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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

INTRODUCTION

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: [email protected].

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

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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.

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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.

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