteem are the strongest predictors and that 54.3% of observed variability in depressive symptoms is accounted for by the full model. Additional analyses (not shown) revealed that the full model excluding shame accounted for 49% of observed variation. Thus, as suggested by the findings shown in Model 5, shame uniquely accounts for about 5% of observed differences in depressive symptoms. The elaborated stress process model also contributes toward an understanding of racial/ethnic variation. We assessed the unique mediating effects of stress exposure, personal resources, social resources, and shame for the race/ethnicity—depressive symptoms relationship in Models 2 to 5, and in Model 6 these factors are considered simultaneously. We formally assessed the extent to which these factors carry the influence of the association between race/ethnicity and depressive symptoms using the Sobel–Goodman method of testing mediation (MacKinnon, Warsi, & Dwyer, 1995; Preacher & Hayes, 2004). Mediation tests controlled for the other variables included in each model. Results are generally consistent with the correlation patterns presented in Table 1. About one third of the elevation in symptoms among Cubans and

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Model 1

Model 2

Model 3

Model 4

Note: OLS = ordinary least squares. Standard errors are given in parentheses. *Significant at .05. **significant at .01. ***significant at .001.

African American -2.303** (0.849) -2.434** (0.783) -1.761** (0.728) -1.199 (0.797) Cuban 2.929* (1.259) 1.994* (1.157) 3.013** (1.076) 3.001* (1.168) Non-Cuban 2.892* (1.339) 0.958 (1.243) 2.625* (1.144) 3.279** (1.241) Hispanic 0.264 (0.610) 0.343 (0.573) 0.216 (0.521) 0.636 (0.568) Female Age -0.105*** (0.021) -0.046* (0.020) -0.082*** (0.018) -0.077** (0.019) Socioeconomic -1.453*** (0.342) -1.703*** (0.322) -0.646* (0.298) -1.245** (0.318) status Level of limitation 1.545*** (0.247) 1.493*** (0.226) 0.674** (0.225) 1.366*** (0.229) 0.361 (1.142) 1.402 (1.056) -0.910 (0.982) -0.073 (1.064) Foreign born Major life events -0.166 (0.318) — — Discrimination 1.241*** (0.304) — — events Recent life events 0.535 (0.321) — — 1.968*** (0.336) — — Chronic stress Mastery -2.478*** (0.296) — Self-esteem -2.242*** (0.295) — -2.153*** (0.281) Family support Friend support -0.997*** (0.271) Shame Constant 17.957*** (1.498) 14.035*** (1.464) 17.112*** (1.288) 15.748*** (1.411) R-squared .201 .335 .419 .317



-1.391** (0.663) 2.095* (0.970) 0.624 (1.049) 0.364 (0.481) -0.023 (0.017) -0.926** (0.269) 0.403* (0.206) 0.012 (0.893) -0.038 (0.267) 0.227 (0.262) 0.674* (0.261) 1.139*** (0.280) -1.703*** (0.268) -1.517*** (0.284) -0.837*** (0.252) -0.614** (0.228) 1.533*** (0.274) 11.444 (1.288) .543

0.468 (0.554) -0.056** (0.019) -1.457*** (0.311) 0.738** (0.236) 1.040 (1.041) — — — — — — — — 3.089*** (0.287) 11.719*** (1.480) .341

Model 6

-2.147** (0.772) 1.732 (1.150) 0.818 (1.232)

Model 5

Table 4. OLS Regression of Depressive Symptoms on Stress, Personal Resources, Social Resources, and Shame (N = 550)

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67% among non-Cuban Hispanics are explained by variation in stress exposure (Model 2); additional mediation tests (not presented) reveal that this effect is largely driven by variation in chronic stress. In contrast, discrimination stress alone explains the effect change for African Americans (compared to Model 1). Model 3 reveals that personal resources explain about 24% of the effect observed for African Americans (compared to Model 1) and that Cubans report slightly higher levels of depressive symptoms with these resources controlled; significant mediating effects are not observed for nonCuban Hispanics in this model. Additional tests (not shown) indicate that mastery plays the largest role in explaining the effect observed among Cubans, whereas self-esteem plays the largest role for African Americans. In Model 4, significant mediating effects are observed only among African Americans. The coefficient for African Americans falls by 48%, compared to Model 1; additional tests reveal that family support accounts for this effect. In Model 5, shame significantly influences the levels of depressive symptoms among both of the Hispanic subgroups but not among African Americans, explaining 41% and 72% of the coefficient for depressive symptoms for Cubans and non-Cuban Hispanics, respectively. The full model, compared to Model 1, explains 29% of the observed elevation in depressive symptoms among Cubans and 79% of the elevation among other Hispanics relative to non-Hispanic Whites. Analysis of the range of factors considered (not shown) reveals that shame and chronic stress exert the strongest mediating effects for non-Cuban Hispanics. Chronic stress is also the most central of the factors considered for understanding variation in depressive symptoms among Cuban respondents. In addition, the full model explains 40% of the lower levels of depressive symptoms among African Americans. Further tests revealed that, of the factors considered in the model, this effect is most strongly predicted by family support. Tests also show that the coefficient for African Americans would be even lower than that predicted in Model 1 were it not for the higher levels of discrimination stress (see also Model 2). Model 4 of Table 3 (presented above) revealed evidence that non-Cuban Hispanics are more vulnerable or emotionally responsive to given levels of physical limitation. Additional analyses (not shown) were conducted to evaluate the capacity of the stress process variables considered to account for this difference in vulnerability. We found that the full model explained 43% of the observed elevation in vulnerability among non-Cuban Hispanics. Shame and the experience of chronic stress nearly equally account for this mediating effect. The question of whether the mental health significance of shame varies with status on other stress process variables is addressed in Table 5.

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Table 5. OLS Regression of Depressive Symptoms on Stress, Personal Resources, Social Resources, and Shame Interactions (N = 550) Shame × Major life events Shame × discrimination stress Shame × Recent life events Shame × Chronic stress Shame × Mastery Shame × Self-esteem Shame × Family support Shame × Friend support Shame × Level of limitation

.505*** (.173) .489*** (.129) .286 (.176) -.176 (.175) -.654** (.232) -.354* (.202) -.832** (.178) -.109 (.195) .308 (.196)

Note: OLS = ordinary least squares. Standard errors in parentheses. *Significant at .05. **significant at .01. ***significant at .001.

Interaction terms entered one at a time into the full model (Model 6 of Table 4) reveal that several components of the stress process model condition the shame—depression relationship or vice versa. The regression slope for shame is steeper in the context of high exposure to major life events and discrimination, and less steep where mastery, self-esteem, or family support is high. Additional analyses (not shown) assessing the interactions between both race/ethnicity and immigrant status and shame offered no evidence of race/ethnic or immigrant status variations in the degree to which increases in shame are translated into increased symptoms of depression. Thus, we interpret this as suggesting that shame has direct rather than conditioning effects.

Discussion The aging of the U.S. population will undoubtedly be accompanied by a dramatic increase in the prevalence of physical disability. As noted, there are grounds for anticipating more substantial increases in disability among Hispanics. Accordingly, this article focused on the question of racial/ethnic differences in levels of depressive symptoms among persons who are physically disabled and attempted to identify factors that may underlie these differences. This examination clearly demonstrates that, among persons who are physically disabled, Hispanics represent a high-risk group with respect to depression. Both Cubans and other Hispanics are found to experience higher levels of depressive symptoms in the context of disability than non-Hispanic Whites, and increased limitation is associated with significantly more symptoms among non-Cuban Hispanics relative to non-Hispanic Whites. In contrast, African

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Americans report fewer symptoms of depression than non-Hispanic Whites in the context of physical disability. The observed racial/ethnic differences in depressive symptoms do not appear to be simply an artifact of whether one is foreign born, though we do find that increases in limitation have a greater psychological impact for individuals who are foreign born compared to those who are not. Unfortunately, because the majority of Hispanic respondents included in this study are foreign born, we are unable to effectively consider racial/ethnic differences in variation by immigrant status in the association between level of limitation and depressive symptoms. We recommend further consideration of the influence of immigration for understanding racial/ethnic differences in psychological distress among persons with disabilities. This examination also demonstrates that a substantial portion of observed variation in depressive symptoms is accounted for by the stress process model considered, adding the specification that shame makes an independent contribution in the context of more conventional stress process measures. Moreover, these factors bear importantly on the question of the possible origins of racial/ ethnic differences in levels of depressive symptoms among persons who are physically disabled. With respect to the lower levels of symptoms reported by African Americans relative to non-Hispanic Whites, these factors (particularly family support) account for 40% of the difference. Variation in level of reported shame and the stress process model variables examined account for 29% of the observed elevation in depressive symptoms among Cubans and 79% of the elevation among other Hispanics in this sample relative to nonHispanic Whites. Chronic stress is the most central of the factors considered for understanding variation in depressive symptoms among Cuban respondents, and, of the range of factors considered, shame and chronic stress exert the strongest effects for non-Cuban Hispanics. In addition, the observation that increases in limitation are associated with a greater elevation in depressive symptoms for non-Cuban Hispanics than non-Hispanic Whites is substantially explained by variations in feelings of shame and chronic stress exposure. These factors explain nearly half of the elevation in risk associated with increases in limitation among non-Cuban Hispanics. In our view, these findings reinforce the need for considering diversity among the Hispanic population in the United States. Although both Cubans and other Hispanics are found to experience higher depression in the context of disability than non-Hispanic Whites, increased limitation is clearly a greater mental health risk for non-Cuban Hispanics. This increased risk appears to derive from the greater stress exposure and shame experienced by non-Cuban Hispanics relative to non-Hispanic Whites, African Americans, and Cubans. This pattern of findings may be occasioned by the community context of this

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study. Miami-Dade County, Florida, is home to a flourishing Cuban American community (Baca Zinn & Wells, 2000). Belonging to this community may, to some degree, be protective of the mental health of its members, though its benefits may not extend to other Hispanics living in the region. Future research should assess whether these findings are generalizeable to Cuban Americans living in other regions of the United States and to Hispanic subgroups other than those represented in this study. In particular, the two largest Hispanic subgroups within the United States (Puerto Ricans and persons of Mexican descent) are virtually unrepresented in this sample. In addition, future research should be mindful of the considerable diversity among the Cuban American population in Miami-Dade County related to the timing of immigration. Early waves of Cuban émigrés tended to be socioeconomically advantaged and were generally treated more hospitably than those who immigrated during and after the 1980 Mariél boatlift (García, 1996; Portes & Stepick, 1993). Although we do not find variation in the pattern of findings reported based on the amount of time one has lived in the United States, we were not able to consider the circumstances surrounding immigration and recommend this consideration for further research. Another aspect of the current study warranting further investigation is the inclusion of shame in the stress process framework. A relatively recent development informed by the sociology of emotions literature is increased attention to both the meaning of stressful circumstances and emotional reactions to such experiences (Elstad, 1998; Thoits, 1995). The importance of shame for understanding psychological distress among persons with physical limitations is evident in the finding that, except for the personal resources of mastery and selfesteem, shame is the strongest predictor of depression. Its added value is also reflected in the finding that shame moderates the protective effects of mastery, self-esteem, and family support for well-being, while exacerbating the apparently deleterious effects of exposure to major life events and discrimination stress. In addition, shame clearly contributes to an understanding of racial/ ethnic differences in levels of depressive symptoms among persons who are physically disabled, explaining 41% of the elevation in symptoms among Cubans and 72% for other Hispanics compared to non-Hispanic Whites. This latter finding indicates that shame may be an emotion of particular significance for understanding mental health contingencies among Hispanics with physical limitations. We hypothesized that feelings of shame may represent a unique source of strain among individuals with disabilities because of ideologies regarding American individualism and because disability may interfere with one’s ability to fulfill valued social roles. We suggest the possibility that difficulties associated with experiencing a disability may

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reinforce or exacerbate power differentials among Hispanics and non-Hispanic Whites, and make it more difficult for Hispanics who are physically disabled to achieve dominant cultural ideals. In our view, feelings of shame would likely result from such a circumstance. The challenge of fulfilling valued roles may also amplify the impact of shame among some physically limited Hispanics because of unique cultural expectations associated with Latino culture, such as the gender ideals of marianismo and machismo. Marianismo, the feminine ideal based on the Catholic belief in the Virgin Mary, symbolizes that women are morally superior to men and, thus, better able to endure hardship (Quiñones Mayo & Resnick, 1996; Ruiz, 1995). The male ideal of machismo is associated with strength and the ability to provide for and protect one’s family (Quiñones Mayo & Resnick, 1996). Although these norms are generalizations, the inability to fully realize these ideals may nonetheless occasion more intense shame, or greater vulnerability to shame, among Hispanics who are physically limited. Future research might address the influence of such cultural expectations for the observed elevation in risk for depression among Hispanics with physical limitations. It is important to emphasize that the data employed in this study are crosssectional and provide only a snapshot of the undoubtedly complex relationships between race/ethnicity, disability, and depression. Ideally, a study examining the experience of disability would consider adaptation and adjustment over an extended period of time. Also, the cross-sectional nature of this data raises the question of whether the influence of stress exposure and coping resources for racial/ethnic differences in the physical limitation—depression association stem from difficulties associated with experiencing depression rather than disability. Nonetheless, we believe there are important clues within these findings for the development of mental health prevention or intervention efforts in the service of Hispanic Americans with physical limitations. The evidence presented points to the elements of the stress process model, and to the experience of shame, as highly promising and potentially modifiable prevention or intervention targets. Declaration of Conflicting Interests The authors had no conflicts of interest with respect to the authorship or the publication of this article.

Funding The authors received the following financial support for the research and/or authorship of this article: project supported by grants R01DA13292 and R01DA16429 from NIDA awarded to R. Jay Turner.

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Erratum

Journal of  Aging and Health 23(6) 1010 © The Author(s) 2011 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0898264311414690 http://jah.sagepub.com

Brown, R. L., & Turner, R. J. (2010). Physical disability and depression: Clarifying racial/ethnic contrasts. Journal of Aging and Health, 22(7), 977-1000. (Original DOI: 10.1177/0898264309360573)

In the October 2010 issue of Journal of Aging and Health, lead author Dr. Brown’s name and affiliation appeared as “Robyn Lewis Brown, MS, Florida State University, Tallahassee.” It should have read, “Robyn Lewis Brown, PhD, DePaul University, Chicago, IL, USA.” The corresponding author information should have read, “Robin Lewis Brown, Department of Sociology, DePaul University, 990 West Fullerton Ave., Suite 1100, Chicago, IL 60614, USA. Email: [email protected].”