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Psychosomatic Medicine:
doi: 10.1097/01.psy.0000197673.29650.8e
Original Articles

Ethnic Differences in Pain Reports and the Moderating Role of Depression in a Community Sample of Hispanic and Caucasian Participants With Serious Health Problems

Hernandez, Annya MS; Sachs-Ericsson, Natalie PhD

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Author Information

From the Department of Psychology, Florida State University, Tallahassee, FL.

Address correspondence and reprint requests to Natalie Sachs-Ericsson, PhD, Department of Psychology, Florida State University, Tallahassee, FL, 32306-1270. E-mail: sachs@psy.fsu.edu

Received for publication October 8, 2004; revision received August 15, 2005.

Data for this project was obtained from: Kessler, R. NATIONAL COMORBIDITY SURVEY, 1990–1992. University of Michigan, Survey Research Center. Ann Arbor, MI: Inter-university Consortium for Political and Social Research, 2000.

The original collector of the data and the relevant funding agency bear no responsibility for uses of this collection or for interpretations or inferences based upon such uses.

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Objective: The present study examined ethnic differences in pain reports between Hispanics (n = 147) and Caucasians (n = 1308) with serious health problems. It was predicted that Hispanics would report more pain in relation to their health problems than would Caucasians, depression would be associated with increased pain reports in both groups, and depression’s influence on pain reports would be greater for Hispanics compared with Caucasians.

Methods: Data from Hispanic and Caucasian participants with a current health problem were utilized from the National Comorbidity Survey, a nationally representative epidemiological sample. Participants’ pain reports, relative to their health problems, were obtained. Hierarchal regression analyses were conducted to examine the relationship between ethnicity and reported pain and the potentially moderating role of depression.

Results: Findings indicated that Hispanics reported more pain compared with Caucasians and that depression was associated with higher pain reports in both groups. Depression moderated the relationship between ethnicity and pain such that ethnic differences in pain reports were even greater among depressed participants than among nondepressed participants. That is, pain reports for Hispanics were higher in the presence of depression than was found for the Caucasian participants.

Conclusions: Cultural differences in the acceptability and the expression of distress may be related to higher pain reports among Hispanics as compared with Caucasians, particularly in the presence of depression. The interplay of biological, psychological and sociocultural processes involved in both pain and depression were considered.

NCS = National Comorbidity Survey; HPA = hypothalamus-pituitary adrenal.

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Chronic pain is associated with increased levels of stress, unemployment, and psychiatric symptoms and can be quite debilitating (1,2). Ethnic differences in the levels of pain reports have been found in both clinical and laboratory settings with members of minority groups often reporting higher levels of pain than Caucasians (3–7). In association with health problems, Hispanics often report more pain and a greater number of physical symptoms than Caucasians (8–12). For example, research evaluating a cancer pain management program indicated that Hispanics reported more severe pain than Caucasians (9). In a study of patients with chronic spinal pain, Mexican Americans reported higher levels of pain than Caucasians (13). Additionally, in another clinical study, Hispanic patients reported greater postoperative pain than Caucasian patients (8). Interestingly, whereas Hispanics may report more pain when experiencing health problems than Caucasians, Hispanics are less likely to receive any pain medication (14) or adequate medication for pain relief (15,16) when they seek treatment for their pain.

However, not all studies have found that Hispanics report more pain than Caucasians. For instance, among individuals participating in a methadone maintenance program, researchers found Hispanics reported less chronic pain than did Caucasians (17). Moreover, mixed results were found when pain and physical distress symptoms experienced by Mexican Americans and Caucasian patients were examined in a community-based program (10).

The above studies examining ethnic differences in pain reports relied predominately on clinical samples. Because Hispanics are less likely to use health services than Caucasians (18,19), epidemiological samples may provide further insight into the relationship between ethnicity and pain. In fact, some epidemiological studies have found that Hispanics report more pain than Caucasians in relation to health problems. For example, in an epidemiological study, Hispanics reported significantly more chronic vulvar pain than Caucasians (20). In a geriatric community sample, Puerto Ricans were found to report more ankle joint pain, tenderness and loss of sensation when compared with Caucasians (21). In a population-based survey (22), while Caucasians reported experiencing chronic pain for a longer duration than the minority participants, Caucasians reported experiencing significantly less pain severity than either the Hispanic or African American participants.

The association between measures of psychiatric symptoms (or psychological well-being) and pain has also been investigated in both epidemiological and clinical samples (1, 23). In particular, researchers have documented a relationship between depression and reports of pain (2, 24–26). In a clinical study of patients with arthritis and myofascial pain disorders, more severe depression was associated with more severe pain reports (24). In a prospective epidemiological study, depression at baseline predicted subsequent pain; however, pain at baseline also predicted subsequent depression (25). Data from the National Comorbidity Survey (NCS) suggest that, for participants with arthritis, chronic pain was positively associated with both mood and anxiety disorders (26). However, not all studies have found a positive relationship between depression and pain. For example, a meta-analysis of laboratory studies found that depressed subjects were less likely to perceive a sensory stimulus as being painful when compared with nondepressed controls (27).

Nevertheless, many studies have found an association between Hispanic ethnicity and pain reports, as well as an association between depression and pain reports. Moreover, some, but not all, epidemiological studies have found higher rates of depression among Hispanics as compared with Caucasians (28–30). Thus, it is possible that higher rates of depression among Hispanics could contribute to higher reports of pain in this ethnic group.

Cultural differences regarding the acceptability of expressing psychiatric distress may contribute to ethnic differences in pain reports. Some have suggested that the possible stigma associated with psychiatric illness in the Hispanic culture may result in Hispanics being disinclined to communicate their mental health problems (31,32). Others have speculated that expressing physical pain provides a culturally acceptable means by which to communicate emotional distress (11).

To expand on past research, the current study examined a sample of Hispanic and Caucasian participants from the NCS (33) who had a serious health problem and examined the severity of pain they reported in relation to their health problems. We hypothesized that there would be ethnic differences in pain reports, such that Hispanics would report more pain than Caucasians. Moreover, we expected that depression would be associated with increased pain reports. However, because Hispanics may be less likely than Caucasians to report symptoms of psychological distress, we also predicted that ethnic differences in pain reports would be greater for depressed participants than nondepressed participants.

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The current study draws on the NCS, a nationwide epidemiological study designed to assess the prevalence and psychosocial correlates of DSM III-R psychiatric disorders (34). The NCS administered structured psychiatric interviews to a US nationally representative sample formed by interviewing a widely dispersed group of all people living in households in the US (35).

The survey was carried out in the early 1990s with a sample of over 8000 respondents between the ages of 15 to 54. A second survey was administered to a subsample of the respondents, which included questions related to psychosocial correlates of psychiatric disorders (n = 5877). The participants were selected through a multistage area, probability sample based on household, within a stratified sample of counties within the US. Weights were used to adjust for differential probability of selection both within and between households and to adjust the data to the national population distribution (36).

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The 158 interviewers received an intensive 7-day training course and were carefully supervised. They had, on average, 5 years of experience at interviewing with the Survey Research Center.

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Participants were interviewed in their home and informed consent was obtained. For the NCS sample (n = 5877), the average age was 33.2 years (SD = 10.70), and participants were 75.6% Caucasian, 11.6% African American, 9.4% Hispanic, and 3.4% categorized as “Other.” For the current study sample (n = 1455), we included only the Hispanic and Caucasian participants who reported having a current health problem (see below).

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Health Problems

Individuals were asked to look at a list of serious health problems and to indicate if they had experienced any of these problems during the last 12 months. Problems included arthritis, rheumatism, bone or joint diseases; respiratory problems (i.e., asthma, bronchitis, tuberculosis, etc.); AIDS; blindness or deafness; cancer; diabetes; hypertension; heart problems; hernia; kidney or liver disease; lupus, thyroid or autoimmune disorders; multiple sclerosis, epilepsy, or neurological disorders; stroke; stomach or gall bladder disease; ulcers; or any other serious health problem.

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Participants were asked how much pain they were experiencing because of their health problems. Participants responded by using a 4-point Likert-type scale anchored by (1) “A lot” and (4) “None at all.” Participants’ responses were reverse coded such that higher ratings represented more severe pain ratings.

Although single item, self-report assessments of health have psychometric limitations, perceived health has been shown to provide an accurate gauge of physical health outcomes (37,38), to possess good reliability (39), have good predictive validity (40,41) and good agreement with physician diagnosis (42). Additionally, research supports the validity of one- and two-item versions of commonly used measures of pain (43).

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Participants’ Psychiatric Diagnoses

The Composite International Diagnostic Interview (CIDI, (44)), a semi-structured interview, was used to assess the participants’ 1-year diagnosis of major depression.

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Cultural Variables

Several variables related to cultural identification were included in the NCS, including participant’s nativity and languages other than English spoken at home during childhood. Participants were also asked how close their ideas and feelings about things were to those of other people of the same ethnic descent, anchored by (1) “Very close” and (4) “Not close at all.”

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Among the entire NCS sample, we identified the Caucasian and Hispanic participants who reported having a serious health problem in the past year (n = 1455). The proportion of the Caucasians and Hispanics that had a health problem did not differ significantly (29.9% and 28.7%, respectively). This subsample with health problems was 49% male and 90% Caucasian. Among the 10% of the sample that was Hispanic, 25.5% identified themselves as Mexican, 31.4% as Mexican American, 5.9% as Chicano, 18.6% as Puerto Rican, 1.0% as Cuban, and 17.6% as other Spanish origin.

The demographic differences between Hispanics and Caucasians in this subsample were consistent with differences of the sample as a whole. Similar to the sample as a whole, Hispanics in the subsample were younger, had lower incomes, and had fewer years of education compared with the Caucasians (all p’s ≤ .05; see Table 1).

Table 1
Table 1
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To establish the representativeness of the Hispanics in the subsample, we determined whether there were any systematic demographic differences between participants with and without health problems for the sample as a whole and then determined if these differences were parallel to differences between Hispanics with and without health problems. For the sample as a whole, there were no differences between those with and those without health problems with respect to gender or education. However, participants with health problems were older (36.4 versus 32.2, F(1,4982) = 169.3, p < .001) and had lower incomes ($39,140 versus $43,375, F(1,4982) = 27.01, p < .001). Similar to the differences found for the sample as a whole, Hispanics with a health problem compared with Hispanics without a health problem were older (33.9 versus 27.8, F(1,549) = 41.82, p < .001) and had lower incomes ($28,441 versus $33,547, F(1,549) = 4.54, p = .034). Also consistent, there were no differences regarding education. However, more Hispanic women than men reported having a health problem (56.1% versus 43.9%, χ2(df = 1, n = 550) = 5.2, p < .05), whereas there were no gender differences for the sample as a whole. Thus, in general, the differences in participants with and without health problems for the sample as a whole were similar to differences between Hispanics with and without health problems.

To further examine the representativeness of the Hispanics in the subsample, we considered differences between Hispanics with and without health problems on variables more salient to the Hispanic population. Hispanic participants with health problems were more likely than those without health problems to be born outside of the US (30.8% versus 21.2%, χ2(df = 1, n = 548) = 4.3, p = .04). There were no significant differences between Hispanics with and without health problems as to whether a language other than English was spoken at home (χ2(df = 1, n = 547) = 0.56, p = .49), in their identification with Hispanic culture (F(1,515) = 1.60, p = .18), or with respect to the participants’ self-identified Hispanic origin (χ2(df = 5, n = 541) = 9.1, p = .11).1

In sum, differences between participants with and without health problems were similar for Hispanics and Caucasians. Moreover, culturally pertinent characteristics among Hispanics did not differ for those with and without health problems. Thus, this subsample appears to be a representative sample of Hispanics and Caucasians in the community with current health problems.

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Depression, Health Problems and Ethnicity

The subsample with health problems had approximately double the rate of depression in the past year when compared with those without health problems (13.4% versus 6.6%, χ2(df = 1, n = 4986) = 61.31, p < .001). Whereas previous NCS studies showed Hispanics, compared with Caucasians, had higher rates of depression (29), among the subsample with health problems there were no differences between Hispanics and Caucasians in the rate of depression (15% and 13%, respectively).

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Health Problems and Ethnic Differences

The rate of each specific health problem is described by ethnicity in Table 2. Caucasians reported higher rates of respiratory problems, heart problems, autoimmune disorders, and stomach problems, whereas Hispanics reported higher rates of AIDS, diabetes, kidney or liver disease, and other health problems (all p’s < .05; see Table 2). Both Caucasians and Hispanics reported having, on average, more than one disorder (1.5 and 1.4, respectively). This difference was not statistically significant.

Table 2
Table 2
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Ethnicity, Pain and Depression

A hierarchical regression analysis was performed to examine the influences of ethnicity and depression on pain reports (see Table 3). Demographic variables and ethnicity were entered in the first step of the analysis. Ethnicity was found to be related to pain reports such that Hispanics reported more pain than Caucasians, F(1,1450) = 5.28, p = .02, (pr) = −0.06.

Table 3
Table 3
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Depression, entered in the second step, was related to pain reports such that depressed individuals reported higher levels of pain than those who were not depressed, F(1,1449) = 13.27, p < .001, (pr) = 0.10. However, after depression was entered, ethnicity was still significantly related to pain reports such that Hispanics had higher pain reports than Caucasians.2

We established that Hispanics reported higher levels of pain than Caucasians and that depression was positively associated with pain reports. Next, we wished to determine whether there was an interaction between depression and ethnicity. Thus, the interaction between depression and ethnicity was entered in the third step, and was significant, F(1,1448) = 6.27, p < .01, (pr) = 0.07. Further analyses conducted to determine the nature of the interaction indicated that ethnic differences in pain reports were even greater for depressed participants than nondepressed participants. Thus, Hispanics who were depressed reported more pain than Caucasians who were depressed. Therefore, depression was found to be a moderator of the relationship between ethnicity and pain (see Figure 1).

Figure 1
Figure 1
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Finally, because Hispanics and Caucasians were found to have different frequencies of some health problems (see Table 2), additional analyses were conducted including each of the specific health problems and number of health problems. Even after controlling for the health problems, the results were quite similar. That is, Hispanics reported higher rates of pain than Caucasians, depression was associated with pain, and depression was found to be a moderator of the relationship between ethnicity and pain reports.

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In a large epidemiological sample, the current study examined ethnic differences in pain reports among Hispanics and Caucasians with a current health problem. Findings indicated that Hispanics, when compared with Caucasians, reported more pain in relation to their health problems. Depression was positively associated with pain reports in both groups. There were, however, no ethnic differences in the rate of depression. Thus, the higher pain reports found in Hispanics, compared with Caucasians, was not the result of ethnic differences in depression. Additionally, depression was identified as a moderator of the relationship between ethnicity and pain reports such that ethnic differences in pain reports were even greater among those who were depressed. Specifically, pain reports for Hispanics were higher in the presence of depression than for Caucasians who were depressed.

An association between depression and pain has been found repeatedly in the literature (1,2,24,45). Whereas studies addressing the temporal relationship between pain and depression have often found pain to precede the onset of depression, depressive disorders may also precede the onset of pain (2). Further, the relationship between depression and pain may also be bi-directional (1,2,25). Several factors have been identified that may contribute to the comorbidity of pain and depression. Biological, psychosocial and cultural theories have been proposed to explain the link between depression and pain (1).

Biologically, the related neurochemistry underlying both depression and pain may enhance their association. Specifically, depression is associated with a neurochemical imbalance of neurotransmitters (46,47), including serotonin, norepinephrine, and dopamine (48,49). Analgesic effects are produced by serotonin and norepinephrine through descending pain pathways, and these effects may be disrupted by decreased levels of these neurotransmitters (48,49). The pain modulation system influences affect and attention to peripheral stimuli and plays a role in suppressing minor signals coming from the body (49,50). These signals may be less suppressed when serotonin and norepinephrine are depleted (46). Thus, the association between pain and depression may be due, in part, to the neurochemical impact depression plays in the pain response (49).

Emotionally negative mood states may also reduce tolerance to aversive stimuli (51,52). The motivational priming model proposes that unpleasant affective states augment pain while pleasant affective states attenuate it. Specifically, studies have shown that negative affective states decreased pain tolerance to aversive stimuli while positive affective states increased tolerance to aversive stimuli (51,52). Thus, in the current study, the negative affective states of the depressed participants may have magnified the participants’ experience of pain.

There may also be biological, social, and cultural differences between Hispanics and Caucasians that affect the experience of pain. Individual differences in pain perception may be related to genetic differences in pain sensitivity (53). Kim and colleagues examined the role of genetic factors in pain associated with gender, ethnicity and temperament and found that individuals with European American ancestry had longer cold withdrawal time than Hispanic individuals (54). Further, they suggest that there are variations in the TRPV1 gene related to sensory pain that interact with ethnicity to influence pain reports.

Ethnic differences in response to pharmacological agents (e.g., ethnopsychopharmacology) are also important to consider in relation to ethnic differences in pain response (55,56). Ethnic differences in medication response may be due to genetic and biological differences in pharmacokinetics (i.e., factors related to how the body handles drugs) or in pharmacodynamics (i.e., factors related to the effect of a drug on the body) (55). Asians and Hispanics often require different dosages of psychotropic medications than Caucasians, although this was found in some but not all studies (55, 56). Thus, reported ethnic differences in drug metabolism suggest that ethnic differences in pain reports, as well as the higher pain reports among depressed Hispanics, may be associated with similar or related biological mechanisms.

In the current study, while Hispanics reported more pain compared with Caucasians, ethnic differences in pain reports were amplified among those participants who were depressed. Cultural differences may partially explain these differences. Patients from ethnic minority groups often present with somatic rather than psychological complaints (55). The stigma associated with psychiatric distress in the Hispanic culture may result in Hispanics being reluctant to admit that they have mental health problems (32). Depression is comprised of cognitive, affective, and somatic symptoms (57). However, expressing cognitive and affective symptoms of depression may be less acceptable in the Hispanic culture, and, thus, depression may be expressed more likely by somatic distress, including symptoms of pain (11). Further, the expression of pain symptoms may be more acceptable in the Hispanic culture than among Caucasians. For example, in a population-based survey, Hispanics generally rated their family and friends to be more supportive regarding their chronic pain than did Caucasians and African Americans (22). Moreover, growing evidence suggests that somatic symptoms are common presenting features of depression throughout the world, and those from traditional cultures may not distinguish between the emotions of anxiety, irritability, and depression because they tend to express distress in somatic terms (58).

In addition to stigma associated with psychological symptoms, idioms and thresholds of distress (cultural ways of talking about distress) as experienced in the Hispanic culture, may also influence the conceptualization and experiences of pain and depression. Culture influences individuals’ sources, symptoms and idioms of distress, their explanatory models, coping mechanisms and help-seeking behavior, as well as the social response to their distress (58). Because each culture has its own emotional lexicon, cultural background is likely to determine whether depression will be experienced and expressed in emotional or in physical terms (58,59).

Cultural values and beliefs also influence the assessment of pain among Hispanics (60). For example, work-related injuries for Hispanic workers are perceived and managed within a context of cultural expectation and meaning. Hispanics immerse themselves in hard work and grueling work conditions because they firmly believe they have to sacrifice for their families’ survival (60). The issue of bearing pain with dignity, which in Spanish is known as aguantar, has been consistent among Hispanics and may be related to a history of being oppressed, requiring that unpleasant emotions be mastered by self-control (60).

Some have proposed a diathesis stress model in understanding the development of depression among individuals with chronic pain (1,61,62). Preexisting psychological characteristics of the individual, such as negative schemas (63), skill deficits (64), and a negative attributional style leading to helplessness (65,66), may be a diathesis for the development of depression among individuals with chronic pain. These psychological characteristics may be activated by the stress of chronic pain, which may consequently lead to depression. Moreover, other psychosocial stressors may contribute to the development of depression among individuals with chronic pain (66–68).

Being Hispanic in the US may be associated with stressful life experiences, such as discrimination, decreased opportunities for education, employment, and income (64,69,70). This stress may, in turn, influence biological mechanisms that affect sensitivity to pain and vulnerability to depression. Stress is associated with chronically high levels of sympathetic activation (71) and higher levels of cortisol production (72). Continual activation of the stress system can be disruptive to the hypothalamus-pituitary adrenal (HPA) axis (73), which may then affect pain perception (72). HPA disruption and prolonged high cortisol levels have been associated with both depression and pain (49,72,74).

Cultural differences, especially in terms of discrimination and racial inequality in the US and their impact on health functioning, have not been adequately studied (71). Explanations for ethnic differences in pain reports are inevitably quite complicated. Thus, a biopsychosocial model of pain is warranted in the interpretation of these differences (16). This model conceptualizes pain to be influenced by the interaction of biological, psychological, and sociocultural processes. Therefore, ethnic differences are influenced by neurobiological systems involved in pain, as well as psychosocial processes such as strategies for coping with pain and pain-related expectations.

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Limitations and Future Research

In considering our study’s findings, several limitations should be considered. First, because the study was cross-sectional, all measures were assessed at the same time, making determination of causation problematic. Thus, we were unable to determine if being depressed lead to participants reporting more pain, if the experience of pain lead to reporting more depression, or if causality between pain and depression is bidirectional.

Further, while Caucasians and Hispanics reported relatively similar health problems, we cannot rule out the possibility that the severity of the specific health problems may have been greater for Hispanics than Caucasians, and may have accounted for their higher pain ratings. Differences in health utilization and use of pharmacological agents, with Hispanics less likely to utilize services (18,19) or receive adequate medication (14–16), may have also enhanced ethnic differences in pain reports. Additionally, some health problems, such as orthopedic problems, which may have contributed to overall pain, were not specifically included among the health problems. Ethnic differences in pain reports may have been influenced by other such health problems not considered. Further, research has indicated there is cultural bias inherent in response patterns to Likert-type scales. Researchers have noted different patterns of response styles in individualistic (e.g., Caucasian) compared with collectivistic (e.g., Hispanic) cultures (75). Future studies should ascertain whether such biases influence ethnic differences in pain reports.

Finally, while we included an epidemiologically representative sample of Hispanics with health problems, it was nonetheless relatively small, and results based on smaller samples may be less reliable. Moreover, some research has shown differences among Hispanic groups, such as Mexican Americans and Puerto Ricans, in relation to mental health symptoms (76). Such differences may also be found among Hispanic groups in relation to reports of health problems and pain, which we were unable to adequately explore because of the relatively small sample size of Hispanic participants. Thus, a larger sample of Hispanic participants may have led to more conclusive results, and this should be taken into account when considering the findings from our study. Future research with larger samples of Hispanic participants from different Hispanic groups would provide further insights into the relationship between ethnicity and pain.

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Evidence is accumulating from both clinical and epidemiological studies demonstrating that pain reports are higher for Hispanics than Caucasians. Consistent with such previous research, the current findings suggest that, in association with health problems, Hispanics report more pain than Caucasians. Additionally, while a relationship between depression and pain has long been established in the literature, the current study found that depression moderated the relationship between ethnicity and pain such that ethnic differences in pain reports were greater among depressed participants. We proposed that cultural differences in the expression of psychological distress might be related to higher pain reports among depressed Hispanics compared with depressed Caucasians.

While ethnic differences in pain reports are likely to be influenced by the interplay of biological, psychological, and sociocultural processes, future research that can better identify and elaborate on the underlying biopsychosocial and cultural mechanisms that lead to such ethnic differences in pain reports may potentially further our understanding of the etiology and treatment of pain.

The authors would like to thank Dr. Karen Berkley for her insightful suggestions on earlier drafts of this manuscript.

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1For the analyses comparing Hispanic participants with and without health problems on demographic and socio-cultural characteristics in which no differences were found, the relatively small sample size, particularly in relation to the differing self-identified Hispanic origins, may have affected the reliability of the results. Cited Here...

2Restricting the sample to Hispanics with health problems, a regression analysis was conducted to determine if variables related to acculturation were associated with pain. Whereas depression continued to be associated with higher pain reports, F(1,137) = 11.3, p < .001, none of the acculturation variables were related to pain (i.e., participant’s nativity, F(1,137) = 2.16, p = .14, parental nativity, F(1,137) = 1.5, p = .23, language other than English spoken at home, F(1,137) = .86, p = .36, identification with culture, F(1,137) = .05, p = .82). Cited Here...


pain; depression; ethnic differences; Hispanics

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