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Abstract
The Black-white Depression paradox, the lower prevalence of major depression among
non-Hispanic Black (relative to non-Hispanic white) individuals despite their greater
exposure to major life stressors, is a phenomenon that remains unexplained. Despite
a decade plus of research, there is little clarity as to whether the paradoxical observations
are an invalid finding, spuriously produced by selection bias, information bias, or
confounding, or are a valid finding, representative of a true racial patterning of
depression in the population. Though both artefactual and etiologic mechanisms have
been tested, a lack of synthesis of the extant evidence has contributed towards an
unclear picture of the validity of the paradox and produced challenges for researchers
in determining which proposed mechanisms show promise, which have been debunked, and
which require further study. The objective of this critical review is to assess the
state of the literature regarding explanations for the Black-white depression paradox
by examining some of the more prominent hypothesized explanatory mechanisms that have
been proposed and assessing the state of the evidence in support of them. Included
mechanisms were selected for their perceived dominance in the literature and the existence
of at least one, direct empirical test using DSM major depression as the outcome.
This review highlights the very limited evidence in support of any of the extant putative
mechanisms, suggesting that investigators should redirect efforts towards identifying
novel mechanisms, and/or empirically testing those which show promise but to date
have been relatively understudied. We conclude with a discussion of the broader implications
of the evidence for well-accepted social theories and raise questions regarding the
use of DSM major depression to assess mental health burden in Black communities.