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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life 13 Cumulative Psychosocial Risks and Resilience: A Conceptual Perspective on Ethnic Health Disparities in Late Life Hector F. Myers and Wei-Chin Hwang Over the past decade, concern has been growing about society’s ability to meet the mental health needs of elderly Americans in certain racial/ethnic groups. This issue has become particularly salient given the rapid increase in the U.S. elderly population. In fact, between the years of 1990 and 2000, the elderly population in the United States increased 12 percent, and elderly Americans currently comprise 12.4 percent of the U.S. population (U.S. Census Bureau, 2001). Moreover, the population of racial/ethnic elderly is estimated to be increasing at a faster rate than that of whites (Ruiz, 1995). Despite these concerns, relatively little attention have been given to studying the mental health needs of aging ethnic minorities. In this chapter, we review the extant literature on ethnic disparities in mental health in late life, using depression as an illustrative disorder. We discuss methodological and conceptual gaps in the literature, and we review available clinical and epidemiological evidence. Moreover, we provide a conceptual framework for understanding the relationships among ethnicity, age, and well-being for elderly minority populations. Specifically, we present a biopsychosocial model of cumulative psychological and physical vulnerability and resilience in later life in which chronic stress burden and psychosocial resources for coping are hypothesized as playing a significant role in accounting for ethnic disparities in mental health. Implications and suggestions for future research are discussed. AGING AND DEPRESSION Because of a number of conceptual, diagnostic, and methodological challenges in studying depression in the elderly, findings from research
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life studies have been mixed, with most studies reporting lower prevalence of depression in the elderly (Regier et al., 1988), and some studies showing higher prevalence (Blazer, Burchett, Service, and George, 1991). Similar trends in low prevalence of mood disorders among ethnic elders also have been reported (Weissman, Bruce, Leaf, Florio, and Holzer, 1991), with no significant overall differences between groups in the Epidemiological Catchment Area (ECA) study (George, Blazer, Winfield-Laird, Leaf, and Fischbach, 1988). It would seem that healthy, functioning older adults are at no greater risk for becoming depressed. Instead, age-related effects may be attributable to physical health problems, functional and cognitive disability, chronic illness, low social support, and financial difficulties (Blazer et al., 1991; Roberts, Kaplan, Shema, and Strawbridge, 1997a). Nevertheless, a number of methodological limitations may lead to underestimates in rates of depression in community studies. Karel (1997) noted that low prevalence rates of major depression among older adults may reflect (1) invalid measurement of depression in older adults (e.g., diagnostic difficulties, symptoms being misattributed to medical causes, symptom recall, and older adults being viewed as less likely to be functionally impaired by depressive symptoms), (2) sampling bias (e.g., older adults may have died, may be unable to participate due to illness and disability, and may be institutionalized or residing in community dwellings for the elderly), or (3) cohort effects due to sociocultural changes (i.e., rates of depression increase in cohorts born after World War II). Several studies have confirmed that rates of depression are increasing in the United States and worldwide (Cross-National Collaborative Group, 1992). In examining depression in the elderly, it is also important to distinguish between recurrent illness that began earlier in life and first onset illness that manifests itself in late life. Early onset depression has been associated with a more malignant course (Klein et al., 1999; Lewinsohn, Fenn, Stanton, and Franklin, 1986; Sorenson, Rutter, and Aneshensel, 1991), greater vulnerability to chronic life stress (Hammen, Davila, Brown, Gitlin, and Ellicott, 1992), greater psychiatric comorbidity (Kasch and Klein, 1996; Lewinsohn, Rohde, Seeley, and Fischer, 1991), and greater genetic liability (Klein, Taylor, Harding, and Dickstein, 1988; Lyons et al., 1998). Early disorder onset is also associated with greater family psychiatric burden, neuroticism, and dysfunctional past maternal relationships (Brodaty et al., 2001; Van den Berg et al., 2001). On the other hand, first episode of depression in later life is associated with greater medical disability, and decreased neuropsychological and psychophysiological functioning (Lewinsohn et al., 1991). Therefore, it is important to distinguish between depressive subgroups that may possess different etiological pathways: (1) those with early onset and longstanding psychobiological and familial vulnerability, who carry this risk for recurrence into old age; (2) those who
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life become depressed as seniors, perhaps as a reaction to severe life stress; and (3) those whose depression may be associated with significant medical and vascular dysfunction and disability (Van den Berg et al., 2001). ETHNIC DISPARITIES IN DEPRESSION Results from large epidemiological studies on ethnic differences in the prevalence of major depression in the United States are mixed, with African Americans and Asian Americans showing lower rates of major depressive disorder (MDD), and Hispanics showing higher rates than whites (Blazer, Kessler, McGonagle, and Swartz, 1994; Somervell, Leaf, Weissman, Blazer, and Bruce, 1989; Zhang and Snowden, 1999). On the other hand, studies with smaller and less representative community samples report a greater prevalence of depressive symptoms in ethnic minorities (Kuo, 1984; Roberts, Roberts, and Chen, 1997b; Siegel, Aneshensel, Taub, Cantwell, and Driscoll, 1998), and more severe depression among ethnic minorities in treatment (Myers et al., 2002a). There has also been debate about the accuracy of these ethnic group differences, especially given the evidence for possible ethnic differences in symptom expression of depression. Although some studies have found similarities in the core features of major depression in all ethnic groups (Ballenger et al., 2001; Weissman et al., 1996), others have found a greater tendency among racial/ethnic minorities in the United States and nonwhites worldwide to somatize their psychological distress, which may also contribute to underestimates of disease prevalence (Kirmayer and Young, 1998; Kuo, 1984; Myers et al., 2002; Zheng, Lin, Takeuchi, Kurasaki, and Cheung, 1997). Several studies have reported that depressed African-American patients are more likely to report anxiety, anger, hostility, and suspiciousness than white patients (Fabrega, Mezzich, and Ulrich, 1988; Myers et al., 2002; Raskin, Crook, and Herman, 1975). Cross-national studies reveal different rates of major depression in various countries around the world (Weissman et al., 1996). Although we can speculate that differences in risk factors or cultural differences in expression and/or reporting of symptoms may account for some of the differences, we cannot assume they account for all of the differences. Furthermore, no cross-national studies have specifically compared rates of depression among the elderly, with most including only participants up to age 65. Findings from the ECA and National Comorbidity Study (NCS), the two largest epidemiological studies in the United States, have been mixed. ECA results indicated that whites and Hispanics evidenced higher rates of lifetime major depression (5.3 percent and 4.6 percent) than Asians and African Americans (3.6 and 3.4 percent) (Zhang and Snowden, 1999). Additionally, Hispanics reported higher rates of dysthymia than the other three groups, who reported comparable rates (4 percent, 2.6 percent, 3.2
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life percent, and 3 percent, respectively). African-American women between the ages of 18 and 24 were at particularly high risk in five ECA sites, and African-American men ages 18 to 24 were at lower risk compared with white men (Somervell et al., 1989). The NCS also confirmed the existence of some ethnic and gender differences in the prevalence of MDD (Blazer et al., 1994), with whites and Hispanics evidencing higher current and lifetime rates than African Americans, and women in all ethnic groups evidencing consistently higher rates than men. African-American women between the ages of 35 and 44 were also at particularly high risk for becoming depressed. Results from the more recent NCS also confirmed the existence of some ethnic and gender differences in the prevalence of MDD (Blazer et al., 1994), with whites and Hispanics evidencing higher lifetime rates of major depression than African Americans, and women in all ethnic groups evidencing consistently higher rates than men (see Table 13-1). Risk also varied by age groups, with African-American women between the ages of 35 and 44 and Hispanic women between the ages of 35 and 54 evidencing TABLE 13-1 Prevalence of Lifetime Major Depressive Episode, by Race/ Ethnicity, Sex, and Age from the National Comorbidity Survey (N = 8,098) Males Females Total Race/Ethnicity % SE* % SE % SE White (years) 15-24 11.6 2.1 23.1 2.3 16.9 1.5 25-34 14.0 1.4 19.6 1.5 17.0 1.1 35-44 15.2 2.0 24.2 2.4 19.5 1.8 45-54 12.7 2.0 23.1 2.9 17.9 1.6 Total 13.5 1.0 22.3 1.0 17.9 0.8 Black 15-24 4.7 2.2 9.2 2.7 7.1 1.8 25-34 9.0 4.1 18.6 4.4 14.5 3.3 35-44 5.9 1.8 21.1 4.5 14.9 3.3 45-54 10.2 6.2 9.0 3.9 9.6 4.1 Total 7.2 1.9 15.5 2.2 11.9 1.6 Hispanic 15-24 10.8 5.1 22.6 5.7 16.5 3.6 25-34 10.0 3.2 19.8 4.2 15.1 2.2 35-44 17.6 6.7 30.2 9.0 24.2 6.0 45-54 9.3 5.0 30.2 11.7 16.0 6.6 Total 11.7 2.4 23.9 3.6 17.7 1.9 *Standard error. NOTE: Percentages are weighted to the population.
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life particularly high risk. Although rates of 30-day current major depression proved to be less stable, they revealed similar trends. Other studies have found no significant differences in prevalence of depression between African Americans and whites, but have found that depression in African Americans is associated with socioeconomic deprivation, including low urbanization, low education, chronic physical condition, uncertainty, job loss, money problems, and social isolation (Dressler and Badger, 1985), and that race interacts with socioeconomic status (SES) to increase psychological vulnerability among African Americans (Williams, Takeuchi, and Adair, 1992). Because of methodological difficulties and the high cost of surveying the prevalence of psychiatric disorders among the heterogeneous mix of Asian Americans and Native Americans in the United States, we know less about the actual prevalence rates of depressive disorders in these populations. Studies on Chinese and Chinese Americans report lower prevalence rates for depression and lower treatment utilization rates than whites (Chen et al., 1993; Hwu, Yeh, and Chang, 1989; Snowden and Cheung, 1990; Sue, Fujino, Hu, Takeuchi, and Zane, 1991; Takeuchi et al., 1998). For example, lifetime and one-year prevalence of major depression among Chinese Americans as assessed by the University of Michigan-Composite International Diagnostic Interview was 6.9 percent and 3.4 percent, respectively (Takeuchi et al., 1998). Studies conducted in China and Hong Kong reveal even lower prevalence rates (Chen et al., 1993; Hwu et al., 1989). However, rates of dysthymia among Chinese Americans were comparable to the overall U.S. population (Takeuchi et al., 1998). In addition, some evidence indicates higher prevalence of psychiatric disorders among subgroups such as Southeast Asians who evidence high rates of posttraumatic stress disorder (PTSD) (Nicassio, 1985). Studies have also shown that Asian Americans seek treatment less often than other groups, and are more severely impaired at entry into treatment than whites. Therefore, treatment statistics may severely underestimate the need for mental health services in this population (Takeuchi, Leaf, and Kuo, 1988). In any event, mood disorders are the most prevalent psychiatric problem among Asian Americans and the main reason they seek treatment (Altschuler, Wang, Qi, Wang, and Xia, 1988; Flaskerud and Hu, 1994; Nakane et al., 1991). Moreover, there is evidence that Asians and Asian Americans report more severe distress and depressive symptoms in community and treatment settings (Kuo, 1984; Siegel et al., 1998; Sue and Sue, 1987), and that they tend to have worse treatment outcomes compared to whites (Zane, Enomoto, and Chun, 1994). Immigrant status and acculturation further complicate risk associated with depression and other health and mental health problems in many ethnic minority groups. Some studies indicate that the risk for more severe depressive symptoms and/or syndromal depression increases as ethnic im-
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life migrants become more acculturated (Burnam, Hough, Karno, Escobar, and Telles, 1987; Escobar, 1998; Golding, Karno, and Rutter, 1990; Takeuchi et al., 1998; Vega et al., 1998), and that the age of onset for depression is later for those born outside the United States (Hwang, Chun, Takeuchi, Myers, and Prabha, in press; Sorenson et al., 1991). In addition, there is some evidence that gender differences become more pronounced as immigrants become more acculturated (Swensen, Baxter, Shetterly, Scarbro, and Hamman, 2000; Takeuchi et al., 1998). It is possible that when immigrants come to the United States, the increased stress and burden of adapting to a new place increases risk for becoming depressed, and/or that important cultural protective factors (e.g., large family and friend networks) become attenuated. It is also possible that as immigrant populations assimilate into the United States, they evidence a regression to the normative prevalence rates and age of onset patterns of the general U.S. population (Berry, 1998). Even fewer studies have assessed the mental health needs of Native Americans. Large-scale epidemiological and community studies have failed to include significant numbers of Native Americans to permit meaningful comparisons, especially when the heterogeneity among Native American tribes is considered. Because of past discrimination and relocation, Native Americans remain plagued with economic disadvantage, poverty, physical and mental disability, and lack of access to care (Manson, 1995). In a study conducted by Kinzie et al. (1992), nearly 70 percent of Native Americans in their community sample had experienced a mental disorder in their lifetime. Among Vietnam veterans participating in the American Indian Vietnam Veterans Project, rates of PTSD among Northern Plains and Southwestern Vietnam vets ranged from 27 to 31 percent (current) and 45 to 57 percent (lifetime) (Beals et al., 2002; National Center for Post-Traumatic Stress Disorder and National Center for American Indian and Alaska Native Mental Health Research Center, 1996). Additionally, rates of current and lifetime alcohol abuse and/or dependence were 70 percent and 80 percent, respectively. These rates of PTSD and alcohol use and/or dependence are much higher than for whites, African Americans, and Japanese Americans. ETHNIC DIFFERENCES IN DEPRESSION AMONG THE ELDERLY There is a surprising lack of research available on the psychological well-being of older ethnic minorities. Although the NCS did not include those over 54 years of age, the ECA did survey the prevalence of psychiatric disorders in those 65 years and older. Findings revealed that 25- to 44-year-olds were at highest risk for experiencing a major depressive episode, while those over 65 were at lowest risk (Regier et al., 1988, 1993). Again, women evidenced highest risk for all age groups, and age trends were consistent across ethnic groups (Weissman et al., 1991).
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life On the other hand, in a community study of African Americans, Brown, Ahmed, Gary, and Milburn (1995) found that the one-year prevalence of major depression was highest among those 20 to 29 years old (5.6 percent), decreased among those 30 to 44 years old (2.2 percent) and 45 to 64 (1.2 percent) years old, but then increased among those over age 65 (3.2 percent). Additionally, the large majority of African Americans with major depression did not seek or receive mental health treatment (over 90 percent). Among elderly inpatient veterans at the Veterans Administration hospital, both African-American and Hispanic elderly evidenced significantly higher rates of psychotic disorders than whites (Kales, Blow, Bingham, Copeland, and Mellow, 2000). Although African-American elderly had significantly higher cognitive disorder and substance abuse rates than white and Hispanic elderly, they evidenced lower rates of mood and anxiety disorders. African-American elderly also have been found to report lower levels of depressive symptoms than whites, but report more functional impairment, unmet needs, losses, and physical illnesses, and fewer formal sources of support (Turnbull and Mui, 1995). Common predictors for both groups included the loss of significant others and the loss of a sense of control. Poor perceived health, physical illnesses, and fewer social contacts were significant predictors for frail white elders, but not for African-American elders. Similarly, poor ego strength and chronic medical problems were associated with greater depressive symptoms among African-American elderly in Tennessee (Husaini et al., 1991). Additionally, females were found to be more reactive to life events and to decreases in social support. Epidemiological evidence also notes significant black-white differences in rates of suicide among the elderly, with rates in white men and women (33.1 and 4.85 per 100,000, respectively) significantly higher than for African-American men and women (11.7 per 100,000 for men and rates that are too low for women for a reliable estimate) (Centers for Disease Control and Prevention, 2001). The rates of passive and active suicide ideation among African-American elderly are also reported to be equally low, with 2.5 percent and 1.4 percent for men and women respectively (Cook, Pearson, Thompson, Black, and Rabins, 2002). Among Hispanic elderly, Bastida and Gonzalez (1995) suggested that the stresses of migration, relocation, and adapting to a new cultural environment act as chronic stressors that increase risk for mental health problems. Canino et al. (1987) found that lifetime and 6-month prevalence rates for affective, anxiety, and substance abuse disorders increased with age in Puerto Ricans. However, their study did not examine Puerto Rican elders over age 65. Escobar, Karno, Burnam, Hough, and Golding (1988) also found higher rates of phobic and dysthymic disorders in Mexican women over 40, but again, their study did not include those over age 65. In a study of elderly Hispanics living in the San Luis Valley, no difference in risk of
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life depression was found among men (Swenson et al., 2000). However, Hispanic women evidenced greater depressive symptoms than non-Hispanic women. Additionally, elderly Hispanics who were less acculturated were at greater risk than those who were more acculturated. Female gender, chronic diseases, dissatisfaction with available social support, living alone, and lower income and education enhance risk for more severe depressive symptoms. There are relatively few studies on psychological distress and depression in elderly Asians and Asian Americans. The most frequently cited of these studies is the Chinese American Psychiatric Epidemiological Study, which found that Chinese Americans between the ages of 50 and 65 were at the greatest risk for becoming depressed (Takeuchi et al., 1998). Those who immigrated at a later stage in their lives were especially vulnerable to the deleterious risks of immigrating to a new country (Hwang et al., in press). Most of the major epidemiological studies of depression on Asians in Asia also exclude persons over age 65. However, there is some evidence for high prevalence of affective disorders among Asian elderly. For example, Lee et al. (1990) found a high prevalence of major depression among Koreans in Korea ages 18 to 24 (3.8 percent), a decreased prevalence in 25- to 44-year-olds (3 percent), and an increase in those 45 to 65 years old (3.5 percent). In addition, rates of dysthymia increased with age. Rates of major depression in Korean-American elderly in Los Angeles were similar to American elderly in the ECA sample in St. Louis, but lower than elderly Koreans in Korea (Yamamoto, Rhee, and Chang, 1994). However, the rate of alcohol abuse/dependence in Korean Americans was more than twice that of other elderly Americans. Cooper and Sartorius (1996) also found a gradual increase with age in the prevalence of neurotic disorders among Chinese in 12 areas of China. However, Chen et al. (1993) found that the prevalence of major depression was lower among Chinese ages 45 to 64, but that rates of dysthymia were higher compared to younger Chinese. Depression among Chinese elderly has been found to be associated with poor physical health, financial strains, lack of social support and resources, and stressful family environments (Chou and Chi, 2000; Krause and Liang, 1993; Kua, 1990; Woo, Ho, Lau, and Yuen, 1994). Furthermore, depression among elderly immigrants is often associated with social alienation and isolation, disempowerment, loss of support, and increased risk for suicide. In fact, elderly Chinese Americans, especially women, have been found to have higher rates of suicide than elders from other ethnic groups (Yamamoto et al., 1997; Yu, 1986). Depression in Native American elders is also a common problem. Manson (1992) found significant depressive symptoms in more than 30 percent of elderly Native American adults visiting an urban outpatient medical facility. In addition, nearly 20 percent of Native American elders
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life seeking treatment in primary care settings reported significant psychiatric difficulties (Goldwasser and Badger, 1989; Wilson, Civic, and Glass, 1995), and more than 18 percent of Great Lakes Native Americans endorsed clinically significant levels of depression as measured by the Center for Epidemiologic Study-Depression (Curyto, Chapleski, and Lichtenberg, 1999; Curyto et al., 1998). High prevalence rates of suicide, homelessness, alcohol and drug abuse, poverty, domestic violence, trauma exposure, and comorbidity of health and mental health problems also reflect the significant need for mental health services in this population. In summary, few studies have examined mental health issues among ethnic minorities, especially ethnic elders. The available evidence is mixed, revealing a higher prevalence of affective disorders among Hispanic Americans and Native Americans across the life course. On the other hand, African Americans and Asian Americans seem to have lower rates of diagnosable disorders, but higher rates of depressive symptomatology overall. Differences in the samples studied (i.e., community versus clinical samples), in the assessment measures used (i.e., symptom measures versus diagnostic interviews), as well as possible differences in expression of distress may partially account for these discrepancies. It is also possible that age-related effects and differences in risk for mental health problems in ethnic elderly may be attributable to a disproportionate burden of accumulated stress, physical health problems, functional and cognitive disability, chronic illness, low social support, and financial difficulties (Blazer et al., 1991; Roberts et al., 1997a). In any event, more systematic research examining the prevalence of psychiatric disorders among ethnic elderly is an important priority. CONCEPTUAL MODEL OF CUMULATIVE BIOPSYCHOSOCIAL VULNERABILITY AND RESILIENCE IN LATE LIFE The previous review indicates that the available research on the different ethnic groups is uneven, with limited information on Native Americans and on many racial/ethnic subgroups. Furthermore, few studies of depression and psychological well-being take a developmental life-course perspective in investigating possible ethnic group differences and factors that contribute to such differences. Finally, there is little synergy among the biological, psychosocial, and behavioral explanations that have been offered in accounting for ethnic differences in distress and depression in the elderly. To advance our understanding of the role psychosocial factors might play in ethnic differences in depression and well-being in late life, we offer an integrative biopsychosocial model as a heuristic for organizing our review and discussion of how psychosocial stress and related factors might account for ethnic differences in functional health outcomes. We use de-
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life pression as an illustrative disorder, but acknowledge that there is substantial evidence that the biopsychosocial factors included in this conceptual model may also apply to many other health outcomes, including but not limited to hypertension, cancer, chronic pain and disability, cognitive decline, and immune-mediated disorders. It is also important to acknowledge that depression is often co-morbid with chronic illnesses (e.g., advanced heart disease, diabetes, cancer), and is often a consequence of the anxiety, pain, and disability associated with these chronic conditions. Therefore, this conceptual framework may have broader applicability to both psychiatric and medical illnesses. We also acknowledge that the evidence supporting many of the hypothesized pathways varies in quality and relevance to explaining ethnic group differences in the health of the elderly. Nevertheless, we believe this model can be helpful in guiding future research efforts. The proposed model, depicted in Figure 13-1, makes explicit that (1) sociostructural factors, such as race/ethnicity, social class, environmental factors (e.g., community, family), and (2) biological factors such as genetic vulnerabilities and family medical and psychiatric histories, interact over time to increase (3) burden of psychosocial adversities, which is hypothesized to be the primary predictor of risk. Primary among these adversities are a cluster of life stresses that include chronic life stresses, major life events, ethnicity-related stresses, and age-related stresses. Over the life course, we hypothesize that these stresses will accumulate and contribute to vulnerability to disease and dysfunction. The impact of this stress burden is further exacerbated by personality characteristics, such as anger/hostility, neuroticism, and pessimism, and by the clustering of health-endangering behaviors, such as smoking, alcohol and drug abuse, sedentary lifestyle, and obesity (Contrada et al., 2000; Krieger, Rowley, Herman, Avery, and Phillips, 1993; Myers, Kagawa-Singer, Kumanyika, Lex, and Markides, 1995; Williams, Yu, Jackson, and Anderson, 1997). Our conceptual model builds on the work of several stress and life-course theorists, including McEwen and colleagues’ (McEwen, 1998; McEwen and Seeman, 1999) work on “allostatic load,” the work by Elder and colleagues (Elder, 1998; Elder and Crosnoe, 2002; Wickrama, Conger, Wallace, and Elder, 1999) on “life course and intergenerational transmission of risk,” Singer and Ryff’s (1999) work on “life history methodology,” and Geronimus’s (1992) work on the “weathering hypothesis.” These earlier models identify factors that serve as (4) biobehavioral mediators and moderators of risk for adverse psychological and health outcomes. Furthermore, lifetime burden of adversities is hypothesized as contributing to disease through biological and behavioral pathways that include the chronic triggering of physiological response mechanisms (i.e., allostasis), constitutional predispositions or vulnerabilities, and allostatic load (i.e., wear and tear on the system). In turn, allostatic load is hypothesized to contribute
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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life FIGURE 13-1 Biopsychosocial model of cumulative psychological vulnerability and resistance in late life.
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