Racialdifferences
Choose one diverse population of interest as highlighted in this week’s readings and discuss what information was gained from the article addressing that population which would influence how a student would approach addiction treatment with someone from that population. Length: 300-400 words
Substance Use & Misuse, 47:
734
–744, 2012
Copyright C© 2012 Informa Healthcare USA, Inc.
ISSN: 1082-6084 print / 1532-2491 online
DOI: 10.3109/10826084.2012.666312
ORIGINAL ARTICLE
Racial Differences in Co-Occurring Substance Use and Serious
Psychological Distress: The Roles of Marriage and Religiosity
Celia C. Lo1, Kimberly A. Tenorio2 and Tyrone C. Cheng1
1School of Social Work, University of Alabama, Tuscaloosa, Alabama, USA; 2Florida State College at Jacksonville,
Office of Open Campus, Jacksonville, Florida, USA
The study examined how marriage and religiosity
can protect members of certain racial/ethnic groups
against co-occurring substance use and serious psy-
chological distress. Using the national dataset 2007
National Survey on Drug Use and Health, we ana-
lyzed data via multinomial logistic regression, observ-
ing several important results. Our findings generally
support the deprivation-compensation thesis, in that
religiosity elevates the mental health of racial/ethnic
minority individuals more than that of Whites. We also
found, however, that race/ethnicity moderates effects
of education and poverty on the co-occurring behav-
iors, with Whites’ mental health benefiting more from
wealth and education than Blacks’ or Hispanics’ men-
tal health did.
Keywords social integration, religiosity, marriage, substance
abuse, serious psychological distress, co-occurring behaviors
INTRODUCTIO
N
Co-occurring drug abuse1 and mental illness is
widespread in the United States (NIDA [National
Institute on Drug Abuse], 2007), as is the more specific
instance of co-occurring drug use and serious psycholog-
ical distress (Kessler et al., 1996; Psychiatric Services,
2006; Rosenberg, 2008). Often, one mental health prob-
lem results from another, as when serious psychological
distress occurs following frequent, severe drug use
(Dennis, Key, Kirk, & Smith, 1995) or when drugs are
used in an attempt to self-medicate (Dennis et al., 1995)
1The journal’s style utilizes the category substance abuse as a diagnostic category. Substances are used or misused; living organisms are and can be
abused. Editor’s note.
2The reader is asked to consider that concepts and processes such as “risk” and “protective” factors are often noted in the literature, without
adequately delineating their dimensions (linear, nonlinear, rates of development, sustainability, cessation, etc.), their “demands,” the critical
necessary conditions (endogenously as well as exogenously, micro to macro levels) which are necessary for them to operate (begin, continue,
become anchored and integrate, change as de facto realities change, cease, etc.) or not to operate and whether their underpinnings are theory driven,
empirically based, individual and/or systemic stake holder bound, historically bound, based upon “principles of faith” or what. This is necessary to
clarify, if possible, whether these terms are not to remain as yet additional shibboleths in a field of many stereotypes. Editor’s note.
Address correspondence to Celia C. Lo, School of Social Work, University of Alabama, Box 870314, Tuscaloosa, AL 35487, USA; E-mail:
clo@ua.edu.
or otherwise palliate mental illness (RachBeisel, Scott, &
Dixon, 1999) or, more specifically, psychological distress
(Kessler et al., 1996; Manchikanti et al., 2007). Whatever
their onset order, drug abuse and mental illness alike are
risk factors2 for each other’s appearance (NIDA, 2007).
Racial/ethnic disparities in mental health exist because
American society is organized in a way that creates and
perpetuates social inequalities among its citizens, through
a system of rewards and ascriptive processes (Aneshensel,
1992, 2009; Aneshensel, Rutter, & Lachenbruch, 1991;
Grusky, 2001; Rothman, 2005). Social institutions de-
fine what is acceptable, what is good, within a society.
These social institutions then operate to ensure that only
those groups they endorse are able to win the rewards
available in the society. This sets up generational perpet-
uation, or status crystallization, of the social inequalities
created by the institutions (Grusky, 2001). Health is a re-
ward that is subject to such status crystallization based on
group membership. To a marked degree, the society cre-
ates its citizens’ differential health statuses. While the in-
dividual’s physical condition is always an influence, the
relative exposure to phenomena that damage health, and
to resources that enhance health, is a function of member-
ship in particular social groups (Lynch & Kaplan, 2000;
Marmot, Kogevinas, & Elston, 1987). Those who belong
to a racial/ethnic minority are not fully endorsed by social
institutions and thus constitute the groups on the social
ladder’s lower rungs, where the bulk of physical and men-
tal health problems are located.
Studies seeking to explain co-occurring substance use
and serious psychological distress are few. But many
734
SUBSTANCE ABUSE AND SERIOUS PSYCHOLOGICAL DISTRESS 735
studies have shown race/ethnicity to be a correlate of,
separately, substance use and psychological distress. The
discrimination, stigma, and negative stereotypes associ-
ated with membership in a racial/ethnic minority can
be stressors for members of these groups (Aneshensel,
1992, 2009; Aneshensel et al., 1991; Gary, 2005; Williams
& Rucker, 2000). Social institutions function so that,
in general, these groups’ members—since they are not
fully endorsed—will obtain only low incomes and lesser-
quality services, including health care, but at the same
time will receive relatively more interest from the legal
system, which increases stress (Sachs-Ericsson, Plant, &
Blazer, 2005; Williams & Rucker, 2000).
Not surprisingly, since they meet with differential stres-
sors, the members of different racial/ethnic groups may
respond to stress differently. Whites have been found to
misuse alcohol at a greater rate than the main minor-
ity groups do (Blacks, Hispanics) (Green, Freeborn, &
Polen, 2001; Muthen & Muthen, 2000), although use
rates for illicit drugs appear very similar among Whites,
Blacks, and Hispanics3 (Mosher & Akins, 2007; NIDA,
2003; SAMHSA [Substance Abuse and Mental Health
Services Administration], 2009). At least one study found
a higher rate of psychological distress for Blacks than
Whites (Brown & Keith, 2003), even though more gener-
ally it is Whites who, of any racial/ethnic group, are likeli-
est to experience serious mental illness (SAMHSA, 2009);
furthermore, particular forms of mental health problems
seem to typify Whites, Hispanics, and Blacks who do be-
come ill (McVeigh et al., 2006; SAMHSA, 2009).
Since all racial minorities are socially disadvantaged,
why should their members have lower rates of mental
health disorders than Whites? The finding may reflect
the many subgroups constituting a racial minority in the
United States. The Hispanic minority includes Cuban,
Mexican American, Puerto Rican, and other subgroups,
each of which exhibits a distinct culture, has experienced
a distinct acculturation process, and responds to stress in
distinct behavioral ways (Balcazar, Aoyama, & Cai, 1991;
Nielsen, 2000; Scribner, 1996). The cultures of the sub-
groups nevertheless value certain collectivist, interdepen-
dent ideals, and their members draw powerful social sup-
port from one another that counteracts, to a degree, the
inequity and deprivation they all face (Plant & Sachs-
Ericsson, 2004).
Marriage and religiosity4 illustrate social integration’s
posited protective nature and may enhance psychological
well-being by several mechanisms. First, as compared
to their absence, marriage and religiosity are associated
with less stress and strain, two states detrimental to
psychological well-being (Hackney & Sanders, 2003;
Roohafza et al., 2007). Marriage is a normative life
stage, so having a spouse means reduced exposure to
3The reader is reminded that the three categories of Whites, Blacks,
and Hispanics, as racial or ethnic groups, represent heterogeneity and
not homogeneity in each group and that the 2010 US Census greatly
expanded the choices for ethnic self-identification. Editor’s note
4Religiosity is defined as an individuals’ bonding or commitment to
religion and religious beliefs.
stress and strain compared with never-married, divorced,
and widowed individuals. The latter groups are likely
to face comparatively high levels of financial difficulty,
work–family conflict, and child-care worries, increasing
psychological distress and impairing mental health
(Avison, Ali, & Walters, 2007; Dziak, Janzen, &
Muhajarine, 2010; Roohafza et al., 2007). Similarly,
according to research, those who attend church regu-
larly report less exposure to stress (Ellison, Boardman,
Williams, & Jackson, 2001). Believing their relationship
with God to be good, and having faith that God will pro-
vide love and assistance, religious individuals are more
likely than others to have a low level of psychological
distress (Flannelly, Koenig, Galek, & Ellison, 2007).
Second, social integration’s link to good health of-
ten involves the extension of social networks that—
accompanied by sufficient other psychosocial, social,
health, and material resources—may work to promote
healthy behaviors and neutralize stress (Aneshensel,
2009; Berkman, Glass, Brissette, & Seeman, 2000; Datta,
Neville, Kawachi, Datta, & Earle, 2009; George, Elli-
son, & Larson, 2002; House, Umberson, & Landis, 1988;
Jackson & Neighbors, 1996; Osborne, Ostir, Du, Peek,
& Goodwin, 2005). The larger the network, the more
readily available the social support that enhances coping
with problems (George, 2010). It should be noted, how-
ever, that not all pertinent studies confirm that marriage
is beneficial for coping with stress (Avison et al., 2007).
As for religiosity, its health benefits may be qualified by
the individual’s particular religious experiences. Experi-
encing positive, collaborative relationships with God and
with other believers offers the strongest benefit when it
comes to coping with problems (Ano & Vasconcelles,
2005; George et al., 2002; House, Landis, & Umberson,
1988; Phillips, Pargament, Lynn, & Crossley, 2004).
Third, the kind of social integration that social net-
works promote, in turn, promotes social control. The
social control thus promoted is often consistent with a
healthy lifestyle and with good health (George et al., 2002;
House, Landis, et al., 1988; House, Umberson, et al.,
1988; Umberson, 1987).
Religion and marriage, then, are social integration
factors shown to promote healthy behaviors and psycho-
logical adaptation (Jang et al., 2009; Umberson, 1987).
However, these factors may not function uniformly to
protect the health of the members of different racial/ethnic
groups. Marriage’s and religiosity’s health-promoting
benefits likely vary within different racial/ethnic groups,
because racial/ethnic status is linked both to the quantity
and quality of social relationships (House, Landis, et al.,
1988).
In the present study, our interest was understanding
interactions involving race/ethnicity and marital status
and religiosity, which according to Link and Phelan are
the social conditions that put “people at risk of risks”
(1995, p. 89). By treating marriage and religiosity as
social integration factors and investigating differences in
co-occurring substance use and serious psychological dis-
tress, we intended our study to achieve three objectives.
736 C. C. LO ET AL.
First, we sought to examine systematically whether and
how marriage’s and religiosity’s effects on co-occurring
behaviors differ from one racial/ethnic group to another.
Diverse studies have indicated, thus far, that social inte-
gration factors wield unequal effects on the mental health
of individuals in different social groups (House, Landis,
et al., 1988). Second, in the event we observed evidence
supporting our unequal effects hypothesis, we intended
to measure effects’ relative power, asking whether partic-
ularly strong effects were associated with Whites or with
the Black and Hispanic racial/ethnic minorities. Third, we
meant to explore how the co-occurring behaviors might be
differentially affected by factors beyond our pair of social
integration factors, an understanding that might help min-
imize group-based differences in co-occurring behaviors.
Evidence of how race/ethnicity and poverty and gender
interact, contributing to the development of co-occurring
behaviors, could help answer questions about the proper
role for research and regulatory efforts in improving
mental health (Link & Phelan, 1995; Suthers, 2008).
METHODS
Design and Sample
Data for our study came from the 2007 National Survey
on Drug Use and Health (NSDUH), a national household
survey series describing a representative sample of civil-
ian, noninstitutionalized individuals aged 12 or over in
the United States. NSDUH has been conducted annually
since 1991 and seeks to determine the extent of the use of
illicit drugs, and the rate of mental disorders, in the Amer-
ican civilian population. The final sample employed in the
present study excluded NSDUH respondents who iden-
tified themselves as Native Americans/Alaska Natives,
Asians, and Native Hawaiian/other Pacific Islanders; it
also excluded those claiming more than one racial/ethnic
identity. Our final sample furthermore included only
adults 18 years or older. Ultimately, the sample num-
bered 34,650 individuals who identified themselves as
non-Hispanic White, non-Hispanic Black, or Hispanic.
Our data analysis employed weighting to ensure that
data collected were representative of the population as a
whole and to adjust for sampling inaccuracy.
Measures
The dependent variable co-occurring drug use and seri-
ous psychological distress in the past year was indicated
by four categories: presence of co-occurring serious psy-
chological distress and substance use in the past year;
presence of serious psychological distress in the past year;
presence of substance use in the past year; and the refer-
ence category, absence of both serious psychological dis-
tress and substance use. Respondents were classified as
substance use if they self-reported activities and experi-
ences meeting criteria from the Diagnostic and Statistic
Manual of Mental Disorders IV (DSM-IV) for drug abuse
or drug dependence in the past year. NSDUH determined
serious psychological distress using the K6 scale for non-
specific psychological distress. The scale’s six questions
asked respondents to think back to the 1 month from the
past year during which they had been at their worst emo-
tionally and to report how many times in that month they
felt nervous, hopeless, restless, depressed, low in energy,
and worthless. Response categories were (0) none of the
time/do not know/refused, (1) a little of the time, (2) some
of the time, (3) most of the time, and (4) all of the time.
Scores on all six questions were totaled, and respondents
scoring 13 or higher were said to have had serious psy-
chological distress in the past year.
A 4-item index was employed to indicate religiosity.
Three index questions asked how strongly respondents
agreed with statements about sharing one’s religious
beliefs with friends, religious beliefs shaping one’s
decisions, and religious beliefs’ overall importance in
one’ sexperience. Response categories ranged from (1)
strongly disagree to (4) strongly agree. The index’s fourth
item involved a 6-point scale measuring the number of
church services a respondent had attended in the past 12
months, to gauge involvement with religion. Response
categories were (1) 0 times, (2) 1 to 2 times, (3) 3 to
5 times, (4) 6 to 24 times, (5) 25 to 52 times, and (6)
more than 52 times. The total index score was the sum
of the 4 items’ standardized scores. The index achieved
moderately high consistency (alpha = .82).
Marital status was a further variable and was recoded as
a dichotomous variable; individuals not presently married
provided the reference group. We similarly recoded the
three-category race variable into two dichotomous vari-
ables, Black and Hispanic; White provided the reference
group.
Other status variables were indicated using respon-
dents’ gender, income level, education, and age. Gender
was a dichotomous variable, female providing the refer-
ence group. We constructed two dichotomous variables
from the three-category income measure. The two were
(a) 100%–199% of the US Census poverty threshold and
(b) equal to or greater than 200% of the poverty threshold;
less than 100% of poverty threshold provided the refer-
ence group. We measured education as a continuous vari-
able, its response scale including (1) less than high school
education, (2) high school graduate, (3) some college, and
(4) college graduate. Age was measured as a continu-
ous variable, the responses being (in years) (1) 18–25, (2)
26–34, and (3) 35orolder. Younger adults are likelier than
older ones to use substances and also to exhibit psycho-
logical distress; adults who have completed higher educa-
tion are less likely to have mental health problems than
those lacking such education (Mosher & Akins, 2007;
Schieman, 2008; Schieman, Van Gundy, & Taylor, 2001).
Data Analysis
Using multinomial logistic regression, we evaluated for
Whites, Blacks, and Hispanics the effects of our two social
integration factors and of gender, poverty, education, and
age, on the four-category dependent variable co-occurring
substance use and serious psychological distress. Eval-
uation was conducted separately for each race/ethnicity.
Group difference testing determined whether the
SUBSTANCE ABUSE AND SERIOUS PSYCHOLOGICAL DISTRESS 737
differences observed among coefficients of marriage and
religiosity for each race/ethnicity variable reached statis-
tical significance. To achieve simultaneous comparison
of the groups’ coefficients (as we had for the independent
variables), we performed separate multinomial logistic
regressions for each independent variable. During these
separate regressions, we included all independent vari-
ables, as well as all interactions involving the minority
groups and the independent variable in question; White
respondents constituted the reference category. Where
an identified interaction between a minority group and
a particular independent variable (e.g., between Black
and education) was statistically significant, a significant
difference was indicated between that group and White, in
terms of the independent variable’s effect on co-occurring
behaviors within the group. As we conducted the data
analyses, we used STATA software to take the sample
weight into account.
RESULTS
The descriptive statistics in Table 1 show that 4.3% of
our respondents reported experiencing co-occurring sub-
stance use and serious psychological distress, 14.8% re-
ported experiencing serious psychological distress but not
substance use, and a further 14.6% reported abusing a sub-
stance but not experiencing serious psychological distress.
Females made up the majority (54%) of the respondents;
White was the majority racial/ethnic group, comprising
71% of the sample, while Blacks constituted 13% and
Hispanics 16%. More than 6 in 10 respondents (63%) re-
ported income of at least 200% of poverty level, 21% had
income of 100%–199% of poverty level, and 14% lived
below poverty level. On average, our respondents were
26–34 years old and had a high-school education.
In general, the results of correlations between our
mental health variables, social status, and the two social
integration factors were as expected. Co-occurring
behaviors, serious psychological distress, and substance
use all were likelier to be found in individuals who
were living below poverty or at 100%–199% of poverty,
who were unmarried, younger, less educated, and less
religious. Members of the Hispanic group were less
likely than Whites to report experiencing, in the past year,
co-occurring behaviors or either serious psychological
distress or substance use singly. In contrast, Blacks
were equally likely, compared with Whites, to report
co-occurring behaviors or serious psychological distress
singly. Males were likelier than females to report abusing
a substance; females were likelier to report experiencing
serious psychological distress. Males and females were
equally likely to report co-occurring behaviors. Concern-
ing the two social integration factors, Whites were more
likely than minority-group members to be married, and
non-Whites were more likely to be religious.
Table 2 presents the data outlining marriage’s role and
religiosity’s role as a protective factor, along with data on
how other social status factors may contribute to substance
abuse, serious psychological distress, and co-occurring
behaviors within all three racial/ethnic groups. Table 2
also presents results derived from statistical significance
tests we conducted to evaluate group differences in our
independent variables’ particular effects on co-occurring
behaviors; Whites provided the reference group. Group
differences proving to be significant are indicated in the
table by underscoring of the odds ratio of the specific
independent variable. We did not generally observe that
race/ethnicity moderated effects of the two social integra-
tion factors on co-occurring behaviors. Neither did we find
significant differences between Whites and the minori-
ties in terms of marriage’s or religiosity’s effects on seri-
ous psychological distress singly and substance use singly.
However, only among Whites were marriage and religios-
ity found to significantly affect all three categories of the
outcome variable co-occurring behaviors; among Blacks
and Hispanics, only 1 and 2 categories were significantly
affected by the social integration factors.
We obtained interesting results with our independent
variables beyond marriage and religiosity. Increasing edu-
cation was, for Whites, associated with lower likelihood of
serious psychological distress and of co-occurring behav-
iors; no such association was observed for the two minori-
ties. In addition, we found significant differences between
Whites and Hispanics in terms of education’s effects on
co-occurring behaviors as well as on serious psychologi-
cal distress.
In general, age was observed to have a negative effect
on substance use, serious psychological distress, and
co-occurring behaviors within all three groups. For
Blacks and Hispanics, however, age’s negative effects on
serious psychological distress were not statistically sig-
nificant. Moreover, tests of significance applied to group
differences indicated that age’s effects on co-occurring
behaviors and on substance use singly were significantly
stronger among Whites versus Blacks. Again for all
three groups, being male was linked to increased (versus
females) likelihood of reporting substance use singly;
females, however, were more likely than males to report
serious psychological distress. Hispanic males (but
not Black or White males) were significantly more
likely than females in their group to report co-occurring
behaviors. In general in our study, gender’s effect on
co-occurring serious psychological distress and substance
was significantly stronger for Hispanics than for Whites.
In our study, poverty affected reporting of co-occurring
behaviors very differently for members of the three dif-
ferent groups. We observed a lower likelihood of co-
occurring behaviors among Whites and Hispanics in the
200% and 100%–199% poverty categories, versus poorer
Whites and Hispanics. Among Blacks, in contrast, being
poor was not found to significantly increase co-occurring
behaviors; moreover, among respondents in the 200%
poverty category, Whites were better protected by their
relative wealth than Blacks were, against co-occurring be-
haviors. In addition, Whites in the 200% poverty category
were much better protected against serious psychologi-
cal distress than Hispanics in that category were. Among
Hispanics, those in the two lowest income categories and
738 C. C. LO ET AL.
T
A
B
L
E
1.
M
ea
ns
,s
ta
nd
ar
d
de
vi
at
io
ns
,a
nd
co
rr
er
la
ti
on
s
of
al
l
in
cl
ud
ed
va
ri
ab
le
s
(1
)
(2
)
(3
)
(4
)
(5
)
(6
)
(7
)
(8
)
(9
)
(1
0)
(1
1)
(1
2)
(1
3)
M
ea
n
S
D
N
C
o-
oc
cu
rr
in
g
be
ha
vi
or
s
(1
)
1.
00
0.
04
0.
20
34
,6
50
P
sc
yh
ol
og
ic
al
di
st
re
ss
(2
)
0.
51
1.
00
0.
15
0.
36
34
,6
50
S
ub
st
an
ce
ab
us
e
(3
)
0.
51
0.
17
1.
00
0.
15
0.
35
34
,6
50
M
al
e
(4
)
0.
01
a
−0
.1
0
0.
14
1.
00
0.
46
0.
50
34
,6
50
W
hi
te
(5
)
0.
02
0.
03
0.
04
0.
01
1.
00
0.
71
0.
45
34
,6
50
B
la
ck
(6
)
0.
00
a
−0
.0
1a
−0
.0
3
−0
.0
3
−0
.6
0
1.
00
0.
13
0.
33
34
,6
50
H
is
pa
ni
c
(7
)
−0
.0
2
−0
.0
3
−0
.0
2
0.
02
−0
.6
9
−0
.1
7
1.
00
0.
16
0.
37
34
,6
50
10
0%
po
ve
rt
y
(8
)
0.
04
a
0.
08
0.
03
−0
.0
7
−0
.1
9
0.
14
0.
11
1.
00
0.
17
0.
37
33
,9
81
10
0%
–1
99
%
po
ve
rt
y
(9
)
0.
01
0.
03
0.
01
a
−0
.0
3
−0
.1
1
0.
04
0.
11
−0
.2
3
1.
00
0.
21
0.
41
33
,9
81
20
0%
+
po
ve
rt
y
(1
0)
−0
.0
4
−0
.0
9
−0
.0
3
0.
07
0.
24
−0
.1
4
−0
.1
7
−0
.5
8
−0
.6
6
1.
00
0.
63
0.
48
33
,9
81
M
ar
ri
ed
(1
1)
−0
.1
1
−0
.1
1
−0
.1
8
−0
.0
3
0.
12
−0
.1
4
−0
.0
2
−0
.1
8
−0
.0
8
0.
20
1.
00
0.
38
0.
49
34
,6
50
E
du
ca
ti
on
(1
2)
−0
.0
4
−0
.0
6
−0
.0
3
−0
.0
6
0.
23
−0
.0
8
−0
.2
1
−0
.2
1
−0
.1
9
0.
32
0.
14
1.
00
2.
51
1.
01
34
,6
50
R
el
ig
io
si
ty
(1
3)
−0
.0
9
−0
.0
7
−0
.1
5
−0
.1
2
−0
.1
2
0.
13
0.
02
0.
00
a
0.
00
a
0.
00
a
0.
17
0.
05
1.
00
0.
01
3.
23
33
,8
52
A
ge
(1
4)
−0
.1
0
−0
.1
0
−0
.1
8
−0
.0
2
0.
10
−0
.0
4
−0
.0
9
−0
.1
6
−0
.0
8
0.
19
0.
46
0.
13
0.
14
2.
88
0.
91
34
,6
50
N
o
te
:
A
ll
co
rr
el
at
io
ns
re
ac
h
st
at
is
ti
ca
l
si
gn
ifi
ca
nc
e
at
.0
5
le
ve
l
ex
ce
pt
in
g
fo
r
th
os
e
si
gn
ifi
ed
w
it
h
a
.
SUBSTANCE ABUSE AND SERIOUS PSYCHOLOGICAL DISTRESS 739
TABLE 2. Determinants of the log-odds of co-occurring substance abuse and psychological distress for three racial/ethnic groups
White Black Hispanic
Variables b Odds ratio (95% CI) b Odds ratio (95% CI) b Odds ratio (95% CI)
Co-occurring behaviors
Age −0.63∗∗ 0.53 (.47–.61) −0.32∗ 0.73 (.53–.99) −0.73∗∗ 0.48 (.34–.68)
Male 0.22 1.25 (.99–1.56) 0.16 1.17 (.63–2.19) 0.90∗∗ 2.46 (1.41–4.27)
100%–199% poverty −0.56∗∗ 0.57 (.40–.83) −0.45 0.64 (.35–1.16) −0.80∗ 0.45 (.21–.98)
200%+ poverty −0.68∗∗ 0.51 (.36–.72) 0.01 1.01 (.57–1.80) −0.74∗ 0.48 (.22–1.05)
Education −0.26∗∗ 0.77 (.69–.87) −0.17 0.84 (.58–1.23) 0.09 1.10 (.79–1.51)
Married −1.05∗∗ 0.35 (.25–.48) −0.83 0.44 (.16–1.21) −0.65 0.52 (.23–1.19)
Religiosity −0.11∗∗ 0.90 (.87–.93) −0.18∗∗ 0.83 (.77–.90) −0.02 0.98 (.90–1.07)
Constant 0.21 −1.55∗ −1.41∗
Psychological distress
Age −0.24∗∗ 0.78 (.73–.84) −0.15 0.86 (.72–1.04) −0.09 0.91 (.73–1.13)
Male −0.80∗∗ 0.45 (.39–.52) −0.44∗ 0.64 (.44–.95) −0.92∗∗ 0.40 (.27–.58)
100%–199% poverty −0.16 0.85 (.68–1.07) 0.06 1.06 (.69–1.64) −0.21 0.81 (.50–1.30)
200%+ poverty −0.64∗∗ 0.53 (.43–.65) −0.56∗ 0.57 (.37–.88) 0.08 1.09 (.71–1.67)
Education −0.13∗∗ 0.88 (.82–.95) −0.18 0.83 (.69–1.01) −0.01 0.99 (.84–1.18)
Married −0.37∗∗ 0.69 (.59–.81) −0.40 0.67 (.43–1.06) −0.50∗∗ 0.61 (.41–.91)
Religiosity −0.06∗∗ 0.94 (.92–.96) −0.09∗∗ 0.92 (.87–.96) −0.05 0.96 (.86–1.03)
Constant 0.01∗∗ −0.80∗ −1.35∗∗
Substance Abuse
Age −0.61∗∗ 0.54 (.50–.59) −0.21∗ 0.81 (.67–.99) −0.42∗∗ 0.66 (.50–.86)
Male 1.04∗∗ 2.81 (2.41–3.29) 1.37∗∗ 3.94 (2.66–5.87) 1.26∗∗ 3.53 (2.29–5.45)
100%–199% poverty −0.06 0.95 (.70–1.27) 0.11 1.12 (.68–1.82) −0.08 0.92 (.55–1.55)
200%+ poverty −0.12 0.88 (.70–1.12) 0.10 1.10 (.72–1.70) −0.12 0.89 (.55–1.44)
Education 0.05 1.05 (.98–1.13) 0.01 1.01 (.82–1.24) 0.11 1.12 (.93–1.34)
Married −0.59∗∗ 0.55 (.47–.66) −0.85∗∗ 0.43 (.25–.73) −0.68∗∗ 0.51 (.32–.81)
Religiosity −0.10∗∗ 0.90 (.88–.92) −0.08∗∗ 0.92 (.86–.98) −0.11∗∗ 0.89 (.85–.94)
Constant −0.75∗∗ −2.47∗∗ −1.91∗∗
Weighted cases 23,713 4,198 5,283
Model chi-square 1,721 209 291
Pseudo R2 0.09 0.07 0.07
∗p < .05. ∗∗p < .01.
those in the 200% poverty category were equally likely to
report having experienced serious psychological distress.
That is, for Hispanic respondents, a higher income did not
protect against experiencing serious psychological dis-
tress singly. For respondents across all three racial/ethnic
groups, poverty showed no significant effect on the expe-
rience of substance use singly.
DISCUSSION AND CONCLUSIONS
We employed multinomial logistic regression to explain
respondents’ co-occurring behaviors by racial/ethnic
group (White, Black, Hispanic). Our results may be sum-
marized as follows.
Despite occupying a relatively disadvantaged status,
Hispanics in the United States fared better, overall, than
Whites in terms of mental health, reporting fewer experi-
ences of serious psychological distress, substance use, and
co-occurring behaviors (Muthen & Muthen, 2000; Smith
et al., 2006). Substance use was also less frequent among
Blacks versus Whites. But according to our findings, these
differences do not stem from marriage or religiosity. The
two social integration factors do not appear to contribute
differentially to Americans’ mental health; the health ad-
vantage they provide extends to all. In other words, our
results are evidence that the protective effects of mar-
riage and religiosity against serious psychological distress
and/or substance use are not moderated by race/ethnicity.
While our study identified a mental health advantage
for minority groups over Whites, it is likely that minor-
ity individuals’ relatively low economic and educational
statuses chip away at this advantage (Turner & Avison,
2003). In fact, the most significant findings from our ex-
amination of race/ethnicity’s interactions with other status
factors (e.g., poverty, education) include our observation
that avoiding poverty does not necessarily protect Blacks
and Hispanics from mental health problems the way it
consistently does protect Whites.
Consistent with the literature on social integration fac-
tors and the promotion of mental health (House, Landis, et
al., 1988), our results show generally that marriage and re-
ligiosity functioned persistently and significantly to make
co-occurring substance use and serious psychological dis-
tress less likely, and either behavior alone less likely.
740 C. C. LO ET AL.
Several important implications of these findings should be
shared. Our study results clearly support the deprivation-
compensation thesis (Schieman, Pudrovska, & Milkie,
2005) in that Blacks and Hispanics had higher levels of
religiosity, contributing to better overall mental health
relative to Whites. Tending to confirm the deprivation-
compensation theory is a finding by at least one research
team that being religious serves individuals from low-
status groups as a form of compensation for social and
economic deprivation (Schieman, Pudrovska, Pearlin, &
Ellison, 2006). In our study, we treated religiosity as a so-
cial integration factor, a proxy factor measuring bonding
and collaboration with fellow believers. Our results sug-
gest that religiosity has potential to promote mental health
in any social group, especially in racial/ethnic minorities
(Allen & Lo, 2010; Bradshaw, Ellison, & Flannelly, 2008;
Chatters, Taylor, Bullard, & Jackson, 2009).
Because we found, however, that religiosity provided
Hispanics no significant protection5 against serious psy-
chological distress or against co-occurring behaviors,
religiosity may play a less important role in mental
health for this group than others. Still, our data illus-
trate that religiosity does wield mental-health-problem-
specific power across all three groups. For instance, while
for Hispanics in our study, religiosity may not have
provided significant protection against co-occurring be-
haviors or serious psychological distress, it did provide
significant protection against substance use. In a sim-
ilar way, Blacks in our study derived from religiosity
better protection against co-occurring behaviors versus
against either psychological distress or substance use
singly.
Some earlier studies have found marriage’s health-
protective effect to apply equally to individuals of differ-
ent social statuses (Ross & Wu, 1995; Simon, 2002). Oth-
ers have found the protection marriage offers to be clearly
stronger among disadvantaged groups (Plant & Sachs-
Ericsson, 2004; Roxburgh, 2009). The results of our study
tend to support the former, since we found no evidence
that race/ethnicity significantly moderates co-occurring
behaviors. At the same time, however, we should note
that, according to our data, marriage protected Hispan-
ics against serious psychological distress singly; it pro-
tected Hispanics and Blacks against substance use singly;
and it protected Whites significantly against both of the
behaviors singly as well as against co-occurring behav-
iors. In our study, marriage as a protective factor appeared
(like religiosity) to be of a mental-health-problem-specific
nature.
Our findings concerning the prediction of co-occurring
serious psychological distress and substance use are con-
sistent with earlier empirical evidence (limited though
it is) showing that the general health of Whites bene-
fits more strongly from social relationships than does the
5The reader is referred to Hills’s criteria for causation which were devel-
oped in order to help assist researchers and clinicians determine whether
risk factors were causes of a particular disease or outcomes or merely
associated (Hill, 1965). Editor’s note.
general health of minorities (House, Umberson, et al.,
1988; Manzoli, Villari, Pirone, & Boccia, 2007). Lon-
gitudinal researchers have argued that marriage exerts
a cumulative beneficial effect on health, over lifetimes
and generations (Lund, Christensen, Holstein, Due, &
Osler, 2006). Our study results offer evidence that mar-
riage has health-promoting benefits for all racial/ethnic
groups.
The poverty and education factors evaluated in our
study suggest some steps for reducing the rate of co-
occurring substance use/serious psychological distress in
our nation. Although some studies indicate that education
can help balance social disadvantage, shoring up mental
health within low-status groups (Arber, 1997; Goodwin,
2003; Ross & Mirowsky, 2006; Roxburgh, 2009), our
study found that education offered little to protect His-
panics against co-occurring behaviors (though it did
help Whites). Most research on education’s health ef-
fects by race confines itself to Blacks and Whites alone.
By including Hispanics in our study, we hoped for a
more detailed view of education’s differential mental-
health role. We found only insignificant results con-
cerning education’s effects for Blacks and Hispanics,
which may indicate that education affects minorities’ so-
cioeconomic status more strongly than it shapes their
mental health. In addition, we acknowledge that the
slight positive relationship we observed between edu-
cation and substance use (for all groups), although it
was statistically insignificant, is nevertheless inconsistent
with most of the literature (Crum, Bucholz, Helzer, &
Anthony, 1992; Crum, Helzer, & Anthony, 1993; Muthen
& Muthen, 2000). The finding may be attributable to
highly educated people’s relatively tolerant attitudes about
substance use.
We know that many Hispanic Americans are first- and
second-generation immigrants, still being assimilated
in American society, and we suspect that working at
assimilating while simultaneously striving to gain an
education and progress in a (perhaps racist and discrim-
inatory) profession is stressful. African Americans’ path
to assimilation in American society has been different but
has certainly featured its own serious barriers to upward
mobility. Generations of African Americans have lived
in poverty, and a considerable portion of the group now
constitutes an underclass besieged by crime, desperation,
and hopelessness (Wilson, 1987). Thus better-educated
Hispanics and Blacks perhaps experience more stress than
less-educated Hispanics and Blacks do (Turner, Lloyd, &
Taylor, 2006). Education, a flexible resource, does offer
a protective benefit to well-educated members of minori-
ties, but that benefit may be overwhelmed by extreme
stresses, engendering substance use or serious psycholog-
ical distress (Aneshensel, 1992). Explaining our finding
this way is consistent with the social normative thesis,
in that in the United States, it has been normative for
Hispanics and Blacks to eschew advanced education, less
education being more adaptive to their circumstances in
this country. Adaptive behavior is associated with fewer
mental health problems (Roxburgh, 2009).
SUBSTANCE ABUSE AND SERIOUS PSYCHOLOGICAL DISTRESS 741
The social normative thesis is borne out by certain
other findings from our study. For example, our results
indicate that Blacks and Hispanics living in poverty or
slightly above poverty are not necessarily more likely
than wealthier counterparts to report co-occurring be-
haviors, serious psychological distress, or substance use
(Roxburgh, 2009). The persistence of the social norma-
tive phenomenon may partially explain the White major-
ity’s generally higher rates of mental disorders, compared
with Blacks, Hispanics, and other minorities (SAMHSA,
2009).
Study’s Limitations
Several limitations constraining the present study should
be mentioned. The secondary data we used limited our
measures of social integration factors to religiosity and
marriage, and even these two measures could have been
more meaningful and precise. Prior research has sug-
gested that holding “positive” beliefs involving a close,
loving God is associated with a lower rate of psycholog-
ical distress, while holding “negative” beliefs involving
a disapproving, punishing God is associated with insecu-
rity, anxiety, and mental health problems (Bradshaw et al.,
2008; Flannelly et al., 2007). The specific nature of one’s
religiosity, then, may help explain co-occurring behav-
iors, and our data did not detail respondents’ religiosity
in such terms. In addition, some earlier research has indi-
cated that religiosity’s role and marriage’s role in psycho-
logical well-being can in certain circumstances become
clearly truncated (Ano & Vasconcelles, 2005; Bradshaw
et al., 2008). Thus ideally our study would have consid-
ered respondents’ possible dissatisfaction and/or conflict
with spouse and with divinity. Access to such data would
have allowed us to delineate, to an extent, the possible pro-
tective mechanisms linking marriage and religiosity to co-
occurring behaviors. The secondary data also precluded
our measuring such relevant variables as acculturation,
variables with potential to help in the interpretation of our
study’s race/ethnicity-specific results.
Data collected for NSDUH were not intended to
demonstrate cause-effect relationships. This meant that
our study employing the NSDUH data had to be con-
tent simply with seeking to explain any associations of
co-occurring serious psychological distress/substance use
with the social integration and social status variables.
Moreover, our study’s cross-sectional design prevented
the study results from demonstrating cumulative advan-
tages arising from marriage’s and religiosity’s protective
effects. Such cumulative advantages could, over time,
exacerbate differences in race/ethnicity-specific rates of
mental health problems. Future studies should look to lon-
gitudinal data to begin establishing the temporal ordering
of social integration factors and co-occurring behaviors.
Because our scope was limited to substance use and se-
rious psychological distress, our results are not generaliz-
able to explain mental health broadly. People of different
social statuses tend to exhibit very different mental health
problems (Aneshensel et al., 1991). Still, by including
in its dependent variable both an externalizing emotional
problem (substance use) and an internalizing emotional
and anxiety problem (serious psychological distress), our
study successfully highlighted the roles social integration
factors and several other status factors play in the differ-
ential distribution of emotional and substance-use-related
problems across racial/ethnic groups (Simon, 2002).
Declaration of Interest
The authors report no conflicts of interest. The authors
alone are responsible for the content and writing of the
article.
RESUME
Différences raciales dans l’abus de substances
concomitants et graves détresse psychologique: Les
rôles de mariage et la religiosité
L’étude a examiné comment le mariage et la religiosité
de protéger les membres de certains groupes raciaux /
ethniques contre la toxicomanie concomitants et sérieuse
détresse psychologique. Utilisation de la nationale
données de 2007 Enquête nationale sur la consom-
mation de drogues et de la santé, nous avons analysé
des données via la régression logistique multinomiale,
l’observation de plusieurs résultats importants. Nos
résultats tendent généralement à soutenir la thèse de
privation de compensation, en ce que la religiosité élève
la santé mentale des individus issus de minorités raciales /
ethniques de plus que celui des Blancs. Nous avons
également constaté, toutefois, que les effets de la race /
ethnicité modérés de l’éducation et de la pauvreté sur les
comportements de co-produire avec la santé mentale des
Blancs bénéficiant plus de la richesse et de l’éducation
que les Noirs “ou les Hispaniques« santé mentale fait.
RESUMEN
Diferencias raciales en el abuso de sustancias
concurrente y angustia psicológica grave: Los roles del
matrimonio y la religiosidad
El estudio examinó cómo el matrimonio y la religiosidad
proteger a los miembros de ciertos grupos raciales/étnicos
contra el abuso de sustancias concurrente y la angustia
psicológica grave. Utilizando la base de datos nacional
de 2007 la Encuesta Nacional sobre Uso de Drogas y la
Salud, se analizaron los datos mediante regresión logı́stica
multinomial, la observación de varios resultados impor-
tantes. Nuestros hallazgos apoyan en general la tesis de la
privación de compensación, en el que la religiosidad eleva
la salud mental de las personas pertenecientes a minorı́as
raciales / étnicos más que la de los blancos. También se
encontró, sin embargo, que los efectos de raza / etnia mod-
erados de la educación y la pobreza en las conductas con-
currentes, con los blancos de la salud mental beneficiando
a más de la riqueza y la educación de los negros ‘o la salud
de los hispanos mental no.
742 C. C. LO ET AL.
THE AUTHORS
Celia C. Lo, Ph.D., is a
professor in the School of
Social Work at the University
of Alabama. Her research
interests include the sociology of
drugs and alcohol, disparities in
health-risk behaviors and health,
and drugs and crime.
Kimberly A. Tenorio, M.S.,
received her master’s degree
at the University of Alabama.
She is currently a research
analyst at Florida State College
at Jacksonville. Her research
interests include terrorism, social
inequality, and criminological
theory.
Tyrone C. Cheng, Ph.D.,
L.C.S.W., P.I.P., is an associate
professor, School of Social
Work, University of Alabama.
His research interests include
welfare reforms, Medicaid
policies, and child welfare and
drug use.
GLOSSARY
SubstanceUse: In the present study, substance use was de-
fined and measured as self-reported activities and expe-
riences meeting criteria from the DiagnosticandStatis-
tic Manual of Mental Disorders (DSM-IV) for drug
abuse or drug dependence in the past year.
Serious psychological distress: Using the K6 scale for
nonspecific psychological distress, we defined and
classified respondents scoring 13 or higher as having
had serious psychological distress in the past year.
Co-occurring substance use and serious psychological
distress: Respondents’ self-reported activities and ex-
periences indicating the presence of both substance
abuse and serious psychological distress.
Religiosity: Religiosity is defined as an individuals’ bond-
ing or commitment to religion and religious beliefs.
REFERENCES
Allen, T. M., & Lo, C. C. (2010). Religiosity, spirituality, and sub-
stance abuse. Journal of Drug Issues, 40(2), 1045–1071.
Aneshensel, C. S. (1992). Social stress theory and research. Annual
Review of Sociology, 18, 15–38.
Aneshensel, C. S. (2009). Toward explaining mental health dispar-
ities. Journal of Health and Social Behavior, 50(4), 377–394.
Aneshensel, C. S., Rutter, C. M., & Lachenbruch, P. A. (1991).
Social-structure, stress, and mental health: Competing concep-
tual and analytic models. American Sociological Review, 56(2),
166–178.
Ano, G. G., & Vasconcelles, E. B. (2005). Religious coping and
psychological adjustment to stress: A meta-analysis. Journal of
Clinical Psychology, 61(4), 461–480.
Arber, S. (1997). Comparing inequalities in women’s and men’s
health: Britain in the 1990s. Social Science & Medicine, 44(6),
773–787.
Avison, W. R., Ali, J., & Walters, D. (2007). Family structure, stress,
and psychological distress: A demonstration of the impact of dif-
ferential exposure. JournalofHealthandSocialBehavior,48(3),
301–317.
Balcazar, H., Aoyama, C., & Cai, X. (1991). Interpretative views on
Hispanics’ perinatal problems of low birth weight and prenatal
care. Public Health Reports, 106(4), 420–426.
Berkman, L. F., Glass, T., Brissette, I., & Seeman, T. E. (2000).
From social integration to health: Durkheim in the new millen-
nium. Social Science & Medicine, 51(6), 843–857.
Bradshaw, M., Ellison, C. G., & Flannelly, K. J. (2008). Prayer,
God imagery, and symptoms of psychopathology. Journal for
the Scientific Study of Religion, 47(4), 644–659.
Brown, D. R., & Keith, V. M. (2003). The epidemiology of mental
disorders and mental health among African American women.
In D. R. Brown & V. M. Keith (Eds.), In and out of our right
minds (pp. 23–58). New York: Columbia University Press.
Chatters, L. M., Taylor, R. J., Bullard, K. M., & Jackson, J. S.
(2009). Race and ethnic differences in religious involvement:
African Americans, Caribbean blacks and non-Hispanic whites.
Ethnic and Racial Studies, 32(7), 1143–1163.
Crum, R. M., Bucholz, K. K., Helzer, J. E., & Anthony, J. C. (1992).
The risk of alcohol-base and dependence in adulthood: The as-
sociation with educational level. American Journal of Epidemi-
ology, 135(9), 989–999.
Crum, R. M., Helzer, J. E., & Anthony, J. C. (1993). Level of
education and alcohol abuse and dependence in adulthood:
A further inquiry. American Journal of Public Health, 83(6),
830–837.
Datta, G. D., Neville, B. A., Kawachi, I., Datta, N. S., & Earle,
C. C. (2009). Marital status and survival following bladder can-
cer. Journal of Epidemiology and Community Health, 63(10),
807–813.
Dennis, R. E., Key, L. J., Kirk, A. L., & Smith, A. (1995). Ad-
dressing domestic violence in the African-American commu-
nity. Journal of Health Care for the Poor and Underserved, 6(2),
284–293.
Dziak, E., Janzen, B. L., & Muhajarine, N. (2010). Inequalities in
the psychological well-being of employed, single and partnered
mothers: The role of psychosocial work quality and work-family
conflict. International Journal for Equity in Health, 9(6), 1–8.
Ellison, C. G., Boardman, J. D., Williams, D. R., & Jackson, J. S.
(2001). Religious involvement, stress, and mental health: Find-
ings from the 1995 Detroit Area Study. Social Forces, 80(1),
215–249.
SUBSTANCE ABUSE AND SERIOUS PSYCHOLOGICAL DISTRESS 743
Flannelly, K. J., Koenig, H. G., Galek, K., & Ellison, C. G. (2007).
Beliefs, mental health, and evolutionary threat assessment sys-
tems in the brain. Journal of Nervous and Mental Disease,
195(12), 996–1003.
Gary, F. A. (2005). Stigma: Barrier to mental health care among
ethnic minorities. IssuesinMentalHealthNursing,26, 979–999.
George, L. K. (2010). Still happy after all these years: Research
frontiers on subjective well-being in later life. Journal of Gero-
tologist: Social Sciences, 65B(3), 331–339.
George, L. K., Ellison, C. G., & Larson, D. B. (2002). Explaining
the relationships between religious involvement and health. Psy-
chological Inquiry, 13(3), 190–200.
Goodwin, P. Y. (2003). African American and European American
women’s marital well-being. Journal of Marriage and the Fam-
ily, 65(3), 550–560.
Green, C. A., Freeborn, D. K., & Polen, M. R. (2001). Gender and
alcohol use: The roles of social support, chronic illness, and psy-
chological well-being. Journal of Behavioral Medicine, 24(4),
383–399.
Grusky, D. B. (Ed.). (2001). Social stratification: Class, race, and
genderinsociologicalperspective (2nd ed.). Boulder, CO: West-
view Press.
Hackney, C. H., & Sanders, G. S. (2003). Religiosity and mental
health: A meta-analysis of recent studies. Journal for the Scien-
tific Study of Religion, 42(1), 43–55.
Hill, A. B. (1965). The environment and disease: associations or
causation? Proceedings of the Royal Society of Medicine, 58,
295–300.
House, J. S., Landis, K. R., & Umberson, D. (1988). Social rela-
tionships and health. Science, 241(4865), 540–545.
House, J. S., Umberson, D., & Landis, K. R. (1988). Structure and
processes of social support. Annual Review of Sociology, 14,
293–318.
Jackson, J. S., & Neighbors, H. W. (1996). Changes in African
American resources and mental health: 1979 to 1992. In H. W.
Neighbors & J. S. Jackson (Eds.), Mental health in Black Amer-
ica (pp. 189–212). Thousand Oaks, CA: Sage.
Jang, S. N., Kawachi, I., Chang, J., Boo, K., Shin, H. G., Lee, H.,
et al. (2009). Marital status, gender, and depression: Analysis of
the baseline survey of the Korean Longitudinal Study of Ageing
(KLoSA). Social Science & Medicine, 69(11), 1608–1615.
Kessler, R. C., Nelson, C. B., McGonagle, K. A., Edlund, M. J.,
Frank, R. G., & Leaf, P. J. (1996). The epidemiology of co-
occurring addictive and mental disorders: Implications for pre-
vention and service utilization. American Journal of Orthopsy-
chiatry, 66(1), 17–31.
Link, B. G., & Phelan, J. (1995). Social conditions as fundamental
causes of disease. Journal of Health and Social Behavior, 35
(Extra Issue), 80–94.
Lund, R., Christensen, U., Holstein, B. E., Due, P., & Osler, M.
(2006). Influence of marital history over two and three genera-
tions on early death. A longitudinal study of Danish men born in
1953. Journal of Epidemiology and Community Health, 60(6),
496–501.
Lynch, J., & Kaplan, G. (2000). Socioeconomic position. In L. F.
Berkman & I. Kawachi (Eds.), Social epidemiology (pp. 13–35).
New York: Oxford University Press.
Manchikanti, L., Giordano, J., Boswell, M. V., Fellows, B.,
Manchukonda, R., & Pampati, V. (2007). Psychological factors
as predictors of opioid abuse and illicit drug use in chronic pain
patients. Journal of Opioid Management, 32(2), 89–100.
Manzoli, L., Villari, P., Pirone, G. M., & Boccia, A. (2007). Mari-
tal status and mortality in the elderly: A systematic review and
meta-analysis. Social Science & Medicine, 64(1), 77–94.
Marmot, M. G., Kogevinas, M., & Elston, M. A. (1987). Social eco-
nomic status and disease. Annual Review of Public Health, 8,
111–135.
McVeigh, K. H., Galea, S., Thorpe, L. E., Maulsby, C., Henning,
K., & Sederer, L. I. (2006). The epidemiology of nonspecific
psychological distress in New York City, 2002 and 2003.Journal
of Urban Health-Bulletin of the New York Academy of Medicine,
83(3), 394–405.
Mosher, C. J., & Akins, S. (2007). Drugs and drug policy: The con-
trol of consciousness alteration. Thousand Oaks, CA: Sage.
Muthen, B. O., & Muthen, L. K. (2000). The development of heavy
drinking and alcohol-related problems from ages 18 to 37 in
a US national sample. Journal of Studies on Alcohol, 61(2),
290–300.
NIDA. (2003). Drug use among racial/ethnic minorities (DHHS
Pub. No. NIH 03-3888). Bethesda, MD: National Institute on
Drug Abuse, from http://www.drugabuse.gov
NIDA. (2007). Comorbid drug abuse and mental illness. Bethesda,
MD: National Institutes of Health.
Nielsen, A. L. (2000). Examining drinking patterns and problems
among Hispanic groups: Results from a national survey. Journal
of Studies on Alcohol, 61(2), 301–310.
Osborne, C., Ostir, G. V., Du, X. L., Peek, M. K., & Goodwin,
J. S. (2005). The influence of marital status on the stage at diag-
nosis, treatment, and survival of older women with breast cancer.
Breast Cancer Research and Treatment, 93(1), 41–47.
Phillips, R. E., Pargament, K. I., Lynn, Q. K., & Crossley, C. D.
(2004). Self-directing religious coping: A deistic god, abandon-
ing god, or no god at all? Journal for the Scientific Study of Re-
ligion, 43(3), 409–418.
Plant, E. A., & Sachs-Ericsson, N. (2004). Racial and ethnic differ-
ences in depression: The roles of social support and meeting ba-
sic needs. Journal of Consulting and Clinical Psychology, 72(1),
41–52.
Psychiatric Services. (2006). Illicit drug use declines among youths
and increases among adults. Psychiatric Services, 57(10),
1540–1541.
RachBeisel, J., Scott, J., & Dixon, L. (1999). Co-occurring severe
mental illness and substance use disorders: A review of recent
research. Psychiatric Services, 50(11), 1427–1434.
Roohafza, H., Sadeghi, M., Sarraf-Zadegan, N., Baghaei, A.,
Kelishadi, R., Mahvash, M., et al. (2007). Short communication:
Relation between stress and other life style factors. Stress and
Health, 23(1), 23–29.
Rosenberg, L. (2008). Co-occurring disorders— Progress? Journal
of Behavioral Health Services & Research, 35(1), 1–2.
Ross, C. E., & Mirowsky, J. (2006). Sex differences in the
effect of education on depression: Resource multiplication
or resource substitution? Social Science & Medicine, 63(5),
1400–1413.
Ross, C. E., & Wu, C. L. (1995). The links between education and
health. American Sociological Review, 60(5), 719–745.
Rothman, R. A. (Ed.). (2005). Inequality and stratification: Race,
class, and gender (5th ed.). Upper Saddle River, NJ: Pearson
Prentice Hall.
Roxburgh, S. (2009). Untangling inequalities: Gender, race, and
socioeconomic differences in depression. Sociological Forum,
24(2), 357–381.
Sachs-Ericsson, N., Plant, E. A., & Blazer, D. G. (2005). Racial dif-
ferences in the frequency of depressive symptoms among com-
munity dwelling elders: The role of socioeconomic factors. Ag-
ing & Mental Health, 9(3), 201–209.
SAMHSA. (2009). National survey on drug use and health (NS-
DUH), 2008. Rockville, MD: Department of Health and Human
744 C. C. LO ET AL.
Services, Substance Abuse and Mental Health Services Admin-
istration.
Schieman, S. (2008). The education-contingent association be-
tween religiosity and health: The differential effects of self-
esteem and the sense of mastery. Journal for the Scientific Study
of Religion, 47(4), 710–724.
Schieman, S., Pudrovska, T., & Milkie, M. A. (2005). The sense of
divine control and the self-concept—A study of race differences
in late life. Research on Aging, 27(2), 165–196.
Schieman, S., Pudrovska, T., Pearlin, L. I., & Ellison, C. G. (2006).
The sense of divine control and psychological distress: Varia-
tions across race and socioeconomic status. Journal for the Sci-
entific Study of Religion, 45(4), 529–549.
Schieman, S., Van Gundy, K., & Taylor, J. (2001). Status, role,
and resource explanations for age patterns in psychological
distress. Journal of Health and Social Behavior, 42(1), 80–
96.
Scribner, R. (1996). Paradox as paradigm—The health outcomes of
Mexican Americans. American Journal of Public Health, 86(3),
303–305.
Simon, R. W. (2002). Revisiting the relationships among gender,
marital status, and mental health. American Journal of Sociol-
ogy, 107(4), 1065–1096.
Smith, S. M., Stinson, F. S., Dawson, D. A., Goldstein, R., Huang,
B., & Grant, B. F. (2006). Race/ethnic differences in the
prevalence and co-occurrence of substance use disorders and
independent mood and anxiety disorders: Results from the Na-
tional Epidemiologic Survey on Alcohol and Related Condi-
tions. Psychological Medicine, 36(7), 987–998.
Suthers, K. (2008). Evaluating the economic causes and con-
sequences of racial and ethnic health disparities. American
Public Health Association. Retrieved October 1, 2010, from
http://www.apha.org/NR/rdonlyres/EF3D92F8-4758-4E49-
85A1-D6EB8AD8CA89/0/Econ2 Disparities Final
Turner, R. J., & Avison, W. R. (2003). Status variations in stress
exposure: Implications for the interpretation of research on race,
socioeconomic status, and gender. Journal of Health and Social
Behavior, 44(4), 488–505.
Turner, R. J., Lloyd, D. A., & Taylor, J. (2006). Stress burden, drug
dependence and the nativity paradox among US Hispanics. Drug
and Alcohol Dependence, 83(1), 79–89.
Umberson, D. (1987). Family status and health behaviors: Social
control as a dimension of social integration. Journal of Health
and Social Behavior, 28(September), 306–319.
Williams, D. R., & Rucker, T. D. (2000). Understanding and ad-
dressing racial disparities in health care. Health Care Financing
Review, 21(4), 75–90.
Wilson, W. J. (1987). The truly disadvantaged: The inner city,
the underclass, and public policy. Chicago, IL: University of
Chicago Press.
Copyright of Substance Use & Misuse is the property of Taylor & Francis Ltd and its content may not be copied
or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission.
However, users may print, download, or email articles for individual use.