Journal of Anxiety Disorders 32 (2015) 38–45

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Journal of Anxiety Disorders

Anxiety sensitivity and subjective social status in relation to anxiety and depressive symptoms and disorders among Latinos in primary care夽,夽夽 Michael J. Zvolensky a,b,∗ , Jafar Bakhshaie a , Monica Garza c , Jeanette Valdivieso c , Mayra Ortiz a , Daniel Bogiaizian d , Zuzuky Robles a , Anka Vujanovic e a

University of Houston, Department of Psychology, Houston, TX, United States The University of Texas MD Anderson Cancer Center, Department of Behavioral Science, Houston, TX, United States c Legacy Community Health Services, Houston, TX, United States d Psychotherapeutic Area of “Asociación Ayuda”, Anxiety Disorders Clinic, Buenos Aires, Argentina e University of Texas Health Science Center at Houston, Department of Psychiatry and Behavioral Sciences, Center for Neurobehavioral Research on Addictions, Houston, TX, United States b

a r t i c l e

i n f o

Article history: Received 29 January 2015 Received in revised form 6 March 2015 Accepted 7 March 2015 Available online 21 March 2015 Keywords: Anxiety sensitivity Subjective social status Latinos Primary care Anxiety Depression

a b s t r a c t The present investigation examined the interactive effects of anxiety sensitivity and subjective social status in relation to anxiety and depressive symptoms and psychopathology among 143 Latinos (85.7% female; Mage = 39.0, SD = 10.9; 97.2% used Spanish as their first language) who attended a communitybased primary healthcare clinic. Results indicated that the interaction between anxiety sensitivity and subjective social status was significantly associated with number of mood and anxiety disorders, panic, social anxiety, and depressive symptoms. The form of the significant interactions indicated that individuals reporting co-occurring higher levels of anxiety sensitivity and lower levels of subjective social status evidenced the greatest levels of psychopathology and panic, social anxiety, and depressive symptoms. The present findings suggest that there is merit in focusing further scientific attention on the interplay between anxiety sensitivity and subjective social status in regard to understanding, and thus, better intervening to reduce anxiety/depressive vulnerability among Latinos in primary care. © 2015 Elsevier Ltd. All rights reserved.

Latinos are the fastest growing and among the largest (over 53 million) ethnic/minority group in the United States (Bureau, 2010; PRC, 2012). There are significant health disparities for mental health among Latinos in the United States (USDHHS, 2001). For example, when compared with non-Latino Whites, Latinos are less apt to seek and utilize mental health services (Miranda & Green, 1999; Ojeda & Mcguire, 2006) and evidence-based care (USDHHS, 2001). Of the

夽 All of the analyses were conducted after replacing the missing values using multiple imputation technique (Rubin, 1987). The pattern of the results stayed the same using the data with no missing value. 夽夽 We re-ran a supplementary analysis using a logistic regression with a dichotomous variable as an index of psychopathology (0 = absent, 1 = present). The pattern of the results stayed functionally the same (interaction term Wald statistics = 2.8, Beta = −.02, p = 07), considering the proneness of Wald statistic to Type II error (Cohen, Cohen, West, & Aiken, 2003). ∗ Corresponding author at: The University of Houston, 126 Heyne Building, Suite 104, Houston, TX 77204-5502, United States. Tel.: +1 713 743 8056; fax: +1 713 743 8588. E-mail address: [email protected] (M.J. Zvolensky). http://dx.doi.org/10.1016/j.janxdis.2015.03.006 0887-6185/© 2015 Elsevier Ltd. All rights reserved.

mental health problems, anxiety and depressive symptoms and psychopathology are particularly prevalent among Latinos (Alegría et al., 2008; Grant et al., 2004; Vega et al., 1998). Although certain segments of the Latino population appear at greater risk for these mental health problems (e.g., U.S.-born persons of Mexican origin compared to immigrant Latinos), there is a widespread public health need for better understanding anxiety/depressive symptoms and disorders among Latinos (USDHHS, 2001). Primary care medical settings are the most common service domain for Latinos to seek healthcare. Due to such factors as social stigma for seeking mental healthcare among Latinos, primary care settings may be an ideal ‘catchment area’ for early intervention for anxiety/depressive problems (Vega & Lopez, 2001). In fact, numerous studies have shown the feasibility and initial efficacy of interventions delivered in primary care for depression (e.g., ˜ et al., Miranda, Azocar, Organista, Dwyer, & Areane, 2003; Munoz 1995), and to a lesser extent anxiety (e.g., Chavira et al., 2014), among Latinos. Although these clinical investigations are indeed highly promising, notable gaps exist in terms of knowledge about risk factors for anxiety/depressive symptoms and psychopathology

M.J. Zvolensky et al. / Journal of Anxiety Disorders 32 (2015) 38–45

among Latinos in primary care. To the extent that a better understanding of malleable risk candidates for anxiety/depression can be isolated among this population, the greater the ease of screening for high risk segments of the Latino population in primary care and subsequent implementation of psychological services that can help offset the risk or burden of anxiety/depressive problems among this population. One cognitive factor that may be particularly relevant is anxiety sensitivity. Anxiety sensitivity is the fear of anxiety-relevant sensations (Reiss & Mcnally, 1985). In the context of personal threat, anxiety sensitivity marks the extent to which one attends to, and perceives, anxiety-relevant and other aversive, internal sensations (e.g., somatic perturbation) as harmful, dangerous, and indicative of catastrophic consequences across domains (Taylor, 2003). In fact, work on primarily Caucasian samples indicates that anxiety sensitivity is a risk factor for the acquisition and maintenance of anxiety and depressive psychopathology (Olatunji & Wolitzky-Taylor, 2009). For instance, prospective (Li & Zinbarg, 2007; Norris et al., 2002; Norris, Murphy, Baker, & Perilla, 2004; Schmidt, Zvolensky, & Maner, 2006) and laboratory (Brown, Smits, Powers, & Telch, 2003; Galea et al., 2002; Rapee & Medoro, 1994; Zinbarg, Brown, Barlow, & Rapee, 2001; Zvolensky, Feldner, Eifert, & Stewart, 2001) studies suggest that anxiety sensitivity increases the risk for more intense anxiety symptoms and anxiety and depressive psychopathology. Importantly, anxiety sensitivity is a relatively stable, but malleable, construct which serves as an explanatory mechanism in the treatment of anxiety psychopathology (e.g., Berninger et al., 2010; Smits, Berry, Rosenfield, et al., 2008; Smits, Berry, Tart, & Powers, 2008). Although anxiety sensitivity has not been extensively studied among Latinos, available, albeit highly limited, evidence suggests it may be related to mental health processes in a manner largely similar to that reported among Caucasian samples (Pina & Silverman, 2004; Varela, Weems, Berman, Hensley, & De Bernal, 2007; Zvolensky et al., 2007). Yet, no investigation has sought to explore the role of anxiety sensitivity in relation to anxiety and depressive symptoms among adult Latinos in primary care. There also is an increasing understanding that social determinants of health may play formative roles in psychosocial well-being and also serve to help explain health disparities, including those observed among Latinos (Singh-Manoux, Adler, & Marmot, 2003). Of social determinant variables, lower subjective social status, reflecting the subjective ratings of social standing, is consistently related to poorer physical and mental health status among numerous populations even after adjusting for objective indicators of social status (e.g., educational status, employment status; Adler, Epel, Castellazzo, & Ickovics, 2000; Ostrove, Adler, Kuppermann, & Washington, 2000). Researchers have theorized that subjective social status may interplay with psychological processes by increasing (lower subjective social status) or decreasing (greater subjective social status) adverse emotional states, such as anxiety and depression (Adler et al., 2000). For example, a study examining Mexican-origin individuals and the relationship of subjective social status to self-reported mental health found that when controlling for objective social status, subjective social status was associated with lower mental health and self-rated health (Franzini & Fernandez-Esquer, 2006). These findings are similar to other work that has found that subjective social status is related to lower perceived health among Latinos (Sanchon-Macias, Prieto-Salceda, Bover-Bover, & Gastaldo, 2013). Although subjective social status may hold broad-based explanatory relevance to underserved or underrepresented groups, it may be particularly relevant to Latinos. For example, some work has suggested that less acculturated Latinos ranked their subjective social status based on different criteria than other ethnic groups (Franzini & Fernandez-Esquer, 2006). To the best of our knowledge, however, subjective social status has not

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been explored among Latinos in primary care, or in relation to other empirically supported risk candidates for anxiety and depression, such as anxiety sensitivity. Theoretically, anxiety sensitivity and subjective social status may operate with one another to confer greater anxiety and depression vulnerability among Latinos. Specifically, higher levels of anxiety sensitivity may be more strongly associated with an individual’s lower subjective social status in terms of anxiety/depressive symptoms and psychopathology. Therefore, these processes may theoretically function synergistically to confer greater risk for anxiety and depressive-relevant symptoms and disorders. To illustrate, a Latino individual high in anxiety sensitivity who has lower subjective social status may be at an increased risk of experiencing more severe anxiety and depressive symptoms because their perception of subjective social status may make them more apt to be anxious/depressed. That is, the high anxiety sensitive person may be more emotionally reactive to the social stressors related to lower subjective social status. From this perspective, a formative next research step is to further explore the potential interplay of anxiety sensitivity and subjective social status as an integrative explanatory process for anxiety and depressive vulnerability among Latinos. Together, the present investigation sought to test an interactive model of anxiety sensitivity and subjective social status among a Latino sample in primary care. It was predicted that higher levels of anxiety sensitivity would be associated with greater degrees of anxiety/depression when co-occurring with lower levels of subjective social status. Additionally, it was predicted that the interactive effect of anxiety sensitivity and subjective social status would be observed above and beyond the generalized tendency to experience negative affect states (negative affectivity) as well as gender, prior use of mental health services, marital status, employment status, and educational status. That is, the interactive process would not be accounted for by a more (basic) generalized tendency to experience negative mood states or numerous other indicators of social determinants of health.

1. Method 1.1. Participants Participants included 143 adult Latinos (85.7% female; Mage = 39.0, SD = 10.9 and 97.2% used Spanish as their first language) who attended a community-based primary healthcare clinic in Houston, Texas. In terms of ethnic background, 5.4% of participants identified as American/Born in America, 57.8% identified as Mexican/Mexican American, 2.0% identified as Cuban, 3.4% identified as South American, .7% identified as Puerto Rican, 28.6% identified as Central American, and 2.0% identified as “Other.” In this report, we included these multiple subgroups in one group to facilitate comparability to past work as well as the cultural similarity for the constructs studied among these sub-populations (Franzini & Fernandez-Esquer, 2006; Vega & Lopez, 2001). All individuals participated in the Spanish language. In terms of education, 9.5% of participants had less than 6 years of education, 44.9% had 6–11 years of education, 28.6% had 12 years of education (completion of high school), and 17.0% had more than 12 years of education. In terms of marital status, 51.0% of participants were married, 15.6% were living with partner, 26.5% were single, 5.4% were divorced, and 1.4% were widowed. In terms of employment status, 16.3% were employed full time (40 h a week), 13.6% were employed part time (20 h a week), 10.9% were employed less than 20 h a week, 45.6% were unemployed, and 13.6% were looking for employment. The reasons for attendance to clinic were as follows: family medicine (12.2%), dental (26.5%),

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M.J. Zvolensky et al. / Journal of Anxiety Disorders 32 (2015) 38–45

Table 1 Psychopathology among sample. Diagnosis

Number

Percentage

Depressive Disorder Dysthymia Bipolar I or II Disorders Panic Disorder Agoraphobia Social Anxiety Disorder Obsessive Compulsive Disorder Post-traumatic Stress Disorder Generalized Anxiety Disorder Alcohol Dependence/Abuse Substance Dependence/Abuse Anorexia Nervosa Bulimia Nervosa

42 3 2 6 10 6 9 9 10 2 2 0 2

28.5% 2.0% 1.3% 4.1% 6.8% 4.1% 6.1% 6.1% 6.8% 1.3% 1.3% 0.0% 1.3%

*N = 143.

psychiatric/psychological (4.8%), and lab test, physical exam, or other reasons (41.5%). As determined by the baseline Mini International Neuropsychiatric Interview 6.0 (MINI; Sheehan, Shytle, Milo, Janavs, & Lecrubier, 2009), 32.0% of the sample met criteria for current (past year) Axis I psychopathology. Among participants with current psychopathology, the average number of diagnoses per participant was 2.3 (SD = 1.8). Seventy-one percent of the individuals with current (past year) Axis I psychopathology had more than one diagnosis (8 individuals had 2 diagnoses, 7 individuals had 3 diagnoses, and 9 individuals had 4 or more diagnoses). The most common diagnoses were major depressive disorder (18.2%), recurrent depressive disorder (10.2%), agoraphobia (6.8%), obsessive compulsive disorder (6.8%), post-traumatic stress disorders (6.1%), and generalized anxiety disorder (6.1%). See Table 1. The inclusion criteria included: ability to read, write and communicate in Spanish and being between 18 and 64 years old. Participants were excluded based on the following criteria: limited mental competency and inability to provide informed, voluntary, written consent; endorsement of current or past psychotic-spectrum symptoms via structured interview screening; and current suicidality or homicidality. 1.2. Measures Validated, Spanish-language versions of all measures were employed in the present study (see below for description). All measures have been previously translated/back-translated and tested among Latino populations. In brief, the adaptation process generally followed well-accepted and validated guidelines (Butcher, 1996; Clark & Shiota, 1996), including a doctoral level Spanish-speaking clinical psychologist. The adaptation process was performed in stages. First, a Spanish translator who was a native speaker of Spanish was assembled. The translator was instructed to attend to three issues in the translation: understandability, linguistic equivalence, and particularly conceptual equivalence. Final translations were assembled in a draft. Second, drafts were back-translated. These back-translated drafts were revised if they deviated significantly from the originals in endorsement. Demographics Questionnaire. Demographic information collected included gender, age, race, educational level, marital status, employment status, and self-report of any prior use of mental health services (yes/no). These data were used for descriptive purposes. MINI International Neuropsychiatric Interview (MINI 6.0; Lecrubier et al., 1997). Diagnostic assessments were performed using the MINI. The MINI provides reliable DSM diagnoses within a short time frame which is applicable to research settings (Lecrubier et al., 1997). The MINI has demonstrated sound inter-rater and

test–retest reliability and validity (Sheehan et al., 1997). The interviews were administered by trained, Spanish-speaking staff and supervised by independent doctoral-level rater. Approximately 12% of randomly selected interviews were checked (second author) for accuracy; no cases of diagnostic coding disagreement were noted. For this study, the total number of current mood and anxiety disorders per MINI for each individual was used as a criterion variable (range = 0 to 9). Anxiety Sensitivity Index-III (ASI-III; Taylor et al., 2007). The ASIIII is an 18-item measure, based in part upon the original Anxiety Sensitivity Index (ASI; Reiss, Peterson, Gursky, & Mcnally, 1986), in which respondents indicate the extent to which they are concerned about possible negative consequences of anxiety-related symptoms (e.g., “It scares me when my heart beats rapidly”). Responses are rated on a 5-point Likert scale ranging from 0 (very little) to 4 (very much) and summed to create a total score. The ASI-III has strong and improved psychometric properties relative to previous measures of the construct (Taylor et al., 2007). Additionally, the factor structure and psychometric properties of the anxiety sensitivity construct has been explored with a variety of Latino samples (Cintron, Carter, Suchday, Sbrocco, & Gray, 2005; Sandin, Chorot, & Mcnally, 1996; Zvolensky et al., 2003). In the present investigation, the total score was utilized as a primary predictor variable; internal consistency was excellent (Cronbach’s ˛ = .96). Subjective Social Status (SSS; Adler, 2009). Subjective social status was assessed with the US version of the MacArthur Scale (Adler, 2009; Singh-Manoux et al., 2003). Participants were presented with a picture of a 10-rung ladder. The ladder represents where people stand in the U.S., with higher rungs indicating higher status (more money, more education, and better jobs). Participants select the rung that best represents where they think they stand relative to others in the U.S. (From 1 = worst to 10 = best). These ladders have been employed in several studies with ethnically diverse participants (including Latinos) and have demonstrated adequate reliability and validity (Franzini & Fernandez-Esquer, 2006; Ostrove et al., 2000; Reitzel et al., 2014). Inventory of Depression and Anxiety Symptoms (IDAS; Watson et al., 2007). The IDAS is a 64-item self-report instrument that assesses distinct affect symptom dimensions within the past two weeks. The IDAS contains a rich pool of affective content, including 10 specific symptom subscales for suicidality, lassitude, ill temper, well-being, insomnia, appetite loss, appetite gain, panic, social anxiety, and traumatic intrusions, and two broad subscales of general depression and dysphoria. Items are answered on a 5-point Likert scale ranging from “not at all” to “extremely.” The IDAS subscales show strong internal consistency, convergent and discriminant validity with psychiatric diagnoses and self-report measures; and short-term retest reliability (r = 0.79) with both community, and psychiatric patient samples (Watson et al., 2007, 2008). The present study used the panic subscale (8 items; e.g., “I felt a pain in my chest”), the social anxiety subscale (5 items; e.g., “I found it difficult to make eye contact with people”), and the general depression subscale (20 items; e.g., “I felt exhausted” or “I did not have much of an appetite”) as the primary criterion variables. As in past work among Latinos (Zvolensky, Bogiaizian, Salazar, Farris, & Bakhshaie, 2014), the three subscales demonstrated good level of internal consistency among the present sample (Cronbach’s alpha = .91, .80, .95, for panic, social anxiety, and general depression subscales, respectively). Positive and Negative Affect Scale (PANAS; Watson, Clark, & Tellegen, 1988). The PANAS is a self-report measure asking participants to rate the extent to which they experience each of 20 different feelings and emotions (e.g., interested, nervous) based on a Likert scale that ranges from 1 (“very slightly or not at all”) to 5 (“extremely”). The measure yields two factors (negative and positive affect) with strong documented psychometric properties

M.J. Zvolensky et al. / Journal of Anxiety Disorders 32 (2015) 38–45

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Table 3 Hierarchical regression models for psychopathology and panic symptoms.

(Watson, Clark, & Tellegen, 1988). We used the negative affectivity subscale (PANAS-NA) in the present investigation (Cronbach’s ˛ = .89).

Mood and anxiety disorder Step 1 Gender NA N-Services Marital Employment Education

1.3. Procedure Participants were attendees of a community-based primary care integrated healthcare clinic. Individuals interested in participating in the research study completed various demographic, psychological, and medical assessments. Following written informed consent, participants were interviewed using the MINI and then completed the other measures. The study protocol was approved by the Institutional Review Board at the University of Houston. Each participant was paid $20 for study participation.

Step 2 AS SSS Step 3 AS * SSS

1.4. Analytic strategy

Panic symptoms Step 1 Gender NA N-Services Marital Employment Education

First, a series of zero-order correlations was conducted to examine associations between study variables. Then, to test the main and interactive effects of anxiety sensitivity and subjective social status on the criterion variables, a moderation analysis using PROCESS macro (Hayes & Preacher, 2013) was conducted. Specifically, four hierarchical regression analyses were conducted. In the first step of each model, gender, negative affectivity, self-reported prior use of mental health services (0 = no, 1 = yes), marital status, employment status, and educational status were entered as covariates. Next, anxiety sensitivity and subjective social status were entered (second step). Finally, the interaction term between anxiety sensitivity and subjective social status was entered at the third step. Continuous variables were grand mean centered. Four separate regression models were conducted with the following criterion variables: (1) number of mood and anxiety disorders, (2) panic symptoms, (3) social anxiety symptoms, and (4) general depressive symptoms.

Step 2 AS SSS Step 3 AS * SSS

R2 change

Beta

.29

.02 .51*** .10 .02 −.02 −.06

.06

.24** −.13

.06

−.66***

.41

−.06 .57 .04 −.08 .06 −.17*

.05

.14* −.18*

.02

−.21*

Notes: Gender = coded 0 for male and 1 for female; NA = Positive and Negative Affect Scale – Negative Affect subscale (PANAS; Watson et al., 1988); Prior Services = prior use of mental health services (0 = no, 1 = yes); Marital status = coded 0 for not having a partner and 1 for having a partner; Employment = coded 0 for being unemployed and 1 for being employed; Education = coded 0 for having less than 12 years of education and 1 for having 12 years or more of education; SSS = subjective social status in US per MacArthur Scale for Subjective Social Status (SSS; MacArthur, 2014); AS = Anxiety Sensitivity Index-III–total score (ASI-III; Taylor et al., 2007); Number of Mood/Anxiety Disorders = Number of any mood or anxiety disorders per The Mini International Neuropsychiatric Interview (MINI 6.0; Lecrubier et al., 1997); Panic, Social anxiety, and Depressive symptoms = Severity of symptoms per Inventory of Depression and Anxiety Symptoms (IDAS; Watson et al., 2007). * p < .05. ** p < .01. *** p < .001.

2. Results 2.1. Descriptive data and zero-order associations Descriptive data and correlations of the study variables included are presented in Table 2. To determine the pattern of missing data in our samples, we conducted a missing values analysis. No nonmonotone missing data pattern was observed. Results from Little’s test (Little, 1988) suggested that data were missed completely at Table 2 Zero-order correlations among theoretically relevant variables. Variable

1

2

3

1. Gender (% Female) 2. NA 3. Prior services (% who used services) 4. Marital status (% with partner) 5. Employment (% employed) 6. Education (% 12 years plus) 7. SSS 8. AS 9. N-Dx 10. Panic 11. Social 12. Depression

1

.10 1

−.00 .13 .27** −.12 1 −.22* 1

4

5

6

7

−.21* −.00 .11 −.17 1

−.09 .02 .16 .03 −.02 1

−.12 .08 .07 .07 −.28** .57** .55** .56** −.09 .13 .20* .20* .05 −.10 −.07 −.14 −.03 .04 .01 .06 −.01 −.11 −.02 −.14 1 −.20* −.29** −.32** 1 .45** .43** 1 .52** 1

8

9

10

11

12

Mean (or n)

SD (or %)

.07 .61** .18 −.04 −.03 −.04 −.31** .56** .65** .69** 1

.08 .68** .15 −.22* .09 −.08 −.34** .60** .59** .74** .69** 1

– 17.30 40 95 77 65 5.48 33.74 .75 12.42 7.31 53.75

85.7 7.71 27.9 66.7 54.4 45.6 2.34 16.92 1.56 6.20 3.53 21.3

Notes: Gender = coded 0 for male and 1 for female; NA = Positive and Negative Affect Scale – Negative Affect subscale (PANAS; Watson et al., 1988); Prior Services = prior use of mental health services (0 = no, 1 = yes); Marital status = coded 0 for not having a partner and 1 for having a partner; Employment = coded 0 for being unemployed and 1 for being employed; Education = coded 0 for having less than 12 years of education and 1 for having 12 years or more of education; SSS = subjective social status in US per MacArthur Scale for Subjective Social Status (SSS; MacArthur, 2014); AS = Anxiety Sensitivity Index-III – total score (ASI-III; Taylor et al., 2007); Number of Mood/Anxiety Disorders = Number of any mood or anxiety disorders per The Mini International Neuropsychiatric Interview (MINI 6.0; Lecrubier et al., 1997); Panic, Social anxiety, and Depressive symptoms = Severity of symptoms per Inventory of Depression and Anxiety Symptoms (IDAS; Watson et al., 2007). * p < .05. ** p < .01. *** p < .001.

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M.J. Zvolensky et al. / Journal of Anxiety Disorders 32 (2015) 38–45

random (MCAR; Chi-Square = 20.20, df = 13, p = .10) In the case of missing data, pairwise deletion was applied, resulting in sample sizes ranging from 122 to 143 across analyses (Rubin, 2004) Anxiety sensitivity was positively and subjective social status was negatively correlated with each of the dependent measures (see Table 2). Anxiety sensitivity and subjective social status were negatively correlated with one another (r = −.204, p = 014; 4% shared variance). 2.2. Regression analyses In terms of number of mood and anxiety disorders (Cohen, 2003) covariates entered at the first step accounted for a significant amount of variance (R2 = .35, F(6, 137) = 9.4, p < 001); negative affectivity was the only significant predictor (Beta = .51, p < 0.001). At step two, anxiety sensitivity was a significant predictor (Beta = .24, p = 006). The interaction term between anxiety sensitivity and subjective social status was significant (Beta = −.66, p = .0002; see Table 3). Simple slope analyses revealed that subjective social status was related to a greater number of mood and anxiety disorders among individuals with higher (versus lower) levels of anxiety sensitivity (Beta = −0.35, p = .0001; see Fig. 1). The covariates entered at the first step accounted for a significant amount of variance in relation to panic symptoms (R2 = .41, F(6, 120) = 13.8, p < .001); negative affectivity and educational status were significant predictors (Beta = .53, p < .0001; b = −1.2, p = .011 respectively). Both anxiety sensitivity and subjective social status accounted for a significant amount of variance at the second step (Beta = .14, p = .016; Beta = −.18, p = 019, respectively). The interaction term was also significant (Beta = −0.21, p = .03; see Table 3). Simple slope analyses revealed that subjective social status was related to greater panic symptoms among individuals with higher (versus lower) levels of anxiety sensitivity (Beta = −.31, p = .001; see Fig. 1).

2

The covariates entered at the first step accounted for a significant amount of variance in social anxiety symptoms (R2 = .32, F(6, 118) = 6.1, p < .001); negative affectivity was the only significant predictor (Beta = .61, p < .001). At the second step, only anxiety sensitivity was a significant predictor (Beta = .20, p = .002). The interaction term was significant (Beta = −.58, p < .001; see Table 4). Simple slope analyses indicated that subjective social status was related to greater social anxiety symptoms among individuals with higher (versus lower) levels of anxiety sensitivity (Beta = −.42, p < .001; see Fig. 1). In terms of general depressive symptoms, covariates entered at the first step of the hierarchical regression accounted for a significant amount of variance (R2 = .57, F(6, 116) = 26.3, p < .001); negative affectivity was the only significant predictor (Beta = .69, p < .001). At the second step, anxiety sensitivity and subjective social status were significant predictors (b = .30, p = .001; Beta = −.14, p = .009). The interaction term was significant (Beta = −.25, p = 0.047; see Table 4). Simple slope analyses revealed that subjective social status was related to greater depressive symptoms among individuals with higher (versus lower) levels of anxiety sensitivity (Beta = −.19, p = .001; see Fig. 1). 3. Discussion Consistent with prediction, the interaction between anxiety sensitivity and subjective social status was significantly related to each of the dependent measures among the primary care Latino sample. The size of the observed interaction across the models ranged from small for depressive symptoms to medium for anxiety/depressive disorders in effect size (Cohen & Cohen, 1983). Given the magnitude of variance accounted for at steps one and two (ranging from 29% to 64% of variance), it is noteworthy that the interactive effects enhanced the model’s predictive

16 15

1.5

low-AS

14

low-AS

13

1 High-AS

0.5

12

High-AS

11

0

10 Low-SSS

Low-SSS

High-SSS

Number of Mood and Anxiety Diagnoses

High-SSS

Panic Symptoms 70

10

65

9 low-AS

8

60

low-AS

55

7 High-AS

6

50

High-AS

45 40

5 Low-SSS

High-SSS

Social Anxiety Symptoms

Low-SSS

High-SSS

Depressive Symptoms

Fig. 1. Plotting the predicted scores on number of clinical disorders and mood symptoms as a function of the interaction between Subjective Social Status and Anxiety Sensitivity (Mean = +1 SD and Mean = −1 SD). Low-SSS = Subjective Social Status at Mean − 1 SD; High-SSS = Subjective Social Status at Mean + 1 SD; Low-AS = Anxiety Sensitivity at Mean − 1 SD; High-AS = Anxiety Sensitivity at Mean + 1 SD.

M.J. Zvolensky et al. / Journal of Anxiety Disorders 32 (2015) 38–45 Table 4 Hierarchical regression models for social anxiety and depressive symptoms.

Social anxiety symptoms Step 1 Gender NA N-Services Marital Employment Education Step 2 AS SSS Step 3 AS * SSS General depressive symptoms Step 1 Gender NA N-Services Marital Employment Education Step 2 AS SSS Step 3 AS * SSS

R2 change

Beta

.37

−.06 .61*** .005 −.02 .02 −.07

.04

.20* −.10

.05

−.58***

.58

.04 .69*** −.05 −.13 .10 −.09

.06

.30** −.14**

.01

−.25*

Notes: Gender = coded 0 for male and 1 for female; NA = Positive and Negative Affect Scale – Negative Affect subscale (PANAS; Watson et al., 1988); Prior Services = prior use of mental health services (0 = no, 1 = yes); Marital status = coded 0 for not having a partner and 1 for having a partner; Employment = coded 0 for being unemployed and 1 for being employed; Education = coded 0 for having less than 12 years of education and 1 for having 12 years or more of education; SSS = subjective social status in US per MacArthur Scale for Subjective Social Status (SSS; MacArthur, 2014); AS = Anxiety Sensitivity Index-III – total score (ASI-III; Taylor et al., 2007); Number of Mood/Anxiety Disorders = Number of any mood or anxiety disorders per The Mini International Neuropsychiatric Interview (MINI 6.0; Lecrubier et al., 1997); Panic, Social anxiety, and Depressive symptoms = Severity of symptoms per Inventory of Depression and Anxiety Symptoms (IDAS; Watson et al., 2007). * p < .05. ** p < .01. *** p < .001.

power (Abelson, 1985). Moreover, inspection of the forms of the significant interactions indicated similarity. Specifically, Latinos reporting co-occurring higher levels of anxiety sensitivity and lower levels of subjective social status evidenced the greatest levels of psychopathology and panic, social anxiety, and depressive symptoms (see Fig. 1). Overall, these data provide novel empirical evidence suggesting that there is indeed clinically relevant interplay between cognitive (anxiety sensitivity) and social determinants of health (subjective social status) factors in regard to anxiety and depressive symptom expression. Although not the primary focus of the investigation, a number of other observed findings warrant comment. First, there was consistent evidence that negative affectivity was robustly related to each of the dependent measures. These findings are consistent with past work (Watson, 2000), and underscore the explanatory role of a tendency to experience negative affect states in models of anxiety/depressive vulnerability. Second, as has been found in past studies among non-Latinos (Schmidt et al., 2006), anxiety sensitivity was uniquely related to the studied variables after accounting for negative affectivity. This pattern of findings suggests that anxiety sensitivity has a unique explanatory role for anxiety/depressive symptoms and psychopathology among Latinos. Third, there was novel evidence that subjective social status was uniquely related to panic and depressive symptoms. These findings,

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which build from past work on other social determinants of health (Adler et al., 2000), highlight the role of subjective social status across certain anxiety and depressive variables, and by extension, the possible utility in being more systematically studied in relation to vulnerability models of risk for anxiety and mood problems among Latinos, and perhaps, other health disadvantaged groups. At the same time, subjective social status was not related at the main effect level to number of diagnoses or social anxiety in this investigation. Therefore, if replicated, it is possible that subjective social status may not necessarily relate to all anxiety symptoms and disorders in the same manner. Future theory-driven tests of subjective social status and emotional specificity are needed, which will require more refined models of this construct in relation to psychopathological states. As we focused on anxiety and depressive symptoms as the primary dependent measures. It is possible that more culturally specific processes also may be related to anxiety sensitivity and subjective social status. For example, future work may benefit from exploring the explanatory role of anxiety sensitivity and subjective social status in relation to acculturative stress, acculturative-related anxiety, and familism among Latinos. The present findings suggest that there is merit in focusing further scientific attention on the interplay between anxiety sensitivity and subjective social status in regard to anxiety/depressive vulnerability. Although the present study aims were oriented on the global anxiety sensitivity construct and subjective social status given the current stage of (limited) research development in this domain, future work could further refine the types of models tested. Specifically, there may be utility in exploring whether distinct aspects of anxiety sensitivity (e.g., catastrophic cognitions; Hinton, Chong, Pollack, Barlow, & Mcnally, 2008) or other social determinant indicators (e.g., financial strain; acculturation) offer similar or enhanced explanatory value relative to other combinations for certain anxiety/depressive-relevant symptoms or problems. Thus, it would be important for future work to begin to address these types of questions via more theoretically refined explorations of these interactive processes for the purpose of elucidating differential vulnerability mechanisms of specific types of anxiety/depressive problems among Latinos. The current study has a number of limitations that warrant comment. First, the present investigation utilized established selfreport instruments as the principal assessment strategy. Although this approach was prudent at this stage of research development and pragmatic for primary care settings, future work might build upon the present findings and incorporate multi-method approaches to indexing the variables of interest. Second, due to the cross-sectional and correlational nature of the present research design, it is not possible to make definitive, causal statements concerning the relations between the studied variables. One important next step in this line of inquiry would be to use prospective research methodologies and evaluate the consistency of the present findings over time. Third, although anxiety sensitivity, an established transdiagnostic risk factor for anxiety/depressive problems (Schmidt et al., 2006), was conceptualized a priori as a cognitive factor ideally suited to the examination of singular and interactive associations with subjective social status, it is only one of many risk factors for mood psychopathology. Future work directed at isolating the types of risk factors with which subjective social status may interact (e.g., perceived control over stressful life events) would be important in terms of systematically shaping the potential explanatory parameters of this construct. Fourth, we collapsed across anxiety and depressive disorder diagnoses to index the number of diagnoses due to the sample size (cf. analyzing data by disorder). Future work may benefit by testing whether the interactive model between anxiety sensitivity and subjective social status is particularly applicable to certain types of mood psychopathology. Fifth, the present Latino sample was largely female and seeking medical services for a wide

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range of issues. Future work could evaluate the generalizability of the present model to other sectors of the Latino community, including samples with a larger percentage of males and those persons not seeking medical services. Sixth, Latinos often employ an extreme and acquiescent response style relative to other groups (Davis, Resnicow, & Couper, 2011). Accordingly, there is the possibility that a response bias may have influenced in the present observations, although this issue should be minimized in the current study because the tests conducted were within group (rather between-group) in nature. Finally, we did not have data on generation level or acculturation stress in this sample. As these factors are often highly relevant to the psychological experience of Latinos (Davis et al., 2011), future work would benefit by measuring these variables, and perhaps, adjusting for them in relation modeling the effects of risk factors for mental health processes. It also be may useful to explore the role of other social indicators as explanatory variables, such as financial strain, and how they may interplay with anxiety sensitivity for culturally specific and general mental health symptoms among Latinos. Clinically, the present findings suggest intervention programs for anxiety/depressive symptoms and disorders among Latinos might benefit from screening for anxiety sensitivity and subjective social status for early intervention. For example, targeting Latinos with high levels of anxiety sensitivity and lower levels of subjective social status in primary care may help isolate a high-risk segment of the Latino population for anxiety/depressive problems. This segment of the Latino population may benefit from brief, psychosocial interventions that target reducing anxiety sensitivity and increasing subjective social status through psychoeducation and cognitive-behavioral skills training.

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