Ciência & Saúde Coletiva ISSN: 1413-8123 [email protected] Associação Brasileira de Pós-Graduação em Saúde Coletiva Brasil

Smolen, Jenny Rose; de Araújo, Edna Maria Raça/cor da pele e transtornos mentais no Brasil: uma revisão sistemática Ciência & Saúde Coletiva, vol. 22, núm. 12, diciembre, 2017, pp. 4021-4030 Associação Brasileira de Pós-Graduação em Saúde Coletiva , Brasil

Available in: http://www.redalyc.org/articulo.oa?id=63053795019

How to cite Complete issue Scientific Information System More information about this article Network of Scientific Journals from Latin America, the Caribbean, Spain and Portugal Journal's homepage in redalyc.org Non-profit academic project, developed under the open access initiative REVIEW 4021 DOI: 10.1590/1413-812320172212.19782016 ------Race, Skin color, Mental health Mental color, Skin Race, Mental health disorders contributeMental a

. Key words Key the six multivariate analyses statisti that found a indicated five greater results, significantcally prevalence or odds of mental in health disorder of as (measure Whites to compared non-Whites sociationbetweenreview This 1.18-1.85). identi the assoregarding fied the in the literature trend ciation between and mental health disorders. race important difficulties the complicate However, principallycomparability of the studies, in func tion of the differences in the mental health disor ders the method studied, of categorizing race/skin and the screening used tools studies in the color, analyzed rature reviewrature summarize aims to the current sta and mental color on race/skin of te the literature and PubMed Methods: health disorders in . searched using descriptorsLilacs were mental for Common anxiety, health disorders (depression, etc.) and psychiatric Disorders, Mental morbidity, Studies find studies to conducted in Brazil. race analyze that did not of non-population groups, which for or the mental disorder color, race/skin After the object not excluded. was were of study 14 articles selected were evaluation for of quality, higher an overall was There prevalen inclusion. Ofce of mental health disorders in non-Whites. Abstract Abstract This systematic lite to significantsociety. burden Race/skin color and mental health disorders in Brazil: in Brazil: health mental and disorders color Race/skin reviewa systematic of literature the 1 1 Núcleo de Pesquisa Pesquisa de Núcleo de Santana BA Brasil. Brasil. Santana BA de [email protected] Universidade Estadual Estadual Universidade Av. Santana. de Feira de Novo s/n, Transnordestina 44036-900 Feira Horizonte. em Desigualdades em Programa Saúde, em Pós-Graduação de Coletiva, Saúde em 1 Jenny Rose Smolen Smolen Rose Jenny Araújo de Edna Maria 4022

Introduction of this study is to systematically review the liter- ature on race and mental health in Brazil to un- Smolen JR, Araújo EM JR, Smolen Mental health is one of the largest contributors to derstand this association in the Brazilian context. the burden of disability worldwide; in the Glob- al Disease Burden Study 2010, mental and sub- stance abuse disorders accounted for the highest Methodology proportion (22.9%) of years lived with disabil- ity (YLD). Depressive disorders are particularly Search process important to study: within the category of men- tal and substance abuse disorders, the affective Two reference databases were used to cap- mental health disorders such as depression and ture all the published research on this theme – anxiety disorders account for the largest portion PubMed was searched to find the internation- of YLD globally1. This pattern of morbidity bur- ally published research, and Lilacs was searched den also exists in Brazil. Schramm et al.2 showed to find the research published in Brazil. Search that neuropsychiatric disorders accounted for strings were created separately for each database. the highest proportion of YLD, both in Brazil Keywords were chosen according to the theme of as a whole (34%) and in the Northeast (32.9%). the review, with the aim of using general terms to Despite the costly impact on population health, cast the widest net. mental health is less studied than physical health. The controlled vocabulary thesauruses for Few studies have examined the association be- each database were consulted to find the con- tween race/skin color and mental health in Bra- trolled vocabulary corresponding with the key- zil, or even included race as a unit of analysis. words–the MeSH (Medical Subject Headings) Relatively little research has been performed system for PubMed, and the DeCS (Descriptores in Brazil on health inequalities according to race/ en Ciências de la Salud) system for LILACS. Free skin color, principally because researchers do not terms were also used so as not to miss articles include a question about race/skin color on sur- that have not yet been indexed. vey instruments. Chor and Lima3 attribute this to three potential hypotheses: acceptance of the Search strings “myth of racial democracy”; difficulties in classi- fying race/ethnicity; and the opposition between The PubMed search was carried out using class and race. Although Brazil never had a legal the following search string: “((((((((((“Depres- or formal policy of racial segregation, this does sion”[Mesh]) OR “Depressive Disorder”[Mesh]) not mean race has no influence on Brazilian soci- OR “Anxiety Disorders”[Mesh]) OR “Stress, ety–there are clear inequalities present4,5. Psychological”[Mesh]) OR “Minor psychiatric Race/skin color can influence the opportuni- disorders”) OR “psychiatric morbidity”) OR ties that a person receives in life–educational, fi- “psychological distress”) OR “common mental nancial, and social–which affects socioeconomic disorders”)) AND (((((“Ethnic Groups”[Mesh]) status6,7. A current theoretical framework to ex- OR race) OR “skin color”) OR black) OR plain the path that connects race to mental health white)) AND brazil*”. The LILACS search was is that exposure to stress is the causal mecha- elaborated using the following search string: nism8. According to Williams et al.9, race may in- tw:( (“distúrbios psíquicos menores” OR “tran- fluence exposure to stress through two possible stornos psiquiátricos menores” OR “distúr- pathways: stress linked to social structure, social bios psiquiátricos menores” OR “morbidade status, and social roles – i.e. the stress caused by psiquiátrica” OR “transtornos mentais comuns” the fact that race is a determinant of socioeco- OR “depressão” OR “transtorno depressivo” OR nomic position; and stress linked to experiences “transtornos de ansiedade” OR “estresse psi- of racism and discrimination. cológico”) AND (“Distribuição por raça ou et- Many of the studies on the association be- nia” OR “grupos étnicos” OR “Desigualdades em tween race and mental health were performed Saúde” OR raça OR “cor da pele” OR branco OR in the United States9-14. Considering the differ- branca OR negro OR negra OR preto OR pre- ence in social, cultural, and historical contexts ta)) AND (instance:”regional”) AND ( db:(“LI- between the United States and Brazil, the results LACS”)). No date, year, or language limits were of studies performed in the US may not be rep- applied to these searches. The software StArt resentative of the association between race and (State of the Art through Systematic Review) was mental health in Brazil. Therefore the objective used to facilitate the systematic review process. 4023 Ciência & Saúde Coletiva, 22(12):4021-4030, 2017

Inclusion/exclusion criteria

PubMed (n = 192) Only cross-sectional studies on the preva- Articles identified through lence of the aforementioned mental health disor- search in PubMed and Lilacs (n = 262) ders were included in this systematic review, and Lilacs (n = 70) only studies for which the mental health disorder was an object of study. Studies that did not in- Abstracts excluded clude a race or skin color variable were excluded. (n = 209 ) Population studies, or studies of specific popula- tions groups were included in the study; however, Duplicates removed studies of non–population groups (for example, (n = 5) people with a specific medical condition other than the mental health disorders of interest) were Full-text articles evaluated excluded. All included studies reported at least (n = 48) the prevalence of the mental health condition by race. Other studies also include race in the multi- Articles excluded variate analysis. Considering that racial categori- (n = 31) zation as well as the association between race and health outcomes may be culturally determined, Articles evaluated for this review was limited to the Brazilian context– quality (n = 17) only studies performed in Brazil were included. After the initial search, all abstracts were read Articles that did not to determine relevance, according to the afore- meet minimum quality mentioned inclusion and exclusion criteria. Since criteria (n = 6) race, when not the object of study, was not nec- essarily mentioned in the title or abstract, articles Articles included (n = 11) were not eliminated if they did not mention race + articles identified from as a variable in the abstract stage. reference lists (n = 3) The search in PubMed resulted in 70 articles, and the search in Lilacs resulted in 192 (Figure 1). Articles included in Of the 262 total articles identified by the search systematic review (n = 14) strings, 209 abstracts were rejected for not fitting the inclusion/exclusion criteria. Since the StArt software screens out most duplicated articles, Figure 1. Process of identifying articles for only 5 articles were identified as duplicates. The inclusion in the systematic review. full-texts of the 48 articles deemed possibly rel- evant were read in their entirety to determine if they reported the mental health outcome by race in at least the bivariate analysis. Of those 48 ar- ticles, 17 articles met the stated criteria. The ref- Results erence lists of each of these 17 articles were then combed, and three more relevant articles were Of 20 studies that met the inclusion criteria, six identified, downloaded, and judged to fit the cri- were judged not to not meet the minimum qual- teria to be included in the study. ity criteria as laid out in the JBI-PCT, primarily due to lack of randomization in the sampling Evaluation of quality strategy or due to insufficient sample size. Thus, 14 articles were identified for final inclusion (Fig- The Joanna Briggs Institute Prevalence Crit- ure 1). ical Appraisal Tool (JBI-PCT) was used to assess the quality of cross–sectional studies, which con- Setting and subjects sists of 10 questions on various elements of study quality, including the sample and sample selec- As seen in Table 1, three of the fourteen in- tion, appropriate statistical analysis and control cluded studies were of the general population16-18, for confounding15. one with middle–aged women19, three were specifically of older adults20-22, two with young 4024

adults23,24, and five were of pregnant women or Depression symptoms were seen to be signifi- women who recently gave birth25-29. cantly higher among Black middle–aged women Smolen JR, Araújo EM JR, Smolen (52.8%) than among White women (42.3%)19. Mental health disorders studied Among older adults, a significantly higher prev- alence of depressive symptoms/depression mor- All the included studies examined affective bidity was seen in non-Whites as compared to mental health disorders. Three of the fourteen Whites20,22. The difference among non-Whites studies examined depression16-18, three examined varied however in one study Afro- psychiatric morbidity (referred to as depressive (46.5%) and multiracial Brazilians (45.7%) had symptoms, or depression morbidity)19-22, two a higher prevalence than Whites (37.8%)22, while studied Common Mental Disorders23,24, and five in another Blacks had nearly the exact same prev- studies examined ante- or post-natal depression, alence as Whites (17.0% vs. 17.1%, respectively) or depression during pregnancy25-29. Although and the highest prevalence was found among the anxiety was included in the search terms, only category of Asian/Mulatto/Indigenous (25.0%)20. one study included any measure specific to anx- Another study found a lower prevalence among iety; this study examined both antenatal depres- non-Whites (22.7%) than among Whites sion and antenatal anxiety25. (27.5%), however the difference was not signifi- Although several studies examined the same cant21. For antepartum and post–partum depres- mental health outcome, there was little concor- sion, no statistically significant differences were dance in the tool used to assess that outcome. found by race25-29. Only two screening tools appeared more than once – the Edinburgh Postnatal Depression Scale Multivariate analyses (EDPS), and the Geriatric Depression Scale. However, of the three studies that used the EDPS, The multivariate analyses show differing re- two used a cut–off of 1226,29, and the other used a sults, as can be seen in Table 1. Prevalence ratios cut-off of 1328. The two studies that used the GDS of depression in one study show that Black Bra- used different versions of the scale, as one used zilians are actually significantly less likely like to the 30–item version21, and the other used the 15- have depression than Whites (OR = 0.72; 95% CI: item version20. All studies used instruments that 0.56–0.94), and this difference was significant16. were validated for use in Brazilian Portuguese. However, another study of depression in the gen- As seen in Table 1, for the bivariate analyses eral population shows that Moreno (OR = 1.30; twelve studies reported prevalence by race, and 95% CI: 0.85-2.01), Mulatto (OR = 1.78; 95% CI: one reported a prevalence ratio but not preva- 1.09-2.90) and Black Brazilians (OR = 1.14; 95% lence18-29. Only ten articles included race in the CI: 0.70-1.87) Black Brazilians all have greater multivariate analysis16-18,20,22,23-26,28; although in odds of depression compared to White Brazilians, one study the absence of race/skin color in the though this result was only significant for the multivariate model was due to the use of step– Mulatto group18. In a study that adjusted for dis- wise regression27. crimination, no significant difference was found in odds of CMD between Black/Brown and White Prevalence Brazilian university students (OR = 0.9; 95% CI: 0.5–1.4)24. Yet, another study, one that did not Of the studies on depression in the general adjust for discrimination, found that Black or population, only one reported prevalence of de- Mixed Brazilian women have a 25% higher prev- pression by race, and this study found a higher alence of CMD as White women (OR = 1.25; 95% prevalence in the non-White categories (Moreno: CI: 1.09–1.43); a similar pattern was seen among 12.0%, Mulatto: 15.7%, and Black: 11.2%) than men, yet this finding was of only marginal signifi- among Whites (9.4%)18. One study on Common cance (OR = 1.18; 95% CI: 0.98–1.42)23. Mental Disorders (CMD) found a higher preva- Among older adults, multiracial Brazilians lence among Black Brazilians (51.6%) than White showed significantly higher prevalence of depres- Brazilians (37.0%), but a lower prevalence among sion morbidity (PR = 1.41; 95% CI: 1.07–1.86), Brown Brazilians (32.8%), though these differ- and marginally significant higher odds (OR = ences were not significant24. One of the studies on 1.21; 95% CI: 0.99–1.48) than Whites. Afro–Bra- CMD found a significantly higher prevalence of zilian older adults also had marginally significant CMD among Black/Mixed Brazilians than White higher odds of depression morbidity (OR = 1.22; Brazilians, and this was true in men and women23. 95% CI: 0.98–1.53) than Whites20,22. 4025 Ciência & Saúde Coletiva, 22(12):4021-4030, 2017

Table 1. Included studies. Population Measure of Association Authors Screening Tool Prevalence by Race Studied (95% CI) Studies on Depression Munhoz et Adults, 20+ PHQ-9, cut-off of ≥9 Prevalence not reported Prevalence Ratio al., 201316 (n = 2925) Black: 0.72 (0.56-0.94) Other: 1.12 (0.89-1.41) Pavão et Adults, 20+ Self-report of ever told Prevalence not reported Odds Ratio al., 201217 (n = 3863) by a physician you have Mulatto: 1.00 (ref) depression Black: 1.35 (0.91-2.01) Almeida- Adults PSAD subscale of White: 9.4% Odds Ratio Filho et al., (n = 2302) QMPA, cut-off of ≥23 Moreno: 12.0% Moreno: 1.30 (0.85-2.01) 200418 on PSAD combined Mulatto: 15.7% Mulatto: 1.78 (1.09-2.90) with ≥13 on depression Black: 11.2%† Black: 1.14 (0.70-1.87) subscale Non-White (combined): Non-White (combined): 1.40 12.7%† (0.94-2.09) Studies of depressive symptoms Guimarães Middle-aged PRIME-MD, caseness White: 42.3% -- et al., women determined by a “yes” Mulatto: 46.4% 200919 (n = 1249 to one of three pre- Black: 52.8%* determined questions Bretanha Older adults, GDS-15, cut-off of ≥6 White: 17.0% Prevalence Ratio et al., 60+ Black: 17.1% Black: 0.96 (0.65-1.43) 200520 (n = 1593) Asian/Mulatto/Indigenous: Asian/Mulatto/Indigenous: 1.41 25.0% (1.07-1.86) Quatrin et Older adults, GDS-30, cut-off of ≥11 White: 27.5% -- al., 201421 60+ (n = 1007) Non-White: 22.7% Blay et al., Older adults, SPES, cut-off of ≥2 White: 37.8% Odds Ratio 200722 60+ African-Brazilian: 46.5% Afro-Brazilian: 1.22 (0.98-1.53) (n = 6961) Asian: 34.8% Asian: 0.90 (0.35-2.32) Multiracial: 45.7%* Multiracial: 1.21 (0.99-1.48) Studies of Common Mental Disorders Anselmi et Young SRQ-20, cut-off of ≥8 Men: Prevalence Ratio al., 200823 adults, 23-24 for women, ≥6 for men White: 21.9% Men: (n = 4285) Black/Mixed: 26.9%* Black/Mixed: 1.18 (0.98-1.42) Women: Women: White: 30.0% Black/Mixed: 1.25 (1.09-1.43) Black/Mixed: 41.1%* Bastos et Undergraduate GHQ-12, cut-off of ≥3 White: 37.0%; Odds Ratio al., 201424 students Brown: 32.8%; Black/Brown: 0.9 (0.5-1.4) (n = 424) Black: 51.6% Studies of depression related to pregnancy (pre-natal, post-partum, during pregnancy) Faisal- Pregnant Antenatal depression: White: 19.9% Odds Ratio Curry e women BDI, cut-off of ≥16 Non-White: 19.1%† Non-White: 0.95 (0.5-1.81) Menezes, (n = 432) 200725 Antenatal anxiety: White: 58.8% Others: 1.19 (0.70-2.00) STAI, cut-off of ≥41 Non-White: 63.0%† Melo et al., Pregnant Antepartum White: 34.9% Prevalence Ratio 201126 women, 18+ Depression: Non-White: 65.1% Non-White: 1.48 (1.09-2.01) (n = 555) EPDS, cut-off of ≥12 Postpartum White: not reported Non-White: 1.85 (1.11-3.08 Depression: Non-White: 70.0% EPDS, cut-off of ≥12 it continues 4026

Table 1. continuation Population Smolen JR, Araújo EM JR, Smolen Authors Screening Tool Prevalence by Race Measure of Association (95% CI) Studied Pereira et al., Pregnant Depression during White: 14.1% -- 200927 women pregnancy: Non-White: 14.3% (n = 331) CIDI Tannous et Women who Postnatal depression: Caucasian: 16.6%, Prevalence Ratio al., 200828 recently gave EPDS, cut-off of ≥13 Non-Caucasian: 28.1%† Non-Caucasian: 0.80 (0.49-1.32) birth to live infants (n = 271) Ruschi et al., Women 15-45 Postnatal depression: White: 47.8% -- 200729 who gave birth EPDS, cut-off of ≥12 Black: 17.4% to a live infant Brown: 34.8% 31-180 days prior (n = 292) If not designated otherwise, Whites are considered the reference group. *p < 0.05. † p-value not reported.

One study of antepartum depression found ture was based on studies that did not have a di- a statistically significant difference by race: non– verse study sample. For example, of the 14 studies Whites had a 48% higher prevalence of antepar- to include race as a variable of analysis, six had tum depression than Whites (OR = 1.48; 95% samples that were over three quarters White. Ac- CI: 1.09–2.01)26. Postpartum depression was cording to the 2010 Census, Brazil’s population is also found to be significantly different by race– 47.7% White, and 50.7% Black/Brown30; howev- non–Whites had a prevalence 85% higher than er, in the South/Southeast of Brazil, where these in Whites (OR = 1.85; 95% CI: 1.11–3.08)26. Only six studies were carried out, there is a higher one study assessed anxiety, specifically antenatal concentration of White Brazilians. Of the studies anxiety, but did not find any significant results25. with a more mixed sample, and therefore greater As seen in Table 2, nearly of all the significant statistical power to assess race, all significant as- associations found in these articles were in the sociations were in the positive direction. positive direction for the non–White race/skin Race does not have a biological relationship color group. The studies were most commonly with health, therefore there is no biological ba- carried out in the states of Rio de Janeiro and Rio sis for an association between race and mental Grande do Sul, and in most studies 50% or more health31,32. The imperative to study this relation- of the sample population was White. ship stems from a need to identify the populations with the highest burden of poor mental health who are therefore most in need of treatment, and Discussion additionally to better explore and understand (in order to eventually prevent) what societal The existing cross–sectional studies on men- and contextual factors may be contributing to tal health outcomes and race identified in this this association. Since the relationship between review suggest that the prevalence of mental race and mental health is not biological, it is not health disorders is higher among Afro–Brazilians immutable. If the contributing or causal factors than Whites. There was not universal consen- could be identified, they could be prevented and sus among these studies, yet of the multivariate therefore reduce or eliminate the inequality. The analyses that found statistically significant asso- idea that racial disparities in health are caused by ciations, nearly all were in the positive direction biology and genetics has been discredited, and between non–Whites and mental health disor- other theories have taken its place to explain the ders; all of the analyses included socioeconom- association between race and health outcomes. ic variables such as educational level and family A stress theory has been posited, and supported income. This begs future exploration, especially by several studies that found that stress accounts considering that nearly half of the existing litera- for much of the difference in depressive symp- 4027 Ciência & Saúde Coletiva, 22(12):4021-4030, 2017

Table 2. Setting, distribution of race in study sample and direction of association in multivariate analysis. Racial Distribution of Direction of multivariate Authors Study Setting Study Sample Associationa Munhoz et al., 201316 Rio Grande do Sul 80.1% White Black: - * 12.1% Black Others: + 7.8% Other Pavão et al., 201217 Representation from all 77.2% Mulatto Mulatto: (ref) regions of Brazil 22.8% Black Black: + Almeida-Filho et al., 14.9% White Moreno: + 200418 45.9% Moreno Mulatto + * 15.9% Mulatto Black + 20.7% Black Guimarães et al., 200919 Rio de Janeiro 43.3% White -- 40.1% Mulatto 16.6% Black Bretanha et al., 200520 Rio Grande do Sul 78.6% White Black: - 8.7% Black Asian/Mulatto/ 12.7% Asian/ Indigenous: + * Mulatto/Indigenous Quatrin, et al., 201421 Rio Grande do Sul 95.7% White -- 4.3% Non-White Blay et al., 200722 Rio Grande do Sul 84.2% White Afro-Brazilian: + * 6.8% Afro-Brazilian Multiracial: + * 8.6% Multiracial Anselmi et al., 200823 Rio Grande do Sul 78.1% White Black/Mixed: + * 21.9% Black/Mixed Bastos et al., 201424 Rio de Janeiro 51.4% White Black/Brown: - 32.8% Brown 15.2% Black Faisal-Curry e Menezes, São Paulo 83.0% White Non-White (Depression): - 200725 17.0% Non-White Non-White (Anxiety): + Melo et al., 201126 Pernambuco; São 45.5% White Non-White: + * Paulo 54.5% Non-White Pereira et al., 200927 Rio de Janeiro 45.0% White -- 55.0% Non-White Tannous et al., 200828 Porto Alegre 64.6% White Non-White: - 35.4% Non-White Ruschi et al., 200729 Espírito Santo 49.0% White -- 16.8% Black 34.2% Brown a Compared to Whites as the reference group. * Statistically significant (p < 0.05).

toms by race8, and that race-related discrimina- both. Yet this misses an important point, that the tion adversely affects health9,33. A more recent experience of discrimination may lead equally to meta-analysis found that perceived discrimina- poor outcomes among all it affects, yet Black and tion is directly related to poorer mental health Mixed Brazilians still suffer a higher burden of its status, and experimental studies showed experi- sequelae since they are more likely to have expe- ences of discrimination may produce a negative riences of discrimination. One study found that psychological stress response and a heightened Black Brazilians have over 50% higher odds of physiological stress response34. There is a tenden- having experienced discrimination than Whites, cy that articles on mental health either focus on even after controlling for income, education, so- discrimination or on race, as if race can be the cial status, and health problems35. Studies that factor of interest or discrimination can–but not explore the association between discrimination 4028

and mental health are important and necessary, studies used a binary categorization of White yet they should also report results by race and compared to Non–White, while others includ- Smolen JR, Araújo EM JR, Smolen the association by race to show which population ed separate categories for Mulatto or Moreno, or groups bear the risk associated with experiences Multiracial. This reflects the complexity of per- of discrimination. ceptions of skin color and race in Brazil, but com- This systematic review suggests a positive plicates interpretation. Because of the difference association between race and mental health dis- in racial categorization, estimating prevalence of orders, and points out the need for further re- mental health disorders by race/skin color group search into this association, as well as into the was not possible. Future research should use the prevalence/mental health burden of Black and five standardized race categories used in the Bra- Mixed Brazilians. In the initial search results, 262 zilian Census: Black, White, Parda, Asian, and In- articles were identified. Many of these articles digenous. To capture all those with Afro–Brazil- reported on race––but only when describing the ian heritage, researchers commonly group Black demographics of the sample population. Those and Parda together as Negra. This way the litera- that included race as a variable of analysis often ture on race/skin color and mental health would did not report the prevalence of mental health be more comparable and better able to estimate disorder by race, or conduct a multivariate anal- prevalence of mental health disorders according ysis that included race. Efforts should be made to standardized race/skin color categories. Ob- to stimulate the inclusion of race as an analytic taining these prevalence estimates is an important variable in studies of mental health in Brazil. step in identifying health disparities, allocating Eight of the 14 studies in this systematic re- resources, and designing interventions. view were carried out in the South or Southeast This identified the general trend in the pub- of Brazil, a pattern also seen in mental health re- lished literature in the association between race/ search in Brazil as a whole36. Geographic diver- skin color and mental health outcomes, however sity is important in understanding if there are there are important difficulties complicating the regional differences in the relationship between direct comparability between these studies. This race and mental health, yet is also important is primarily due to the different mental health from a statistical standpoint–there is less racial outcomes studied, the different populations diversity in the South and Southeast of Brazil, studied, and the different screening tools and therefore more challenging to recruit a sample cut–off points used. However, so few studies on with a sufficient number of Black participants to mental health have been conducted in Brazil that assess the relationship with race. Nearly half of assess race that it becomes necessary to look at the studies had a sample in which 75% or more what little, varied literature exists to stimulate in- of the participants were White. While it is still terest in conducting new studies. possible to assess the relationship between race This review serves to highlight the state of the and mental health in such samples, the results literature on this theme. As the results show, the will be less reliable due to the small numbers of literature is currently limited, and what exists is other racial groups in the analysis. very fragmented. Few national studies on men- The lack of standardization of racial catego- tal health included a race/skin color variable, and ries used in these studies is problematic when at- when studies included such a variable different tempting to compare results across studies. Some categorizations were used. 4029 Ciência & Saúde Coletiva, 22(12):4021-4030, 2017

Collaborations References

JR Smolen and EM Araújo designed the study 1. Whiteford HA, Degenhardt L, Rehm JR, Ferrari AJ, and search string. JR Smolen carried out the Erskine HE, Charlson FJ, Norman RE, Flaxman AD, Johns N, Burstein R, Murray CJ, Vos T. Global burden search of the literature. Both EM Araújo and JR of disease attributable to mental and substance use Smolen interpreted the results. JR Smolen draft- disorders: findings from the Global Burden of Disease ed the article, and EM Araújo assisted with the Study 2010. Lancet 2013; 382(9904):1575-1586. introduction and discussion, as well as a critical 2. Schramm, JMA, Oliveira AF, Leite IC, Valente JG, Ga- review of the draft and methodology. EM Araújo delha AMJ, Portela MC, Campos, MR. Transição epide- miologica e o estudo de carga de doença no Brasil. Cien approved the final draft of the paper. JR Smolen Saude Colet 2004; 9(4):897-908. and EM Araújo designed the study and search 3. Chor D, Lima CR. Epidemiologic aspects of racial in- string. JR Smolen carried out the search of the equalities in health in Brazil. Cad Saude Publica 2005; literature. Both EM Araújo and JR Smolen inter- 21(5):586-594. preted the results. JR Smolen drafted the article, 4. Heringer R. Desigualdades sociais no Brasil: Síntese de indicadores e desafios no campo das políticas públicas. and EM Araújo assisted with the introduction Cad Saude Publica, 2002; 18(Supl.):57-65. and discussion, as well as a critical review of the 5. Lopes F. Para além da barreira dos números: desi- draft and methodology. EM Araújo approved the gualdades raciais e saúde. Cad Saude Publica 2005; final draft of the paper. 21(5):1595-1601. 6. Solar O, Irwin AA. Conceptual framework for action on the social determinants of health. Social Determi- nants of Health Discussion Paper 2 (Policy and Practice). Geneva: World Health Organization. 2010. 7. Warner DF, Brown TH. Understanding how race/eth- nicity and gender define age-trajectories of disabili- ty: an intersectionality approach. Soc Sci Med 2011; 72(8):1236-1248. 8. Turner RJ, Avison WR. Status variations in stress ex- posure: Implications for the interpretation of research on race, socioeconomic status and gender. J Health Soc Behav 2003; 44(4):488-505. 9. Williams DR, Yu Y, Jackson JS, Anderson NB. Racial differences in physical and mental health: socioeco- nomic status, stress and discrimination. J Health Psy- chol 1997; 2(3):335-351. 10. Breslau J, Kendler KS, Su M, Gaxiola-Aguilar S, Kessler RC. Lifetime risk and persistence of psychiatric disor- ders across ethnic groups in the United States. Psychol Med 2005; 35(3):317-327. 11. Warheit GJ, Holzer CE, Arey SA. Race and mental ill- ness: an epidemiologic update. J Health Soc Behav 1975; 16(3):243-256. 12. Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S, Wittchen HU, Kendler KS. Lifetime and 12-month prevalence of DSM-III-R Psy- chiatric Disorders in the United States. Arch Gen Psych 1994; 51(1):8-19. 13. Riolo SA, Nguyen TA, Greden JF, King CA. Prevalence of depression by race/ethnicity: Findings from the Na- tional Health and Nutrition Examination Survey III. Am J Public Health 2005; 95(6):998-1000. 14. Harris KM, Edlund MJ, Larson S. Racial and ethnic differences in the mental health problems and use of mental health care. Med Care 2005; 43(8):775-784. 15. Munn Z, Moola A, Riitano D, Lisy K. The development of a critical appraisal tool for use in systematic reviews addressing questions of prevalence. Int J Health Policy Manag 2014; 3(3):123-128. 16. Munhoz TN, Santos IS, Matijasevich A. Major de- pressive episode among Brazilian adults: a cross-sec- tional population-based study. J Affect Disord 2013; 150(2):401-407. 4030

17. Pavão ALB, Ploubidis GB, Werneck G, Campos MR. 28. Tannous L, Gigante LP, Fuchs SC, Busnello EDA. Post- Discrimination and health in Brazil: Evidence from a natal depression in Southern Brazil: prevalence and its

Smolen JR, Araújo EM JR, Smolen population-based survey. Ethn & Disease 2012; 22. demographic and socioeconomic determinants. BMC 18. Almeida-Filho N, Lessa I, Magalhães L, Araújo MJ, Psych 2008; 8:1. Aquino E, James SA, Kawachi I. Social inequality and 29. Ruschi GEC, Sun SY, Mattar R, Filho AC, Zandonade depressive disorders in Bahia, Brazil: interactions of E, Lima VJ. Aspectos epidemiológicos da depressão pós gender, ethnicity, and social class. Soc Sci Med 2004; -parto em amostra brasileira. Rev Psiquiatr RS 2007; 59(7):1339-1353. 29(3):274-280. 19. Guimarães JMN, Lopes CS, Baima J, Sichieri R. De- 30. Instituto Brasileiro de Geografia e Estatistica (IBGE). pression symptoms and hypothyroidism in a popula- Censo Demográfico 2010.Rio de Janeiro: IBGE. [aces- tion-based study of middle-aged Brazilian women. J sado 2014 jul 27]. Disponivel em: ftp://ftp.ibge.gov. Affect Disord 2009; 117(1-2):120-123. br/Censos/Censo_Demografico_2010/Caracteristi- 20. Bretanha AF, Facchini LA, Nunes BP, Munhoz TN, cas_Gerais_Religiao_Deficiencia/caracteristicas_reli- Tomasi E, Thumé E. Depressive symptoms in elderly giao_deficiencia.pdf living in areas covered by Primary Health Care Units 31. Cooper R, David R. The biological concept of race and in the urban area of Bagé, RS. Rev Bras Epidemiol 2005; its application to public health and epidemiology. J 18(1):1-12. Health Politics 1986; 11(1):97-116. 21. Quatrin LB, Galli R, Moriguchi EH, Gastal FL, Pat- 32. Goodman AH. Why genes don’t count (for racial differ- tussi MP. Collective efficacy and depressive symp- ences in health). Am J Public Health 2000: 90(11):1699- toms in Brazilian elderly. Arch Gerontol Geriatr 2014; 1702. 59(3):624-629. 33. Goto JB, Couto PF, Bastos JL GOTO. Revisão sistemá- 22. Blay SL, Andreoli SB, Fillenbaum GG, Gastal FL. De- tica dos estudos epidemiológicos sobre discriminação pression morbidity in later life: prevalence and cor- interpessoal e saúde mental. Cad Saude Publica 2013; relates in a developing country. Am J Geriatr Psychiary 29(3):445-459. 2007; 15(9):790-799. 34. Pascoe EA, Richman LS. Perceived discrimination 23. Anselmi L, Barros FC, Minten GC, Gigante DP, Horta and health: a meta-analyitic review. Psychol Bull 2009; BL, Victora CG.Prevalence and early determinants of 125(4):531-554. common mental disorders in the 1982 birth cohort, 35. Macinko J, Mullachery P, Proietti FA, Lima-Costa MF. Pelotas, Southern Brazil. Rev Saude Publica 2008; Who experiences discrimination in Brazil? Evidence 42(Supl. 2):25-32. from a large metropolitan region. Int J Equity Health 24. Bastos JL, Barros AJD, Paradies Y, Faerstein E. Age, class 2012; 11(80). and race discrimination: heir interactions and associ- 36. Medeiros EN, Ferreira M, Vianna RP. Estudos epide- ations with mental health among Brazilian university miológicos na area de saúde mental realizados no Bra- students. Cad Saude Publica 2014; 30(1):175-186. sil. Online Braz J Nurs 2006; 5(1). 25. Faisal-Cury A, Menezes PR. Prevalence of anxiety and depression during pregnancy in a private setting sam- ple. Arch Womens Ment Health 2007; 10:25-32. 26. Melo EF, Cecatti JG, Pacagnella RC, Leite DBF, Vulcani DE, Yakuch MY. The prevalence of perinatal depression and its associated factors in two different settings in Brazil. J Affect Disord 2011; 136(3):1204-1208. 27. Pereira PK, Lovisi GM, Pilowsky DL, Lima LA, Legay LF. Depression during pregnancy: prevalence and risk factors among women attending a public health clin- Article submitted 03/04/2016 ic in Rio de Janeiro, Brazil. Cad Saude Publica 2009; Approved 06/09/2016 25(12):2725-2736. Final version submitted 08/09/2016