Annals of Epidemiology
Volume 22, Issue 2 , Pages 104-111, February 2012

Racial Discrimination, Mood Disorders, and Cardiovascular Disease Among Black Americans

  • David H. Chae, ScD, MA

      Affiliations

    • Rollins School of Public Health, Emory University, Atlanta, GA
    • Corresponding Author InformationAddress correspondence to: David H. Chae, ScD, MA, Emory University, Rollins School of Public Health, Department of Behavioral Sciences and Health Education, 1518 Clifton Road NE, Room 512, Atlanta, GA 30309. Tel.: +1-404-727-8226; Fax: +1-404-727-1369.
    • ,
  • Amani M. Nuru-Jeter, PhD

      Affiliations

    • School of Public Health, University of California, Berkeley, CA
    • ,
  • Karen D. Lincoln, PhD

      Affiliations

    • School of Social Work, University of Southern California, Los Angeles, CA
    • ,
  • Kimberly R. Jacob Arriola, PhD, MPH

      Affiliations

    • Rollins School of Public Health, Emory University, Atlanta, GA

Received 9 June 2011; accepted 14 October 2011. published online 21 November 2011.

Article Outline

Purpose

To examine associations between racial discrimination, mood disorders, and cardiovascular disease (CVD) among Black Americans.

Methods

Weighted logistic regression analyses were performed on a nationally representative sample of Black Americans (n = 5022) in the National Survey of American Life (NSAL; 2001–2003). Racial discrimination and CVD were assessed via self-report. Mood disorder was measured with the World Health Organization Composite International Diagnostic Interview.

Results

Model-adjusted risk ratios (RRs) revealed that participants with a history of mood disorder had greater risk of CVD (RR, 1.28; 95% confidence interval (CI), 1.12–1.45). This relationship was found specifically among those younger than 50 years of age (RR, 1.56; 95% CI, 1.27–1.91). There was a significant interaction between racial discrimination and mood disorder in predicting CVD in the total (F = 2.86, 3 df, p = .047) and younger sample (F = 2.98, 3 df, p = .047). Participants with a history of mood disorder who reported high levels of racial discrimination had the greatest risk of CVD.

Conclusions

The association between racial discrimination and CVD is moderated by history of mood disorder. Future studies may examine pathways through which racial discrimination and mood disorders impact CVD risk among Black Americans.

Key Words: Black Americans, Cardiovascular Disease, Mood Disorders, Racial Discrimination

Selected Abbreviations and Acronyms: NSAL, National Survey of American Life, WMH-CIDI, World Health Organization Composite International Diagnostic Interview, RR, risk ratios, CI, confidence interval

 

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Introduction 

Black Americans experience disproportionately worse cardiovascular outcomes, including hypertension, atherosclerosis, myocardial infarction, and cerebrovascular incidents compared with other racial groups in the United States 1, 2. In addition, Black patients are more likely to die prematurely, experience faster progression of disease, and face worse consequences from heart disease 3, 4. Longitudinal data suggest that the prevalence of hypertension has increased over time, and during the time period from 2003 to 2006, approximately 42.2% of Black men and 44.1% of Black women were hypertensive compared with 30.6% and 31.0% of White men and women, respectively (1). These data indicate that cardiovascular disease is a significant public health concern among Black Americans and emphasize the need to identify relevant risk factors in this population.

There is an established link between mood disorders, particularly depression, and cardiovascular disease 5, 6, 7, 8. Depression subsequent to major cardiovascular events has been shown to exacerbate declines in health and risk of mortality 9, 10. Other investigators 11, 12 suggest that depression itself may be a risk factor for the development of cardiovascular diseases. Mood disorders have been associated with maladaptive health behaviors that increase susceptibility to cardiovascular problems, including poor compliance to taking medication, smoking, heavy consumption of alcohol, and poor diet 5, 13, 14. Patients with depression are at increased risk for developing cardiovascular diseases after one controls for other cardiovascular risk factors, and this association is present even in the absence of a previous diagnosis of depression (15). Depression has been shown to increase the risk of cardiovascular disease 1.5- to 2-fold in otherwise-healthy patients (16).

In recent studies, authors also suggest that psychological factors, such as depression, may have direct effects on cardiovascular health via their impact on biological systems 17, 18, 19. People with mood disorders are characterized by dysregulation of the hypothalamic-pituitary-adrenal axis, elevated baseline immune activation, and heightened inflammatory response, which may aid in the development of hypercholesterolemia, hypertension, and atherosclerosis 17, 18, 20, 21, 22, 23, 24. In previous studies, investigators have found strong correlations between depression and inflammatory biomarkers such as interleukin-1 and -6, tumor necrosis factor, and C-reactive protein, all clinically validated risk markers for atherosclerosis, thrombosis, and vascular occlusion 19, 22, 25, 26, 27, 28, 29. These studies suggest that mood disorders may lead to cardiovascular vulnerability through behavioral and/or neurobiological pathways or that depression and cardiovascular disease may share a common underlying physiologic mechanism.

Racial discrimination may constitute an added source of psychosocial stress that contributes to racial disparities in health and increases the risk of developing cardiovascular diseases among Black Americans 30, 31, 32. Racial discrimination can be experienced in multiple domains, such as employment, housing, the legal system, and in everyday social interactions, both acutely as well as routinely 33, 34. Experiences of these racial stressors across the life-course may contribute to “weathering” or accelerated declines in health due to the cumulative physiologic burden placed on biological systems 31, 35, 36. Consistent with evidence on the deleterious impact of stress on cardiovascular health, the authors of experimental studies have found greater levels of cardiovascular reactivity in response to hypothetical scenarios consisting of a racial stressor compared with those without 37, 38. Sociopsychobiological models of health specifically posit that racial discrimination may adversely impact stress mechanisms associated with cardiovascular health or may exacerbate cardiovascular declines when experienced in tandem with the experience of other stressors 39, 40, 41, 42, 43.

The purpose of this study is to examine associations between a history of mood disorder, racial discrimination, and cardiovascular disease among Black Americans. We further investigate whether associations between racial discrimination and cardiovascular disease are moderated by history of mood disorder. We hypothesized that the association between racial discrimination and cardiovascular disease would be greater among those with a history of mood disorder compared with those without a history of mood disorder.

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Methods 

Sample and Procedures 

Data for this study are from the National Survey of American Life (NSAL; 2001–2003), in which investigators recruited a national household probability sample of Black Americans (N = 5191) 44, 45, 46. In the core sampling component of the NSAL, 64 primary sampling units (PSUs) were sampled, consisting of self-representing metropolitan statistical areas and nonmetropolitan statistical areas. PSUs were selected on the basis of the overall size of the Black population or by the use of a modified probability sampling method. Secondary sampling units, defined as area segments, were selected with the use of probabilities proportionate to the number of 1990 Census Black households. The NSAL Caribbean Supplement was based on an oversampling of housing units in geographic areas with at least a 10% density of people of Caribbean origin. Data were collected between February 2001 and June 2003. Weighted response rates for African American and Caribbean Black participants were 70.7% and 77.7%, respectively. Sampling weights were constructed to take into account joint probabilities of selection of Caribbean participants into the different sampling components.

Measures 

Racial Discrimination 

Racial discrimination was assessed with the Major Experiences of Discrimination measure; participants are asked 9 items pertaining to whether they had ever unfairly experienced any of the following events: being fired, not being hired, being denied a promotion, being abused by the police, being discouraged in education, being prevented from renting or buying housing, experiencing poor treatment by neighbors, being denied a loan, and receiving poor treatment from service providers (47). After each item was a single item assessing the reason for each experience (eg, race, age, gender, socioeconomic status). Participants who reported experiencing the event and made an attribution of race, ancestry, or skin color were classified as having experienced racial discrimination in that situation. The total number of situations in which racial discrimination was reported was categorized into: 1 = none; 2 = low (1–2 situations); 3 = moderate (3–4 situations); and 4 = high (5 or more situations).

Mood Disorder 

Mood disorder was defined as having a history of any of the following: (i) major depression; (ii) dysthymia; and (iii) bipolar disorder I, II. A history of each disorder was assessed with a modified version of the World Mental Health Survey Initiative version of the World Health Organization Composite International Diagnostic Interview (WMH-CIDI) 48, 49. The WMH-CIDI is a structured interview designed to detect mental disorders using Diagnostic and Statistical Manual, Version 4 criteria (50). Major depression criteria include affective, cognitive, and somatic symptoms, including depressed mood, loss of interest, irritability, difficulty concentrating, and changes in appetite, weight, and sleep. Symptoms of dysthymia are similar to those of depression but are more pervasive and less severe, and unlike major depression, are not characterized by discrete episodes. Bipolar I criteria include having at least one manic episode or period of abnormal elevated mood, which can occur with or without episodes of major depression, whereas bipolar II is characterized by less severe hypomanic episodes and at least one episode of major depression. Earlier versions of the WMH-CIDI have been found to have high concordance with blind clinical appraisals (51).

History of Cardiovascular Disease 

History of cardiovascular disease was assessed through self-report. Four items asked participants whether they had ever had hypertension, atherosclerosis, heart attack, or stroke. Participants who indicated that they ever had any of these problems were classified as having a history of cardiovascular disease. Although retrospective reports of cardiovascular health are limited, the authors of previous studies have found high levels of recall accuracy 52, 53. Furthermore, nonclinical terms that were linguistically and culturally appropriate for the target population were used (eg, “high blood pressure,” “blood circulation problems or hardening of the arteries,” “heart trouble or heart attack”). In addition, to take into account differences in knowledge of cardiovascular health resulting from access to medical care, we controlled for insurance status in multivariable models.

Sociodemographic Characteristics 

Covariates were self-reported measures of: ancestry (African American vs Caribbean Black), age, gender, marital status, poverty level specified as the ratio of household income to the poverty threshold, employment status, educational level, insurance status, and region of residence. Social desirability bias was also assessed to control for personality factors that may influence responses to sensitive items, and was calculated as the mean of 10 items endorsed as false (with a value of zero) or true (with a value of one), with greater scores reflecting greater levels of personality bias (54). In addition, four indicators of health were examined: body mass index, which was calculated with the use of self-reported height and weight; smoking status; physical activity, which was measured as the average of three items assessing the frequency of exercise, walking, and household chores, with response choices of 1 = never, 2 = rarely, 3 = sometimes, and 4 = often; and number of chronic conditions from a checklist of 14 common health issues (excluding cardiovascular outcomes), such as arthritis, ulcer, diabetes, and cancer.

Analysis 

A total of 169 participants with missing data on cardiovascular disease were excluded, leaving a total analytic sample size of 5022 participants. Missing data on remaining variables were handled by the use of multiple imputation, in which five imputations for missing values were generated with a Markov chain Monte Carlo technique assuming an arbitrary missing data pattern 55, 56, 57. Imputed data were truncated to fit the bounds of possible values but were not rounded because of potential bias of effect estimates 58, 59.

Multivariable logistic regression models were specified that examined associations between mood disorder, racial discrimination, and the interaction between mood disorder and racial discrimination in predicting cardiovascular disease. Given the greater prevalence of cardiovascular disease among older groups, we also examined interactions by age. We hypothesized that associations with our primary predictors may be less apparent among older participants given that poor cardiovascular outcomes may be driven dominantly by increasing age in this group, masking associations with mood disorders and racial discrimination. We examined interactions between age group (49 years of age or younger vs 50 years of age and older) and both mood disorder and racial discrimination in predicting cardiovascular disease. We chose the cut-point of 50 years of age in light of descriptive analyses indicating a very high prevalence of cardiovascular disease among those 50 years of age and older (67.7%); and a lower prevalence of 24.0% among those 49 years of age and younger.

All analyses were conducted with SAS-callable SUDAAN Version 10.0.0; we took into account sampling weights and study design variables. Because risk ratios are more interpretable than odds ratios in examining common binary outcomes, we computed model-adjusted risk ratios (RRs) and 95% confidence intervals (CIs) on the basis of average marginal predictions (60).

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Results 

The prevalence of cardiovascular disease in our sample was 36.9%. Approximately 13% had a history of mood disorder. Participants with a history of mood disorder had a significantly greater prevalence of cardiovascular disease (43.8%) compared with those without a history of mood disorder (35.8%). Although participants reporting greater levels of racial discrimination had a greater prevalence of cardiovascular disease, this association was not significant. Additional sociodemographic characteristics are presented in Table 1.

Table 1. Weighted descriptive characteristics of Black Americans (N = 5022) in the National Survey of American Life (2001–2003) by history of CVD
History of CVDTotal
NoneAny
History of CVD, n (%)
Any CVD 1769 (36.9)
Hypertension 1568 (33.1)
Atherosclerosis 288 (6.0)
Heart attack 362 (7.6)
Stroke 142 (3.0)
Mood disorder, n (%)∗
No2868 (64.2)1516 (35.8)4384 (87.0)
Yes381 (56.2)250 (43.8)631 (13.0)
Racial discrimination, n (%)
None1826 (64.6)974 (35.5)2800 (55.0)
Low (1–2)976 (62.8)521 (37.2)1497 (32.4)
Moderate (3–4)264 (60.9)156 (39.1)420 (9.5)
High (5+)71 (48.7)58 (51.4)129 (3.1)
Age, mean (SE)‡36.45 (0.46)51.27 (0.54)41.91 (0.50)
Gender, n (%)†
Men1259 (66.0)588 (34.0)1847 (44.4)
Women1994 (60.9)1181 (39.1)3175 (55.8)
Race/ethnicity, n (%)∗
African American2130 (62.7)1306 (37.3)3436 (92.9)
Caribbean Black1123 (69.2)463 (30.8)1586 (7.1)
Nativity, n (%)‡
U.S.-born2352 (62.1)1418 (37.9)3770 (93.2)
Foreign-born871 (78.1)334 (21.9)1205 (6.8)
Marital status, n (%)‡
Married931 (58.5)551 (41.6)1482 (33.3)
Partnered284 (72.1)99 (27.9)383 (9.0)
Widowed, separated, divorced758 (48.3)731 (51.7)1489 (26.0)
Never married1280 (77.7)388 (22.3)1668 (31.7)
Poverty Level, n (%)∗
Poor, <1.00677 (58.6)470 (41.4)1147 (23.3)
Near-poor, 1.00–1.99785 (61.1)476 (38.9)1261 (23.8)
Non-poor, 2.00–3.991095 (66.7)488 (33.3)1583 (32.2)
Non-poor, 4.00+696 (65.0)335 (35.0)1031 (20.7)
Education, n (%)‡
<12 years619 (50.5)563 (49.5)1182 (23.9)
12 years1195 (67.6)574 (32.4)1769 (37.0)
13–15 years848 (66.6)373 (33.4)1221 (24.2)
16+ years591 (66.7)259 (33.3)850 (14.9)
Work status, n (%)‡
Employed2474 (70.0)942 (30.1)3416 (67.6)
Unemployed360 (73.0)150 (27.0)510 (10.1)
Out of labor force419 (38.1)677 (61.9)1096 (22.3)
Insurance, n (%)‡
Any2528 (61.1)1505 (38.9)4033 (81.8)
None725 (72.5)264 (27.6)989 (18.2)
Region, n (%)
Northeast1034 (66.6)477 (33.4)1511 (18.9)
Midwest323 (58.5)236 (41.5)559 (16.7)
South1737 (63.7)966 (36.3)2703 (54.8)
West159 (61.0)90 (39.0)249 (9.7)
Social desirability, mean (SE)∗1.96 (0.04)2.14 (0.07)2.02 (0.04)
Body mass index, mean (SE)‡27.71 (0.15)30.44 (0.18)28.72 (0.12)
Smoking, n (%)‡
Never smoker2191 (68.2)974 (31.8)3165 (58.4)
Former smoker326 (45.4)340 (54.6)666 (14.7)
Current smoker717 (62.5)436 (37.5)1153 (26.9)
Physical activity, mean (SE)‡2.76 (0.02)2.6 (0.03)2.7 (0.02)
Chronic conditions, mean (SE)‡0.46 (0.02)1.28 (0.03)0.76 (0.01)

CVD = cardiovascular disease.

∗p < .05.

†p < .01.

‡p < .001.

Weighted Logistic Regressions Predicting Cardiovascular Disease 

Controlling for covariates, history of mood disorder was positively associated with cardiovascular disease (RR, 1.29; 95% CI, 1.13–1.46; Table 2: model 1). Racial discrimination was not a significant predictor (F = 0.65, 3 df, p = .59; Table 2: model 2). Including both mood disorder and racial discrimination in the model, mood disorder remained statistically significant (RR, 1.28; 95% CI, 1.12–1.45; Table 2: model 3).

Table 2. Model-adjusted RRs from weighted logistic regressions predicting history of CVD among Black Americans (N = 5022) in the National Survey of American Life (2001–2003)
CVD history, model 1 RR (95% CI)CVD history, model 2 RR (95% CI)CVD history, model 3 RR (95% CI)
Mood disorder∗∗∗, ‡‡‡1.29 (1.13–1.46) 1.28 (1.12–1.45)
Racial discrimination (ref: None)
Low (1–2) 1.05 (0.96–1.15)1.04 (0.95–1.14)
Moderate (3–4) 1.01 (0.88–1.13)0.99 (0.86–1.11)
High (5+) 1.18 (0.90–1.54)1.13 (0.87–1.45)
Age∗∗∗,†††,‡‡‡1.05 (1.04–1.06)1.05 (1.04–1.06)1.05 (1.04–1.06)
Gender: women vs men0.97 (0.89–1.05)0.99 (0.91–1.07)0.98 (0.90–1.06)
Caribbean vs African American∗∗,†,‡1.22 (1.05–1.39)1.23 (1.06–1.41)1.22 (1.05–1.39)
Nativity: foreign vs U.S.-born∗∗,††,‡‡0.72 (0.58– 0.93)0.72 (0.57–0.93)0.73 (0.58–0.93)
Marital status (ref: married)
Partnered0.99 (0.84–1.17)0.99 (0.84–1.17)0.99 (0.84– 1.17)
Widowed/separated/divorced0.91 (0.81–1.04)0.92 (0.81–1.04)0.91 (0.81–1.03)
Never married0.98 (0.87–1.13)0.99 (0.87–1.13)0.99 (0.87– 1.13)
Poverty (ref: Poor, <1.00)
Near-poor, 1.00–1.990.93 (0.80–1.08)0.92 (0.79–1.06)0.92 (0.80– 1.07)
Non-poor, 2.00–3.990.88 (0.78–1.00)0.88 (0.78–1.00)0.88 (0.78– 1.00)
Non-poor, 4.00 +0.88 (0.74–1.03)0.87 (0.74–1.03)0.88 (0.74–1.04)
Education (ref: <12 years)∗,†,‡
12 years0.89 (0.80–0.99)0.88 (0.80–0.98)0.89 (0.80–0.98)
13–15 years0.95 (0.84–1.07)0.94 (0.84–1.06)0.94 (0.84–1.06)
16+ years0.84 (0.73–0.97)0.83 (0.72–0.96)0.83 (0.72–0.96)
Work status (ref: employed)
Unemployed0.93 (0.81–1.07)0.93 (0.81–1.07)0.93 (0.81–1.07)
Out of labor force1.08 (0.96–1.21)1.08 (0.96–1.21)1.08 (0.96–1.21)
Insurance: none vs any0.91 (0.80–1.03)0.91 (0.80–1.04)0.91 (0.80–1.03)
Region (ref: South)
Northeast0.91 (0.81–1.01)0.91 (0.81–1.01)0.90 (0.81–1.00)
Midwest1.06 (0.92–1.21)1.07 (0.93–1.23)1.05 (0.92–1.21)
West1.05 (0.92–1.20)1.05 (0.92–1.20)1.05 (0.91–1.20)
Social desirability∗0.98 (0.95–1.00)0.98 (0.95–1.00)0.98 (0.96–1.00)
Body mass index∗∗∗,†††,‡‡‡1.04 (1.03–1.05)1.04 (1.03–1.05)1.04 (1.03–1.05)
Smoking (ref: never)
Former smoker1.05 (0.93–1.20)1.05 (0.92–1.20)1.05 (0.92–1.20)
Current smoker1.03 (0.91–1.16)1.03 (0.91–1.17)1.02 (0.90–1.16)
Physical activity0.97 (0.91–1.03)0.97 (0.91–1.03)0.97 (0.91–1.03)
Chronic conditions∗∗∗,†††,‡‡‡1.27 (1.19–1.36)1.29 (1.21–1.37)1.27 (1.20–1.35)

CI = confidence interval; CVD = cardiovascular disease; RR = risk ratios.

Note: Model 1 examines the association between mood disorder and history of cardiovascular disease; model 2 examines the association between racial discrimination and history of cardiovascular disease; and model 3 examines mood disorder and racial discrimination concurrently in relation to history of cardiovascular disease. All three models adjust for sociodemographic factors.

Model 1: ∗p < .05, ∗∗p < .01, ∗∗∗p < .001.

Model 2: †p < .05, ††p < .01, †††p < .001.

Model 3: ‡p < .05, ‡‡p < .01, ‡‡‡p < .001.

In two separate models testing interactions with age group (≤49 years vs ≥50 years): there was no significant interaction with racial discrimination (F = 0.20, 3 df, p = .89); however, there was a significant interaction with mood disorder (F = 7.29, 1 df, p = .01). We performed age-stratified analyses to illustrate differences in associations by age group (Table 3).

Table 3. Model-adjusted RRs from weighted logistic regressions predicting history of CVD among Black Americans (N = 5022) in the National Survey of American Life (2001–2003) by age group
≤49 years of age (n = 3532), CVD history, RR (95% CI)≥50 years of age (n = 1490), CVD history, RR (95% CI)
Mood disorder∗∗∗1.56 (1.27–1.91)1.02 (0.91–1.14)
Racial discrimination (ref: none)
Low (1–2)1.04 (0.86–1.25)1.04 (0.93–1.16)
Moderate (3–4)0.86 (0.68–1.10)1.07 (0.93–1.23)
High (5+)1.09 (0.70–1.69)1.07 (0.84–1.35)
Age∗∗∗1.06 (1.05–1.08)1.00 (1.00–1.01)
Gender: women vs men0.95 (0.83–1.08)0.98 (0.90–1.07)
Caribbean vs. African American∗1.47 (1.10–1.92)1.01 (0.78–1.31)
Nativity: foreign vs. U.S.-born∗∗0.50 (0.29–0.85)0.96 (0.74–1.25)
Marital status (ref: married)
Partnered1.07 (0.83–1.39)0.92 (0.71–1.20)
Widowed/separated/divorced0.95 (0.78–1.16)0.93 (0.83–1.04)
Never married1.08 (0.88–1.34)0.92 (0.80–1.06)
Poverty (ref: poor, < 1.00)
Near-poor, 1.00–1.990.86 (0.67–1.11)1.04 (0.90–1.19)
Non-poor, 2.00–3.990.78 (0.64–0.96)1.02 (0.88–1.19)
Non-poor, 4.00+0.76 (0.60–0.97)0.96 (0.78–1.16)
Education (ref: <12 years)∗
12 years0.79 (0.66–0.96)0.93 (0.84–1.03)
13–15 years0.89 (0.72–1.10)0.97 (0.84–1.11)
16+ years0.69 (0.52–0.91)0.93 (0.81–1.07)
Work status (ref: employed)
Unemployed0.87 (0.68–1.11)1.02 (0.85–1.23)
Out of labor force1.15 (0.90–1.46)1.12 (0.99–1.28)
Insurance: none vs any∗0.83 (0.69–0.98)0.93 (0.80–1.09)
Region (ref: South)
Northeast0.82 (0.68–0.98)0.99 (0.84–1.15)
Midwest1.01 (0.80–1.27)1.08 (0.97–1.21)
West0.96 (0.80–1.16)1.14 (0.93–1.39)
Social desirability†1.00 (0.96–1.04)0.97 (0.96–0.99)
Body mass index∗∗∗,††1.04 (1.03–1.06)1.04 (1.01–1.08)
Smoking (ref: never)
Former smoker1.17 (0.87–1.59)0.92 (0.82–1.02)
Current smoker1.09 (0.88–1.36)0.88 (0.78–1.00)
Physical activity0.95 (0.86–1.05)0.98 (0.94–1.02)
Chronic conditions∗∗∗,†††1.33 (1.21–1.47)1.22 (1.13–1.31)

CI = confidence interval; CVD = cardiovascular disease; RR = risk ratios.

Among ≤49 years of age: ∗ p < .05, ∗∗ p < .01, ∗∗∗ p < .001.

Among ≥50 years of age: † p < .05, †† p < .01, ††† p < .001.

There was a positive relationship between mood disorder and cardiovascular disease among participants younger than 50 years of age (RR, 1.56; 95% CI, 1.27–1.91). However, among those 50 years of age and older, there was little relationship (RR, 1.02; 95% CI, 0.91–1.14). There was no significant relationship between racial discrimination and cardiovascular disease in either age group. With the exception of social desirability, the magnitudes of associations for significant covariates were greater among those younger than 50 years of age.

Interactions Between Racial Discrimination and Mood Disorder 

We examined interactions between racial discrimination and mood disorder in predicting cardiovascular disease, in the entire sample and by age group (Table 4). To illustrate the relationship between racial discrimination and cardiovascular disease among those without a history of mood disorder, we examined the simple effects of racial discrimination in the model with the interaction; and then rotated the referent category for mood disorder to observe the simple effects of racial discrimination among those with a history of mood disorder (61).

Table 4. Model-adjusted RRs for racial discrimination by mood disorder from simple effects of weighted logistic regression predicting history of CVD among Black Americans (N = 5022) in the National Survey of American Life (2001–2003)
No mood disorder CVD history RR (95% CI)Any mood disorder CVD history RR (95% CI)
Total sample (n = 5022)
Racial discrimination (ref: none)
Low (1–2)1.06 (0.95–1.18)1.00 (0.75–1.32)
Moderate (3–4)1.00 (0.86–1.15)0.94 (0.64–1.40)
High (5+)0.96 (0.72–1.28)1.62 (1.20–2.19)
≤49 years of age (n = 3532)
Low (1–2)1.07 (0.87–1.30)0.91 (0.55–1.48)
Moderate (3–4)0.86 (0.65–1.14)0.85 (0.42–1.79)
High (5+)0.66 (0.34–1.26)2.01 (1.24–3.25)
≥ 50 years of age (n = 1490)
Low (1–2)1.02 (0.91–1.13)1.21 (0.87–1.68)
Moderate (3–4)1.07 (0.93–1.23)1.10 (0.77–1.59)
High (5+)1.01 (0.80–1.28)1.34 (1.02–1.77)

CI = confidence interval; CVD = cardiovascular disease; RR = risk ratios.

Note: Controlling for age, gender, ethnicity, nativity, marital status, poverty, education, work status, insurance, region, social desirability, body mass index, smoking status, physical activity, and chronic conditions.

Interaction between racial discrimination and mood disorder:

Total sample: Wald F = 2.86, 3 df, p = .047.

Age ≤49 years: Wald F = 2.98, 3 df, p = .047.

Age ≥50 years: Wald F = 1.13, 3 df, p = .344.

RRs and 95% CIs by mood disorder obtained by testing the simple effects of racial discrimination in weighted logistic regression models including interaction terms.

The interaction between mood disorder and racial discrimination was significant for the entire sample (F = 2.86, 3 df, p = .047) and those younger than 50 years of age (F = 2.98, 3 df, p = .047). When we used the entire sample, we found that participants with a history of mood disorder and who reported high levels of racial discrimination had the greatest risk of cardiovascular disease (RR, 1.62; 95% CI, 1.20–2.10). Among those younger than 50 years of age who had a history of mood disorder, reporting high levels of racial discrimination was associated with twice the risk of cardiovascular disease compared to reporting no racial discrimination (RR, 2.01; 95% CI, 1.24–3.25). However, there were no significant relationships between racial discrimination and cardiovascular disease among those without a history of mood disorder. Among those 50 years of age or older who had a history of mood disorder, reporting high levels of racial discrimination was also associated with significantly greater risk of cardiovascular disease compared to those who reported no racial discrimination (RR, 1.34; 95% CI, 1.02, 1.77). However, in this age group, the interaction between racial discrimination and mood disorder was not significant (F = 1.13, 3 df, = 0.34).

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Discussion 

The results of this study support previous findings suggesting that mood disorders are associated with greater risk of cardiovascular disease 8, 9, 15. After controlling for demographic, behavioral, and other health characteristics, we found that participants with a history of mood disorder had 28% greater risk of having a cardiovascular disease compared with those without a history of mood disorder. This relationship was pronounced among those younger than 50 years of age, with those with a history of mood disorder having more than 1.5 times the risk of cardiovascular disease.

Although we did not find evidence for main effects of racial discrimination, we found moderated associations with mood disorders in predicting cardiovascular disease. Our results suggest that high levels of racial discrimination may be associated with greater risk of cardiovascular disease among those with a history of mood disorder. A possible interpretation of this finding is that racial discrimination may increase the risk of cardiovascular disease among those who respond to such experiences with negative psychological reactions. Other investigators have consistently found evidence for the negative mental health implications of experiencing racial discrimination 62, 63, 64. This interpretation is also consistent with stress and coping frameworks that suggest that the impact of discrimination on health may depend on appraisals and responses to stress (65). An alternative explanation is that participants with a mood disorder may lack the resources to effectively manage or cope with experiences of racial discrimination. As an additional source of psychosocial burden, those with a mood disorder may be particularly vulnerable to racial discrimination and subsequent declines in cardiovascular health.

There are several caveats to our findings given the cross-sectional nature of the data. First, there were fewer associations found between our predictors and cardiovascular disease among participants 50 years of age or older, and most significant associations were found among those 49 years of age and younger. One possible explanation is that given the greater prevalence of cardiovascular disease among older groups (67.7% in our sample of participants 50 years of age or older), associations with our predictors would be masked or attenuated. Accordingly, associations with our predictors may be more apparent in younger age groups, in whom cardiovascular disease is less common.

In addition, because of the lack of data on the temporal sequence of our exposures and outcome, inferences regarding the causal direction of associations are limited. For example, we are unable to deduce the direction of the relationship between mood disorder and cardiovascular disease, and other authors have found evidence for a bidirectional association, with the onset of cardiovascular disease increasing the risk of depression, as well as depression being an independent risk factor for the onset of cardiovascular disease 9, 10, 11, 12. Furthermore, it is possible that participants with a history of depression and cardiovascular disease were more likely to perceive racial discrimination. Because of the cross-sectional nature of our data, we cannot discount alternative explanations regarding the directions of the associations we found.

An additional limitation of the current study is the self-report of cardiovascular disease history. However, other authors 52, 53 have demonstrated the accuracy of recall and self-report of cardiovascular disease history. Nevertheless, some participants may have been unaware of their cardiovascular disease status. To address possible systematic differences in knowledge as well as disclosure, we controlled for a number of potential confounders in our models, including various socioeconomic indicators, insurance status, and social desirability response bias. In addition, we controlled for four health-related variables in our models that are known risk factors for cardiovascular disease (smoking, body mass index, physical activity, and other chronic conditions). Results from our study also face limitations from possible model misspecification, including variables that were not included in analyses, such as treatment, duration, and severity of mood disorder. In addition, although the NSAL data have been shown to be representative of the Black population in the United States, potential selection bias and nonresponse may have influenced our effect estimates and also impact generalizability of findings.

Future studies examining cardiovascular disease among Black Americans may examine causal relationships through prospective examination of racial discrimination, mood disorders, and the onset of cardiovascular disease. Findings from our study suggest that examining psychological responses to racial discrimination may be informative in understanding racial disparities in cardiovascular health. In addition, our study highlights potential avenues for improving cardiovascular health among Black Americans, including efforts to address mental health and racial discrimination. Additional research investigating both broader social influences as well as psychological factors impacting cardiovascular health among Black Americans is warranted.

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 The National Survey of American Life is supported by the National Institute of Mental Health (NIMH; grant U01-MH57716; P.I.: J. S. Jackson) with supplemental support from the Office of Behavioral and Social Science Research at the National Institutes of Health and the University of Michigan.

PII: S1047-2797(11)00313-9

doi:10.1016/j.annepidem.2011.10.009

Annals of Epidemiology
Volume 22, Issue 2 , Pages 104-111, February 2012

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